对比增强经颅多普勒超声评估右向左分流的可行性

目的研究对比增强经颅多普勒超声（c-TCD）评估右向左分流（RLS）的可行性。 方法回顾性连续纳入2015年8月至2018年11月于苏州大学附属第一医院神经内科住院的隐源性卒中（CS）患者206例,与同期120例住院的大动脉粥样硬化型卒中（LAA）患者的临床特征进行对比;CS患者均行c-TCD、右心声学造影（c-TTE）检查,静息状态下出现的RLS为固有型RLS,仅在Valsalva动作后出现的RLS为潜在型RLS;c-TCD评估为大量RLS且c-TTE阳性的患者行经食管超声心动图（TEE）检查。采用t检验及χ²检验比较CS患者与LAA患者的临床特征,曼-惠特尼秩和检验比较c-TCD和c-TTE对RLS的半定量分级。 结果临床特征：CS组与LAA组患者在年龄、高血压、糖尿病、高脂血症、颈动脉斑块、吸烟史、血浆同型半胱氨酸升高方面,差异均有统计学意义（t=-26.949,χ²=110.380、62.371、17.352、212.099、25.987、35.415,P均<0.001）。c-TCD、c-TTE诊断RLS：阳性率分别为70.4%（145/206例）、46.6%（96/206例）,差异有统计学意义（χ²=24.004,P<0.001）,且c-TCD检出的145例RLS包含c-TTE的96例阳性结果。分析c-TCD、c-TTE的结果差异：c-TCD评估的RLS 66.2%（96/145例）经c-TTE检出,对c-TCD评估的固有型及潜在型RLS,c-TTE阳性率分别为78.5%（73/93例）及44.2%（23/52例）,差异有统计学意义（χ²=17.501,P<0.001）;对c-TCD评估的小量、中量及大量RLS,c-TTE阳性率分别为23.7%（9/38例）、65.4%（17/26例）及86.4%（70/81例）,两两相比,差异均有统计学意义（χ²=11.129、45.620、5.730,P均<0.05）;c-TCD对RLS的半定量分级高于c-TTE,差异有统计学意义（Z=-6.021,P<0.001）。TEE结果：92.9%（65/70例）的RLS确诊为卵圆孔未闭（PFO）。 结论c-TCD可以准确评估RLS,为隐源性卒中患者的"个体化"诊疗提供可靠依据。

Feasibility of evaluating right-to-left shunt by contrast-enhanced transcranial Doppler

ObjectiveTo investigate the feasibility of evaluating right-to-left shunt (RLS) by contrast-enhanced transcranial Doppler (c-TCD). MethodsFrom August 2015 to November 2018, 206 consecutive patients with cryptogenic stroke (CS) hospitalized at the Department of Neurology, First Affiliated Hospital of Soochow University were enrolled retrospectively and compared with 120 hospitalized patients with large-artery atherosclerosis (LAA) with regard to clinical features. All patients with CS underwent c-TCD and contrast echocardiography (c-TTE). RLS was considered permanent if it occurred during normal respiration or latent when it occurred only after the Valsalva maneuver. Some patients with large RLS assessed by c-TCD and positive for c-TTE underwent transesophageal echocardiography (TEE). The clinical features of patients with CS and patients with LAA were compared by t-test and χ²-test. The semi-quantitative classification of RLS by c-TCD and c-TTE was compared by Mann-Whitney rank sum test. ResultsThe differences in age, hypertension, diabetes, hyperlipidemia, carotid plaque, smoking history, and plasma homocysteine between the CS group and LAA group were significant (t=-26.949, χ²=110.380、62.371、17.352、212.099、25.987、35.415, all P<0.001). The positive rates of c-TCD and c-TTE in the diagnosis of RLS were 70.4% (145/206 cases) and 46.6% (96/206 cases), respectively, and the difference was statistically significant (χ²=24.004, P<0.001). Of 145 cases of RLS detected by c-TCD, 96 had positive c-TTE results. Approximately 66.2% (96/145) of RLS cases diagnosed by c-TCD were confirmed by c-TTE. The positive rates of c-TTE were 78.5% (73/93 cases) and 44.2% (23/52 cases) for permanent and potential RLS assessed by c-TCD, respectively, and the differences were statistically significant (χ²=17.501, P<0.001). The positive rates of c-TTE were 23.7% (9/38 cases), 65.4% (17/26 cases), and 86.4% (70/81 cases) for small, moderate, and large RLS assessed by c-TCD, respectively, and the differences were statistically significant (χ²=11.129, 45.620, and 5.730, respectively; P<0.05). The semi-quantitative grade of RLS by c-TCD was significantly higher than that by c-TTE (Z=-6.021, P<0.001). Patent foramen ovale was confirmed in 92.9% (65/70) of cases. Conclusionc-TCD can accurately assess RLS and provide a reliable basis for individualized diagnosis and treatment of patients with cryptogenic stroke.