Research progress on right-to-left shunt associated cryptogenic stroke

doi:10.3877/cma.j.issn.1673-9248.2025.06.014

Abstract

Abstract:

With rising living standards and accelerated population aging, stroke has become the leading cause of premature death in China. Among all patients with ischemic stroke, about 30% of patients lack a clearly identifiable cause of the disease, known as cryptogenic stroke. In recent years, it has been found that right-to-left shunt (RLS) is closely related to cryptogenic stroke. This article reviews the recent progress in the study of the relationship between RLS and cryptogenic stroke.

Key words: Right-to-left shunt, Patent foramen ovale, Cryptogenic stroke

Cheng Huang, Haizhou Qian, Li Wang. Research progress on right-to-left shunt associated cryptogenic stroke[J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2025, 19(06): 546-549.

/ / Recommend

Add to citation manager EndNote|Ris|BibTeX

URL: https://zhnxgbzz.cma-cmc.com.cn/EN/10.3877/cma.j.issn.1673-9248.2025.06.014

https://zhnxgbzz.cma-cmc.com.cn/EN/Y2025/V19/I06/546

References 37

1	《中国脑卒中防治报告2021》编写组. 《中国脑卒中防治报告2021》概要 [J]. 中国脑血管病杂志, 2023, 20(11): 783-792．
2	Gu HQ, Yang X, Wang CJ, et al. Clinical characteristics, management, and in-hospital outcomes in patients with stroke or transient ischemic attack in China [J]. JAMA Netw Open, 2021, 4(8): e2120745.
3	Adams HP, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in acute stroke treatment [J]. Stroke, 1993, 24(1): 35-41.
4	Mac Grory B, Flood SP, Apostolidou E. Cryptogenic stroke: diagnostic workup and management [J]. Curr Treat Options Cardiovasc Med, 2019, 21: 77.
5	Tian L, Zhang M, Nie HJ, et al. Contrast-enhanced transcranial doppler versus contrast transthoracic echocardiography for right-to-left shunt diagnosis [J]. J Clin Monit Comput, 2023, 37(5): 1145-1151.
6	Wang SB, Liu KD, Yang Y, et al. Prevalence and extent of right-to-left shunt on contrast-enhanced transcranial doppler in chinese patients with migraine in a multicentre case-control study [J]. Cephalalgia, 2018, 38(4): 690-696.
7	Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts [J]. Mayo Clin Proc, 1984, 59(1): 17-20.
8	Giampiero V, Fausto P, Dianne Z, et al. Patent foramen ovale: anatomical complexity and long-tunnel morphology related issues [J]. Am J Cardiovasc Dis, 2021, 11(3): 316-329.
9	Naqvi N, McCarthy KP, Ho SY. Anatomy of the atrial septum and interatrial communications [J]. J Thorac Dis, 2018, 10(Suppl 24): S2837-S2847.
10	Yap CW, Wee BBK, Yee SY, et al. The role of interventional radiology in the diagnosis and treatment of pulmonary arteriovenous malformations [J]. J Clin Med, 2022, 11(21): 6282.
11	Mitra S, de Boode WP, Weisz DE, et al. Interventions for patent ductus arteriosus (PDA) in preterm infants: an overview of Cochrane Systematic Reviews [J]. Cochrane Database Syst Rev, 2023, 4(4): CD01588.
12	Shi FF, Sha LH, Li H, et al. Recent progress in patent foramen ovale and related neurological diseases: a narrative review [J]. Front Neurol, 2023, 14: 1129062.
13	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]. J Am Soc Echocardiogr, 2020, 33(2): 201-206.
14	Van H, Poommipanit P, Shalaby M, et al. Sensitivity of transcranial Doppler versus intracardiac echocardiography in the detection of right-to-left shunt [J]. JACC Cardiovasc Imaging, 2010, 3(4): 343-348.
15	Maillet A, Pavero A, Salaun P, et al. Transcranial doppler to detect right to left communication: evaluation versus transesophageal echocardiography in real life [J]. Angiology, 2018, 69(1): 79-82.
16	Zhang WJ, Yang L, Wang SL, et al. Comparison of unilateral middle cerebral artery and bilateral middle cerebral artery monitoring for right-to-left shunt detection by contrast-enhanced transcranial Doppler [J]. Front Neurol, 2022, 13: 891060.
