{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,7]],"date-time":"2026-03-07T14:14:58Z","timestamp":1772892898739,"version":"3.50.1"},"reference-count":28,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"9","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Stroke"],"published-print":{"date-parts":[[1999,9]]},"abstract":"<jats:p>\n            <jats:italic>Background and Purpose<\/jats:italic>\n            \u2014Cardiac right-to-left shunts can be identified by transesophageal echocardiography (TEE) and by transcranial Doppler ultrasound (TCD) with the use of different contrast agents and different provocation procedures. Currently, data on an appropriate time window for the appearance of contrast bubbles in the TCD recording after the injection of the contrast medium and the comparison of different provocation maneuvers to increase right-to-left shunting are insufficient.\n          <\/jats:p>\n          <jats:p>\n            <jats:italic>Methods<\/jats:italic>\n            \u2014Forty-six patients were investigated by both TEE and bilateral TCD of the middle cerebral artery. The following protocol with 6 injection modes was applied in a randomized way: (1) injection of 10 mL of agitated saline without Valsalva maneuver, (2) injection of 10 mL of agitated saline with Valsalva maneuver, (3) injection of 10 mL of a commercial galactose-based contrast agent (Echovist) without Valsalva maneuver, (4) injection of 10 mL of Echovist with Valsalva maneuver, (5) injection of 10 mL of Echovist with standardized Valsalva maneuver, and (6) injection of 10 mL of Echovist with coughing.\n          <\/jats:p>\n          <jats:p>\n            <jats:italic>Results<\/jats:italic>\n            \u2014In 20 patients, a right-to-left shunt was demonstrated by TEE and contrast TCD (shunt-positive). Sixteen patients were negative in both investigations, no patient was positive on TEE and negative on TCD, and 10 patients were only positive on at least 1 TCD investigation but negative during TEE. The amount of microbubbles detected in the various tests decreased in the following order: Echovist and Valsalva maneuver, Echovist with coughing, Echovist and standardized Valsalva maneuver, saline with Valsalva maneuver, Echovist, and saline. With a time window of 20 to 25 seconds for the bubbles to appear in the TCD recording and with a sequence of first Echovist and Valsalva maneuver and then Echovist with coughing, all shunts were reliably identified with a specificity of 65% compared with TEE as the traditional gold standard. The time of first microbubble appearance was not helpful to distinguish between shunts detected on TEE and other shunts.\n          <\/jats:p>\n          <jats:p>\n            <jats:italic>Conclusions<\/jats:italic>\n            \u2014TCD performed twice with 2 provocation maneuvers using Echovist is a sensitive method to identify cardiac right-to-left shunts also identified by TEE.\n          <\/jats:p>","DOI":"10.1161\/01.str.30.9.1827","type":"journal-article","created":{"date-parts":[[2011,6,17]],"date-time":"2011-06-17T20:08:03Z","timestamp":1308341283000},"page":"1827-1832","update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":88,"title":["Contrast Transcranial Doppler Ultrasound in the Detection of Right-to-Left Shunts"],"prefix":"10.1161","volume":"30","author":[{"given":"Dirk W.","family":"Droste","sequence":"first","affiliation":[{"name":"From the Department of Neurology (D.W.D., J-U.K., R.T., B.W., P.Y., E.B.R.) and the Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.C., T.W.), University of Mu\u0308nster (Germany)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jens-Uwe","family":"Kriete","sequence":"additional","affiliation":[{"name":"From the Department of Neurology (D.W.D., J-U.K., R.T., B.W., P.Y., E.B.R.) and the Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.C., T.W.), University of Mu\u0308nster (Germany)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jo\u0308rg","family":"Stypmann","sequence":"additional","affiliation":[{"name":"From the Department of Neurology (D.W.D., J-U.K., R.T., B.W., P.Y., E.B.R.) and the Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.C., T.W.), University of Mu\u0308nster (Germany)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marco","family":"Castrucci","sequence":"additional","affiliation":[{"name":"From the Department of Neurology (D.W.D., J-U.K., R.T., B.W., P.Y., E.B.R.) and the Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.C., T.W.), University of Mu\u0308nster (Germany)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Thomas","family":"Wichter","sequence":"additional","affiliation":[{"name":"From the Department of Neurology (D.W.D., J-U.K., R.T., B.W., P.Y., E.B.R.) and the Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.C., T.W.), University of Mu\u0308nster (Germany)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ralf","family":"Tietje","sequence":"additional","affiliation":[{"name":"From the Department of Neurology (D.W.D., J-U.K., R.T., B.W., P.Y., E.B.R.) and the Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.C., T.W.), University of Mu\u0308nster (Germany)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Birgitta","family":"Weltermann","sequence":"additional","affiliation":[{"name":"From the Department of Neurology (D.W.D., J-U.K., R.T., B.W., P.Y., E.B.R.) and the Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.C., T.W.), University of Mu\u0308nster (Germany)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Peter","family":"Young","sequence":"additional","affiliation":[{"name":"From the Department of Neurology (D.W.D., J-U.K., R.T., B.W., P.Y., E.B.R.) and the Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.C., T.W.), University of Mu\u0308nster (Germany)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"E. Bernd","family":"Ringelstein","sequence":"additional","affiliation":[{"name":"From the Department of Neurology (D.W.D., J-U.K., R.T., B.W., P.Y., E.B.R.) and the Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.C., T.W.), University of Mu\u0308nster (Germany)."}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"276","reference":[{"key":"e_1_3_1_1_2","doi-asserted-by":"publisher","DOI":"10.1378\/chest.108.2.549"},{"key":"e_1_3_1_2_2","doi-asserted-by":"publisher","DOI":"10.1016\/0002-8703(94)90626-2"},{"key":"e_1_3_1_3_2","doi-asserted-by":"publisher","DOI":"10.1378\/chest.101.6.1515"},{"key":"e_1_3_1_4_2","unstructured":"Stendel R Schr\u00f6der K Funk T Brock M. Is transcranial Doppler reliable in the detection of a patent foramen ovale? In: Klingelh\u00f6fer J Bartels EM Ringelstein EB eds. New Trends in Cerebral Hemodynamics. 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Factors influencing the sensitivity of the contrast-TCD method in the detection of right-to-left shunts. In: Klingelh\u00f6fer J Bartels EM Ringelstein EB eds. New Trends in Cerebral Hemodynamics. Amsterdam Netherlands: Elsevier Science BV; 1998:475\u2013482."},{"key":"e_1_3_1_19_2","doi-asserted-by":"publisher","DOI":"10.1016\/0002-8703(93)90073-I"},{"key":"e_1_3_1_20_2","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.41.12.1902"},{"key":"e_1_3_1_21_2","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9149(92)91006-P"},{"key":"e_1_3_1_22_2","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.43.8.1533"},{"key":"e_1_3_1_23_2","doi-asserted-by":"publisher","DOI":"10.1161\/str.24.7.8322376"},{"key":"e_1_3_1_24_2","doi-asserted-by":"publisher","DOI":"10.1159\/000107838"},{"key":"e_1_3_1_25_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0022-510X(97)05367-7"},{"key":"e_1_3_1_26_2","doi-asserted-by":"publisher","DOI":"10.1111\/jon199773159"},{"key":"e_1_3_1_27_2","unstructured":"Horner S Schuchlenz S Harb S Weihs W Ni XS Fazekas F Duft M Kleinert G Niederkorn K. Contrast transcranial Doppler monitoring in stroke patients with pulmonary right-to-left shunts. 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