优化的cTCD联合cTTE同步检测在右向左分流诊断中的应用与效能评估

doi:10.3969/j.issn.1673-5765.2025.09.007

摘要/Abstract

摘要： 目的评估优化的对比增强经颅多普勒超声（contrast transcranial Doppler，cTCD）联合对比增强经胸超声心动图（contrast transthoracic echocardiography，cTTE）同步检测对右向左分流（right-to-left shunt，RLS）的诊断价值，并优化流程操作时机，量化瓦氏动作（Valsalva maneuver，VM）与静脉推注激活生理盐水的时间控制。
方法回顾性分析2023年9月—2024年9月在中南大学湘雅二医院因头晕、头痛、晕厥和不明原因型卒中接受RLS筛查的患者，根据检查策略将患者分为3组：优化同步组（进行优化的cTCD联合cTTE同步检测），优化单项组（进行优化cTCD检测），以及非优化单项组（进行传统cTCD检测）。比较各组RLS阳性检出率及分级分布情况。优化同步组中患者完善对比增强经食管超声心动图（contrast transesophageal echocardiography，cTEE）检查，以cTEE诊断卵圆孔未闭（patent foramen ovale，PFO）为金标准，比较优化的cTCD联合cTTE同步检测对PFO诊断及分级的一致性。统计优化后流程中VM与激活生理盐水注射的时间间隔及心动周期，分析各操作节点时间间隔与心动周期之间的相关性。
结果共纳入342例因头晕、头痛、晕厥、不明原因型卒中进行RLS筛查的患者，其中男性99例，女性243例，平均年龄为（38.3±14.8）岁。优化同步组（192例）及优化单项组（112例）RLS阳性率高于非优化单项组（38例）（78.12% vs. 47.37%，P＜0.001；58.93% vs. 47.37%，P＜0.001）。在完善cTEE检查的优化同步组121例患者中，111例存在由PFO引起的RLS（58例单纯由PFO引起的RLS，53例合并肺水平RLS），10例为单纯肺水平RLS，优化的cTCD联合cTTE同步检测与cTEE在PFO分级诊断中具有中等一致性（κ=0.44）。优化同步组在激活生理盐水开始推注到VM释放（简称推→V松）、VM释放后cTCD检测到第一个微气泡信号（简称V松→泡）的时间点控制上，展现出了良好的一致性与操作效率，推→V松和V松→泡的中位时间间隔分别为5.0 s和2.0 s，中位心动周期分别为7.0个和2.0个心动周期，各动作节点的时间间隔和心动周期呈正相关（推→V松：r=0.645，P＜0.001；V松→泡：r=0.827，P＜0.001）。
结论优化的cTCD联合cTTE同步检测RLS的阳性检出率高于优化cTCD单项检测与传统cTCD单项检测，具有较高的操作指导价值。

文章导读： 本研究总结了超声检查RLS时，优化的瓦式动作流程与激活生理盐水推注的最佳时间节点，研究结果支持对疑诊RLS的患者进行优化的cTCD联合cTTE同步检测，必要时进行cTEE检测以提高检测的准确性。

关键词: 对比增强经颅多普勒超声; 对比增强经胸超声心动图; 对比增强经食管超声心动图; 右向左分流

Abstract: Objective To evaluate the diagnostic value of optimized contrast transcranial Doppler (cTCD) combined with contrast transthoracic echocardiography (cTTE) in synchronous detection of right-to-left shunt (RLS), optimize the procedural timing, and quantify the timing control between the Valsalva maneuver (VM) and intravenous injection of agitated saline.
Methods A retrospective analysis was conducted on patients who underwent RLS screening at the Second Xiangya Hospital of Central South University from September 2023 to September 2024 due to dizziness, headache, syncope, or cryptogenic stroke. Patients were divided into three groups according to the examination strategy: the optimized synchronous group (underwent optimized cTCD combined with cTTE synchronous detection), the optimized cTCD group (underwent optimized cTCD alone), and the non-optimized cTCD group (underwent conventional cTCD alone). The positive rate and grading distribution of RLS were compared among the groups. In the optimized synchronous group, patients underwent contrast transesophageal echocardiography (cTEE), which was used as the gold standard for diagnosing patent foramen ovale (PFO). The consistency of optimized cTCD combined with cTTE synchronous detection in the diagnosis and grading of PFO was evaluated. The time intervals between the VM and injection of agitated saline, as well as the cardiac cycle, were recorded in the optimized protocol. The correlation between these procedural time intervals and cardiac cycles was analyzed.
Results A total of 342 patients who underwent RLS screening due to dizziness, headache, syncope, or cryptogenic stroke were included in the study. Among them, 99 were male and 243 were female, with a mean age of (38.3±14.8) years. The positive rates of RLS in the optimized synchronous group (192 patients) and the optimized cTCD group (112 patients) were higher than that in the non-optimized cTCD group (38 patients) (78.13% vs. 47.37%, P<0.001; 58.93% vs. 47.37%, P<0.001). Among the 121 patients in the optimized synchronous group who completed cTEE examination, 111 had RLS caused by PFO (58 with RLS solely from PFO and 53 with combined pulmonary-level RLS), and 10 had isolated pulmonary-level RLS. The optimized synchronous cTCD combined with cTTE synchronous detection showed moderate consistency with cTEE in PFO grading (κ=0.44). The optimized synchronous group demonstrated good consistency and procedural efficiency in timing control, with median time intervals of 5.0 seconds (7.0 median cardiac cycles) from the start of agitated saline injection to VM release (injection→VM release), and 2.0 seconds (2.0 median cardiac cycles) from VM release to the first microbubble detection by cTCD (VM release→bubble). The time intervals between procedural points and cardiac cycles showed positive correlations (injection→VM release: r=0.645, P<0.001; VM release→bubble: r=0.827, P<0.001).
Conclusions The optimized cTCD combined with cTTE synchronous detection showed a higher positive rate of RLS compared to optimized cTCD alone or conventional cTCD alone, demonstrating superior procedural guidance.

Key words: Contrast transcranial Doppler; Contrast transthoracic echocardiography; Contrast transesophageal echocardiography; Right-to-left shunt

中图分类号:

R74
R445

王昶仑, 刘艳君, 艾祁, 吴勤, 占雅静. 优化的cTCD联合cTTE同步检测在右向左分流诊断中的应用与效能评估[J]. 中国卒中杂志, 2025, 20(9): 1121-1130.

WANG Changlun, LIU Yanjun, AI Qi, WU Qin, ZHAN Yajing. Application and Efficacy Evaluation of Optimized cTCD and cTTE Synchronous Detection in the Diagnosis of Right-to-Left Shunt[J]. Chinese Journal of Stroke, 2025, 20(9): 1121-1130.

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