17	Rubin MN, Shah R, Devlin T, et al. Robot-assisted transcranial Doppler versus transthoracic echocardiography for right to left shunt detection [J]. Stroke, 2023, 54(11): 2842-2850.
18	Song JK. Pearls and pitfalls in the transesophageal echocardiographic diagnosis of patent foramen ovale [J]. J Am Soc Echocardiogr, 2023, 36(9): 895-905.
19	Lee M, Oh JH. Echocardiographic diagnosis of right-to-left shunt using transoesophageal and transthoracic echocardiography [J]. Open Heart, 2020, 7(2): e001150.
20	Yao QY, Xiong HH, Zhang DX, et al. Synchronous multimode ultrasound for assessing right-to-left shunt: a prospective clinical study [J]. Front Neurol, 2023, 14: 1148846.
21	Silvestry FE, Cohen MS, Armsby LB, et al. Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for cardiac angiography and interventions [J]. J Am Soc Echocardiogr, 2015, 28(8): 910-958.
22	Shah S, Malik P, Patel U, et al. Diagnostic yield of TEE in patients with cryptogenic stroke and TIA with normal TTE: a systematic review and meta-analysis [J]. Neurol Int, 2021, 13(4): 659-670.
23	Kramdhari H, Valakkada J, Ayyappan A. Diagnosis and endovascular management of pulmonary arteriovenous malformations [J]. Br J Radiol, 2021, 94(1123): 20200695.
24	Koutroulou I, Tsivgoulis G, Tsalikakis D, et al. Epidemiology of patent foramen ovale in general population and in stroke patients: a narrative review [J]. Front Neurol, 2020, 11: 281.
25	Chen L, Deng W, Palacios I, et al. Patent foramen ovale (PFO), stroke and pregnancy [J]. J Investig Med, 2016, 64(5): 992-1000.
26	Lee PH, Song JK, Kim JS, et al. Cryptogenic stroke and high-risk patent foramen ovale: the DEFENSE-PFO trial [J]. J Am Coll Cardiol, 2018, 71(20): 2335-2342.
27	Nakayama R, Takaya Y, Akagi T, et al. Identification of high-risk patent foramen ovale associated with cryptogenic stroke: development of a scoring system [J]. J Am Soc Echocardiogr, 2019, 32(7): 811-816.
28	He D, Li Q, Xu G, et al. Clinical and imaging characteristics of Pfo-related stroke with different amounts of right-to-left shunt [J]. Brain Behav, 2018, 8(11): e01122.
29	He L, Cheng GC, Du YJ, et al. Importance of persistent right-to-left shunt after patent foramen ovale closure in cryptogenic stroke patients [J]. Tex Heart Inst J, 2020, 47(4): 244-249.
30	Zuin M, Rigatelli G, Rigatelli A, et al. Correlations between serum homocysteine levels and RoPE score in patients with patent foramen ovale [J]. Heart Vessels, 2020, 35(5): 705-711.
31	Sposato LA, Albin CSW, Elkind MSV, et al. Patent foramen ovale management for secondary stroke prevention: state-of-the-art appraisal of current evidence [J]. Stroke, 2024, 55(1): 236-247.
32	Patti G, Pelliccia F, Gaudio C, et al. Meta-analysis of net long-term benefit of different therapeutic strategies in patients with cryptogenic stroke and patent foramen ovale [J]. Am J Cardiol, 2015, 115(6): 837-843.
33	Messé SR, Gronseth GS, Kent DM, et al. Practice advisory update summary: patent foramen ovale and secondary stroke prevention: report of the Guideline Subcommittee of the American Academy of Neurology [J]. Neurology, 2020, 94(20): 876-885.
34	Kasner SE, Rhodes JF, Andersen G, et al. Five-year outcomes of PFO closure or antiplatelet therapy for cryptogenic stroke [J]. N Engl J Med, 2021, 384(10): 970-971.
35	Kent DM, Saver JL, Kasner SE, et al. Heterogeneity of treatment effects in an analysis of pooled individual patient data from randomized trials of device closure of patent foramen ovale after stroke [J]. JAMA, 2021, 326(22): 2277-2286.
36	Favilla CG, Messé SR. Patent foramen ovale and stroke: current evidence and treatment options [J]. Curr Opin Neurol, 2020, 33(1): 10-16.
37	Caso V, Turc G, Abdul-Rahim AH, et al. European Stroke Organisation (ESO) Guidelines on the diagnosis and management of patent foramen ovale (PFO) after stroke [J]. Eur Stroke J, 2024, 16: 23969873241247978.

