TY - JOUR
TI - Transcranial Doppler versus transthoracic echocardiography for the detection of patent foramen ovale in patients with cryptogenic cerebral ischemia: A systematic review and diagnostic test accuracy meta-analysis
AU - Katsanos, A.H.
AU - Psaltopoulou, T.
AU - Sergentanis, T.N.
AU - Frogoudaki, A.
AU - Vrettou, A.-R.
AU - Ikonomidis, I.
AU - Paraskevaidis, I.
AU - Parissis, J.
AU - Bogiatzi, C.
AU - Zompola, C.
AU - Ellul, J.
AU - Triantafyllou, N.
AU - Voumvourakis, K.
AU - Kyritsis, A.P.
AU - Giannopoulos, S.
AU - Alexandrov, A.W.
AU - Alexandrov, A.V.
AU - Tsivgoulis, G.
JO - Annals of Neurology
PY - 2016
VL - 79
TODO - 4
SP - 625-635
PB - John Wiley and Sons Inc
SN - 0364-5134, 1531-8249
TODO - 10.1002/ana.24609
TODO - area under the curve;  Article;  brain ischemia;  cryptogenic cerebral ischemia;  diagnostic accuracy;  diagnostic test accuracy study;  diagnostic value;  echocardiograph;  gold standard;  human;  intermethod comparison;  meta analysis;  patent foramen ovale;  priority journal;  receiver operating characteristic;  sensitivity and specificity;  stroke patient;  systematic review;  transcranial doppler;  transcranial Doppler ultrasonography;  transthoracic echocardiography;  brain ischemia;  comparative study;  echocardiography;  echography;  patent foramen ovale;  sensitivity and specificity;  standards;  transcranial Doppler ultrasonography, Brain Ischemia;  Echocardiography;  Foramen Ovale, Patent;  Humans;  Sensitivity and Specificity;  Ultrasonography, Doppler, Transcranial
TODO - Objective Patent foramen ovale (PFO) can be detected in up to 43% of patients with cryptogenic cerebral ischemia undergoing investigation with transesophageal echocardiography (TEE). The diagnostic value of transthoracic echocardiography (TTE) in the detection of PFO in patients with cryptogenic ischemic stroke or transient ischemic attack has not been compared with that of transcranial Doppler (TCD) using a comprehensive meta-analytical approach. Methods We performed a systematic literature review to identify all prospective observational studies of patients with cryptogenic cerebral ischemia that provided both sensitivity and specificity measures of TTE, TCD, or both compared to the gold standard of TEE. Results Our literature search identified 35 eligible studies including 3,067 patients. The pooled sensitivity and specificity for TCD was 96.1% (95% confidence interval [CI] = 93.0-97.8%) and 92.4% (95% CI = 85.5-96.1%), whereas the respective measures for TTE were 45.1% (95% CI = 30.8-60.3%) and 99.6% (95% CI = 96.5-99.9%). TTE was superior in terms of higher positive likelihood ratio values (LR+ = 106.61, 95% CI = 15.09-753.30 for TTE vs LR+ = 12.62, 95% CI = 6.52-24.43 for TCD; p = 0.043), whereas TCD demonstrated lower negative likelihood values (LR- = 0.04, 95% CI = 0.02-0.08) compared to TTE (LR- = 0.55, 95% CI = 0.42-0.72; p < 0.001). Finally, the area under the summary receiver operating curve (AUC) was significantly greater (p < 0.001) in TCD (AUC = 0.98, 95% CI = 0.97-0.99) compared to TTE studies (AUC = 0.86, 95% CI = 0.82-0.89). Interpretation TCD is more sensitive but less specific compared to TTE for the detection of PFO in patients with cryptogenic cerebral ischemia. The overall diagnostic yield of TCD appears to outweigh that of TTE. ©2016 American Neurological Association.
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