Contrast transcranial Doppler examination in the acute phase of a paradoxical brain embolism associated with pulmonary thromboembolism

The right-to-left shunt is often diagnosed by transcranial Doppler (TCD) with saline contrast with Valsalva's maneuver or cough. In the acute phase of stroke, however, Valsalva's maneuver or cough could not always be performed because of the patient's aphasia or consciousness disturbance. We report an acute aphasic stroke patient with a pulmonary thromboembolism who is diagnosed as having a right-to-left shunt by using TCD with saline contrast without Valsalva's maneuver or cough. In patients who have embolic stroke of undetermined cause, even if they cannot perform Valsalva's maneuver or cough because of aphasia or consciousness disturbance, TCD with saline contrast in the acute phase of stroke may be helpful for diagnosis of a paradoxical embolism.