经食管超声心动图联合右心声学造影诊断隐匿性脑卒中的应用

doi:10.7517/issn.1674-0475.200413

摘要/Abstract

摘要： 选取147例隐匿性脑卒中（CIS）患者进行回顾性研究，其中卵圆孔未闭（PFO）相关CIS患者99例（PFO组）、非PFO相关CIS患者48例（非PFO组），均行经食管超声心动图（TEE）和右心声学造影（cTTE）检查，比较二者的PFO检出率、右向左分流（RLS）分级情况及安全性；对比两组患者的反常性栓塞风险量表（RoPE）、PFO内径、PFO长度，采用接收者操作特征（ROC）曲线及ROC下面积（AUC）评价诊断效能；并分析了RoPE评分与PFO内径、RLS分级的相关性。结果发现，cTTE+TEE检出PFO阳性率（67.35%）高于cTTE （55.10%），检出RLS分级Ⅰ+Ⅱ+Ⅲ级患者占比（64.63%）高于cTTE （53.06%），RoPE评分+PFO内径联合诊断PFO相关CIS的AUC最高（0.928），RoPE评分与PFO内径、RLS分级均呈正相关（P<0.05）。综上，cTTE联合TEE可提高PFO检出率并判断RLS程度，RoPE评分和PFO内径可用于PFO-RLS相关性CIS的诊断。

关键词: 经食管超声心动图, 右心声学造影, 隐匿性脑卒中, RoPE评分, PFO内径, ROC

Abstract: A total of 147 patients with cryptogenic ischemic stroke (CIS) were selected for a retrospective study. Among them, there were 99 patients with patent foramen ovale (PFO) related CIS (PFO group) and 48 patients with non-PFO related CIS (non-PFO group). All patients underwent transesophageal echocardiography (TEE) and contrast transthoracic echocardiography (cTTE). The detection rate of cTTE and cTTE+TEE for PFO and right-to-left shunt (RLS) grade were compared, as well as their safety. And the score of paradoxical embolism (RoPE) scale, the inner diameter of PFO, the length of PFO were compared between the two groups. The receiver operating characteristic (ROC) curve and the area under the ROC (AUC) were used to analyze the diagnostic efficacy. The correlation between RoPE score, PFO inner diameter and RLS classification were also analyzed. The results showed that the 855 positive rate of PFO detected by cTTE+TEE (67.35%) was higher than that of cTTE (55.10%). The proportion of patients with RLS grade Ⅰ+Ⅱ+Ⅲ (64.63%) detected by cTTE+TEE was also higher than that of cTTE (53.06%). The highest AUC of RoPE score combined with the inner diameter of PFO in diagnosis of PFO-related CIS was 0.928, and RoPE score was positively correlated with inner diameter of PFO and RLS classification (P<0.05). In summary, cTTE combined with TEE can improve the detection rate of PFO and judge the degree of RLS collectly. RoPE score and inner diameter of PFO can be used for the diagnosis of PFO-RLS-related CIS.

Key words: transesophageal echocardiography, contrast transthoracic echocardiography, cryptogenic ischemic stroke, RoPE score, PFO inner diameter, ROC

段秉慧, 黄磊, 尹玉良, 许方芳, 陆雨晨. 经食管超声心动图联合右心声学造影诊断隐匿性脑卒中的应用[J]. 影像科学与光化学, 2020, 38(5): 855-861.

DUAN Binghui, HUANG Lei, YIN Yuliang, XU Fangfang, LU Yuchen. Application of Transesophageal Echocardiography Combined with Contrast Transthoracic Echocardiography in Diagnosis of Cryptogenic Ischemic Stroke[J]. Imaging Science and Photochemistry, 2020, 38(5): 855-861.

