{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,22]],"date-time":"2026-01-22T20:27:27Z","timestamp":1769113647446,"version":"3.49.0"},"reference-count":33,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"7","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Stroke"],"published-print":{"date-parts":[[2000,7]]},"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 contrast agents and a Valsalva maneuver (VM) as provocation procedure. Currently, data on the appropriate timing of the VM, the use of a diagnostic time window, and a threshold in contrast agent microbubbles detected are insufficient.\n          <\/jats:p>\n          <jats:p>\n            <jats:italic>Methods<\/jats:italic>\n            \u2014Fifty-eight patients were investigated by both TEE and bilateral TCD of the middle cerebral artery. The following protocol with injections of 10 mL of the commercial galactose-based contrast agent Echovist was applied in a randomized way: (1) no VM, (2) VM for 5 seconds starting 2 seconds after the beginning of contrast injection, (3) VM for 5 seconds starting 5 seconds after the beginning of contrast injection, (4) VM for 5 seconds starting 8 seconds after the beginning of contrast injection, and (5) repetitive short VMs in between 2 and 13 seconds after the beginning of contrast injection. In addition to the single tests, we also tested the sensitivity and specificity of combined results of the tests with VM.\n          <\/jats:p>\n          <jats:p>\n            <jats:italic>Results<\/jats:italic>\n            \u2014In 21 patients, a right-to-left shunt was demonstrated by TEE and contrast TCD (shunt positive). Twenty-one patients were negative in both investigations, no patient was positive on TEE and negative on TCD, and 16 patients were only positive on at least 1 TCD investigation but negative during TEE. Test 3 was the most appropriate test when combined with the results of 1 of the other tests with VM. The highest sensitivities were achieved with a diagnostic time window of 40 seconds and when the presence of a single microbubble was sufficient for the diagnosis of a shunt.\n          <\/jats:p>\n          <jats:p>\n            <jats:italic>Conclusions<\/jats:italic>\n            \u2014TCD performed twice with 2 provocation maneuvers with Echovist is a sensitive method to identify TEE-proven cardiac right-to-left shunts. The VM should be performed for 5 seconds starting at 5 seconds after the beginning of contrast injection.\n          <\/jats:p>","DOI":"10.1161\/01.str.31.7.1640","type":"journal-article","created":{"date-parts":[[2011,6,17]],"date-time":"2011-06-17T20:10:52Z","timestamp":1308341452000},"page":"1640-1645","update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":78,"title":["Contrast Transcranial Doppler Ultrasound in the Detection of Right-to-Left Shunts"],"prefix":"10.1161","volume":"31","author":[{"given":"Dirk W.","family":"Droste","sequence":"first","affiliation":[{"name":"From the Department of Neurology (D.W.D., K.S., V.K., K.K., E.B.R.) and Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.G., T.W.), University of Mu\u0308nster (Germany)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Karen","family":"Silling","sequence":"additional","affiliation":[{"name":"From the Department of Neurology (D.W.D., K.S., V.K., K.K., E.B.R.) and Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.G., 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., K.S., V.K., K.K., E.B.R.) and Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.G., T.W.), University of Mu\u0308nster (Germany)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Matthias","family":"Grude","sequence":"additional","affiliation":[{"name":"From the Department of Neurology (D.W.D., K.S., V.K., K.K., E.B.R.) and Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.G., T.W.), University of Mu\u0308nster (Germany)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vendel","family":"Keme\u0301ny","sequence":"additional","affiliation":[{"name":"From the Department of Neurology (D.W.D., K.S., V.K., K.K., E.B.R.) and Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.G., 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., K.S., V.K., K.K., E.B.R.) and Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.G., T.W.), University of Mu\u0308nster (Germany)."}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Karsten","family":"Ku\u0308hne","sequence":"additional","affiliation":[{"name":"From the Department of Neurology (D.W.D., K.S., V.K., K.K., E.B.R.) and Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.G., 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., K.S., V.K., K.K., E.B.R.) and Department of Cardiology and Angiology and Institute for Arteriosclerosis Research (J.S., M.G., 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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