[1]	Hongyu Tao, Jingjing Ye, Jin Yu, Xiuzhen Yang, Jingjing Qian, Bin Xu, Weize Xu, Qiang Shu. Value of contrast transthoracic echocardiography in assessing right-to-left shunt-related diseases in children [J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2024, 21(10): 959-965.
[2]	Ying Kong, Pinjing Hui, Yafang Ding, Bingyuan Zhou. Clinical significance of contrast-enhanced transcranial Doppler based multimodal ultrasound in assessing right-to-left shunt associated with patent foramen ovale [J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2024, 21(04): 345-351.
[3]	Hongmei Zhang, Chunmei Li, Yi Wang, Qingfeng Zhang, Geqi Ding, Yan Deng, Ni Lin, Wenhua Li, Lixue Yin. Value of different right atrial pressurization methods in evaluating occult right to left shunt of patent foramen ovale by contrast transthoracic echocardiography [J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2022, 19(06): 508-513.
[4]	Juyi Fu, Pinjing Hui, Yafang Ding, Yanhong Yan, Bai Zhang, Yongming He, Qi Fang. Feasibility of evaluating right-to-left shunt by contrast-enhanced transcranial Doppler [J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2020, 17(03): 255-261.
[5]	Siqing Ma, Siwei Chen, Tianyi Wu. Research progress of patent foramen ovale and high-altitude pulmonary edema [J]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), 2017, 03(04): 308-311.
[6]	Jiali Tian, Xiaobo Chen. Analysis of the influence of tunnel characteristics of patent foramen ovale on interventional closure [J]. Chinese Journal of Interventional Radiology(Electronic Edition), 2023, 11(04): 346-351.
[7]	Yongzhan Song, Baolong Liu, Ping Wang, Dengming Zhou, Yongsheng Liu. Single center experience in occlusive treatment of patent foramen ovale [J]. Chinese Journal of Heart and Heart Rhythm(Electronic Edition), 2024, 12(02): 94-101.
[8]	Yuxuan Lou, Yang Hua, Fengze Yang, Jing Shi, Wei Sun, Xiangqing Kong. Characteristics of patients with atrial septal defect presenting with neurological symptoms and the efficacy of occlusion [J]. Chinese Journal of Heart and Heart Rhythm(Electronic Edition), 2022, 10(02): 84-87.
[9]	Dewei Wu, Xiuling Wang, Chenglong Guo, Yanyan Chu, Jing Gao, Yubin Wang, Chunlin Yin. Relationship between CT pulmonary angiography-undetectable pulmonary arteriovenous communications and cardioembolic embolism [J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2025, 19(03): 207-212.
[10]	Xinpeng Jiang, Xiaoming Li, Hang Yang, Yichen Gong, Yuanhao Fu, Yu Fu, Zhe Zhang. Evaluation of the safety and efficacy of patent foramen ovale closure guided by transthoracic echocardiography [J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2023, 17(04): 320-324.
[11]	Chenjun Yin, Zhe Zhang, Xiaoming Li. Advance in mechanisms of patent foramen ovale-associated thrombosis [J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2023, 17(04): 307-311.
[12]	Junyan Huo, Yu Fu. Clinical application of detection methods for patent foramen ovale [J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2022, 16(05): 310-313.
[13]	Xinpeng Jiang, Zhe Zhang. Research status of the radiographic features of patients with cryptogenic cerebral infarction related to patent foramen ovale [J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2021, 15(02): 112-114.
[14]	Xin Zhao, Yan Deng. Research progress in Patent foramen ovale and cryptogenic stroke [J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2020, 14(03): 163-166.
[15]	Wenjun Zhou, Jin Lin, Xinpeng Jiang, Hang Yang, Yichen Gong, Yuanhao Fu, Qingli Sun, Yu Fu, Xiaogang Li, Jieli Feng, Xinhang Feng, Xiaoming Li, Zhe Zhang. Clinical efficacy of solo transcatheter closure of patent foramen ovale guided by transthoracic echocardiography [J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2020, 14(02): 100-103.

Please choose a citation manager

Content to export