| The paper involved two aspects:(1)The feasibility of evaluating right-to-left shunt by contrast-enhanced transcranial Doppler;(2)The correlation between right-to-left shunts and cryptogenic stroke.Part Ⅰ:The feasibility of evaluating right-to-left shunt by contrast-enhanced transcranial DopplerObjectiveThis study explored whether contrast-enhanced transcranial Doppler can be an acceptable tool to evaluate right-to-left shunt.Methods1 Case data:From August 2015 to November 2018,206 consecutive patients with cryptogenic stroke from the Hospitalization of Department of Stroke Center,First Affiliated Hospital of Soochow were enrolled retrospectively and compared with the Baseline data of 120 hospitalized patients with large-artery atherosclerotic.All patients with CS underwent c-TCD and contrast-echocardiography(c-TTE).Some patients with large RLS assessed by c-TCD and positive manifestation in c-TTE underwent transesophageal echocardiography(TEE).2 Inclusion criteria:(1)the relevant imaging and blood biochemical tests had been completed,and the patients were diagnosed by neurologist according to the TOAST type;(2)informed consents had been signed.Exclusion criteria:(1)the patients had a history of serious heart or lung disease,such as myocardial infarction,severe pneumonia,asthma,etc;(2)the patients has cognitive impairment and were unable to learn the ways of performing the Valsalva action or to execute the Valsalva action;(3)those with poor puncture vascular conditions who are unable to accept c-TCD;(4)neither arm of the patients had suitable blood vessels to puncture and could not complete the bolus injection;(5)those who have doubts about the examination.3 Research Methodology:Using activated saline as contrast medium,c-TCD and c-TTE were examined three times.The first examination was performed at rest,and the patient was followed by two examinations with Valsalva movements,with intervals of two minutes between each examination,the patient was trained in the Valsalva movement before examination.When TEE is performed,the patient is asked to cough due to difficulty in Valsalva movement,or the doctor may press the patient’s abdomen to increase chest pressure and improve the examination of patent foramen ovale.The results of c-TCD,c-TTE and TEE were compared to explore the feasibility of c-TCD in the assessment of RLS.4 Statistical Analysis:The statistical software was SPSS 17.0.The data conforming to the normal distribution were expressed as mean standard deviation,t test and chi-square test was used for inter-group comparison.Counting data was denoted by percentages.Correlation analysis of ordered variables was analyzed with Man-whitney rank sum.We considered that the value of P<0.05 was statistically significant.Results1 Baseline data:The differences of age,hypertension,and plasma homocyst-eine and so on between patients with cryptogenic stroke and patients with large-artery atherosclerotic were significant(P<0.001).The rest had no sta-tistical difference.2 Diagnosis of RLS:70.4%(145/206 cases)of the patients with RLS was discovered by c-TCD and 46.6%(96/206 cases)of the patients with RL-S was identified by c-TTE.There was a statistically significant(χ2=17.501,P<0.001)difference between two means.3 The results of c-TCD and c-TTE were analyzed:66.2%(96/145)of RLSassessed by c-TCD were diagnosed as positive by c-TTE.The positive rate-s of c-TTE were 78.5%(73/93 cases)and 44.2%(23/52 cases)for p-ermanent and potential RLS assessed by c-TCD,respectively,and the diffe-rences were statistically significant(P<0.001).The positive rates of c-TT-E 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、5.730,all P<0.05).A higher semiquantitative grade of RLS could be gain by c-TCD Instead of c-TTE,and the differences of semi-quantitative grading between two examinations were significant(Z=-6.021,P<0.001).4 The results of TEE:A total of 70 patients were assessed by c-TCD with large amount of RLS and positive manifestation in c-TTE.TEE was perfor-med in these patients.Among them,92.9%(65/70)were diagnosed as p-atent foramen ovale(PFO),and 3 patients were suspected positive for PFO.TEE showed that "the primary septum and the secondary septum appeared to be crevices,but no perforating septum blood flow".2 patients were negative.Conclusionsc-TCD can be an accurately examination to evaluate RLS.And this test make itviable to be a trustworthy background for individual diagnosis and treatment of patients with cryptogenic stroke.Part II:The correlation between right-to-left shunts and cryptogenic strokeObjectiveThe connection between right-to-left shunt and cryptogenic stroke was explored.Methods1 Case data:From August 2015 to November 2018,155 patients with cryptogenic stroke(study group),and 62 patients with dizziness or headache(control group)from the Hospitalization of Department of Stroke Center,First Affiliated Hospital of Soochow University were enrolled retrospectively.All patients were screened for RLS by contrast-enhanced transcranial Dopler Sonography(c-TCD),improve the relevant auxiliary examination(such as cranial magnetic resonance imaging,carotid artery ultrasound,transcranial Dopler ultrasound,echocardiography,biochemical complete set).2 Inclusion criteria:(1)the relevant imaging and blood biochemical tests have been completed,and the patient was diagnosed by neurologist according to the patient’s condition and TOAST type;(2)informed consent has been signed.Exclusion criteria:(1)those with migraineurs;(2)the patients had a history of severe heart and lung disease,such as severe arrhythmia,ventricular septal defect,severe pneumonia,etc;(3)the patients has cognitive impairment and could not to execute the Valsalva action;(4)those with poor puncture vascular conditions who are unable to accept c-TCD;(5)neither arm of the patients had suitable blood vessels to puncture and could not complete the bolus injection;(6)those who have doubts about the examination.3 Research group:Baseline data,such as common stroke risk factors and c-r-eactive,proteinplasma homocysteine,were compared between the study andcontrol groups.The characteristics of RLS in the two groups were compared,and the correlation between RLS and CS was analyzed.4 Statistical Analysis:SPSS 17.0 was our statistical software.The data confo-rming to the normal distribution were expressed as mean standard deviati-on,t test and chi-square test was used for inter-group comparison.Countin-g data was denoted by percentages.We considered that the value of P<0.05 was statistically significant.Results1 Baseline data:The level of serum c-reactive protein in the study group was higher than that in the control group,the difference was statistically significant(P<0.001).The differences of age,hypertension,and plasma homocysteine and so on between CS group and control group were significant(P<0.001).2 The two groups were compared with RLS:The positive rates of RLS in the study group and the control group were 72.3%(112/155 cases)and 27.4%(17/62 cases),respectively,more moderate RLS were detected,more RLS were detected(12.3%vs 3.2%,41.9%vs 1.6%),and the difference was statistically significant(All P<0.05).There was no significant difference in the detection rate of small RLS between the study group and the control group(18.1%vs 22.6%,P>0.05).ConclusionsModerate and large right-to-left shunts were risk factors for cryptogenic stroke.Small right-to-left shunts were not associated with cryptogenic stroke. |
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