参考文献

[1] Tokunaga K, Yasaka M, Kuwashiro T, et al. Association between the maximal distance of atrial septal protrusion and cryptogenic stroke[J]. International Journal of Stroke, 2017, 12(9):941-945.
[2] 陈竹林,黄光. 卵圆孔未闭与隐源性卒中的研究进展[J]. 中国卒中杂志,2019,14(5):457-462.
[3] West B H, Noureddin N, Mamzhi Y, et al. Frequency of patent foramen ovale and migraine in patients with cryptogenic stroke[J]. Stroke, 2018, 49(5):1123-1128.
[4] 张传经,池菊芳,郑良荣,等. 隐源性卒中合并卵圆孔未闭的治疗进展[J]. 中华内科杂志,2019,58(9):701-704.
[5] Renard D, Ion I, Ricci JE, et al. Chronic small cortical cerebellar infarctions on MRI are associated with patent foramen ovale in young cryptogenic stroke[J]. Cerebrovascular Diseases, 2020, 49(1):105-109.
[6] Friedrich S, Ng P Y, Platzbecker K, et al. Patent foramen ovale and long-term risk of ischaemic stroke after surgery[J]. European Heart Journa, 2019, 40(11):914-924.
[7] Le Moigne E, Timsit S, Ben Salem D, et al. Patent foramen ovale and ischemic stroke in patients with pulmonary embo-lism:a prospective cohort study[J]. Annals of Internal Medicine, 2019, 170(11):756-763.
[8] Yang T, Butera G, Ouyang W B, et al. Percutaneous closure of patent foramen ovale under transthoracic echocardiography guidance-midterm results[J]. Journal of Thoracic Disease, 2019, 11(6):2297-2304.
[9] Han Y, Zhang X, Zhang F. Patent foramen ovale closure by using transesophageal echocardiography for cryptogenic stroke:single center experience in 132 consecutive patients[J]. Journal of Cardiothoracic Surgery, 2020, 15(1):11.
[10] Balouch M, Gucuk Ipek E, Chrispin J, et al. Trends in transesophageal echocardiography use, findings, and clinical outcomes in the era of minimally interrupted anticoagulation for atrial fibrillation ablation[J]. JACC:Clinical Electrophysiology, 2017, 3(4):329-336.
[11] Figueroa Córdoba A V, Bertazzo B B, Gonzalez Grima J, et al. Effectiveness of transthoracic echocardiogram in patent foramen ovale diagnosis. Systematic review of last ten years[J]. Rev Fac Cien Med Univ Nac Cordoba, 2019, 76(4):211-216.
[12] 王嶒,张健,范小明,等. 实时右心声学造影对卵圆孔未闭相关偏头痛的观察[J]. 心脑血管病防治,2018,18(3):192-195.
[13] 杨晓萌. 隐源性卒中与原因不明的栓塞性卒中[C]. 中华医学会第十七次全国神经病学学术会议论文汇编(上). 2014.
[14] 梅文丽. 伴发卵圆孔未闭的隐源性卒中的神经影像学特征分析[D]. 郑州:郑州大学,2017. 12-16.
[15] 冯坤. 3种不同手振激活声学造影剂在经胸超声心动图右心声学造影及经颅脑血管微泡试验中应用的对比研究[D]. 泸州:西南医科大学,2018.
[16] 袁树华,李艾帆,李永芳,等. RoPE量表结合cTCD对隐源性脑卒中的应用价值[J]. 卒中与神经疾病,2019,26(3):286-289.
[17] He L, Cheng G S, Du Y J, et al. Clinical relevance of atrial septal aneurysm and patent foramen ovale with migraine[J]. World Journal of Clinical Cases, 2018, 6(15):916-921.
[18] Moon J, Kim M, Oh P C, et al. Residual shunt after patent foramen ovale device closure in patients with cryptogenic stroke:serial bubble contrast transesophageal echocardiography data[J]. Journal of Stroke & Cerebrovascular Diseases, 2019, 28(2):347-353.
[19] Mirijello A, D'Errico M M, Curci S, et al. Paradoxical embolism with thrombus stuck in a patent foramen ovale:a review of treatment strategies[J]. European Review for Medical and Pharmacological Sciences, 2018, 22(24):8885-8890.
[20] Chu W, Wang H. Transesophageal echocardiography in cardiogenic embolic cerebral infarction[J]. Pakistan Journal of Medical Sciences, 2018, 34(1):58-61.
[21] Böjti P, Bartha N E, May Z, et al. Relationship between patent foramen ovale and cryptogenic stroke in a retrospective hospital-based study[J]. Ideggyogyaszati Szemle, 2018, 71(5-6):169-177.
[22] Mazzucco S, Li L, Binney L, et al. Prevalence of patent foramen ovale in cryptogenic transient ischaemic attack and non-disabling stroke at older ages:a population-based study, systematic review, and meta-analysis[J]. Lancet Neurology, 2018, 17(7):609-617.
[23] 孔学军, 柴青芬, 郭科, 等. 成人卵圆孔未闭超声检查及右心声学造影分析[J]. 中华医学杂志, 2017, 97(43):3380-3383.
[24] Vindiš D, Hutyra M, Šaňák D, et al. Patent foramen ovale and the risk of cerebral infarcts in acute pulmonary embolism-a prospective observational study[J]. Journal of Stroke & Cerebrovascular Diseases, 2018, 27(2):357-364.
[25] Takaya Y, Watanabe N, Ikeda M, et al. Importance of abdominal compression valsalva maneuver and microbubble grading in contrast transthoracic echocardiography for detecting patent foramen ovale[J]. Journal of the American Society of Echocardiography, 2020, 33(2):201-206.
[26] Chen J, Chen L, Hu W, et al. A comparison of contrast transthoracic echocardiography and contrast transcranial Doppler in cryptogenic stroke patients with patent foramen ovale[J]. Brain Behavior, 2019, 9(5):e01283.
[27] Zhao H, Yue Q, Wang T, et al. Sensitivity of contrast-enhanced transthoracic echocardiography for the detection of residual shunts after percutaneous patent foramen ovale closure[J]. Medicine (Baltimore), 2019, 98(4):e14276.
[28] Mahmoud A N, Elgendy I Y, Agarwal N, et al. Identification and quantification of patent foramen ovale-mediated shunts:echocardiography and transcranial doppler[J]. Journal of Interventional Cardiology, 2017, 6(4):495-504.
[29] Wang P, Chen S S, Li Y, et al. Value of the cough maneuver for detecting right-to-left shunt during contrast transthoracic echocardiography[J]. Echocardiography, 2019, 36(4):654-658.
[30] Maggiore P, Bellinge J, Chieng D, et al. Ischaemic stroke and the echocardiographic "bubble study":are we screening the right patients[J]. Heart Lung and Circulation, 2019, 28(8):1183-1189.