Die kontrastmittelverstärkte transkranielle Doppler-Sonographie in der Diagnostik von Rechts-links-Shunts

Zusammenfassung

Paradoxe Hirnembolien über kardiale oder extrakardiale Rechts-links-Shunts sind eine häufig verkannte Ursache des ischämischen Insults bei jungen Erwachsenen unter 50 Jahren. Kardiale Rechts-links-Shunts können mittels transösophagealer Echokardiographie oder transkranieller Doppler-Sonographie identifiziert werden. Hierzu sind die Gabe intravenöser Ultraschallkontrastmittel und die Durchführung eines Provokationsmanövers zur Umkehr des intrakardialen Druckgefälles zwischen rechtem und linkem Kreislauf notwendig. Bislang vorliegende Studien verwendeten bei der Durchführung der Untersuchung teilweise unterschiedliche Kontrastmittel, wählten verschiedene Zeitpunkte zur Durchführung des Shunt-Provokationsmanövers nach Injektion des Kontrastmittels und benutzten uneinheitliche Auswertekriterien. Der vorliegende Artikel beleuchtet die Vor- und Nachteile dieser unterschiedlichen Verfahrensweisen und soll Hilfestellungen zur bestmöglichen praktischen Durchführung geben.

Abstract

Paradoxical brain embolism via cardiac or extracardiac right-to-left shunts is an underrecognised cause of stroke in young adults under the age of 50. Right-to-left-shunts can be identified by means of transoesophageal echocardiography or transcranial Doppler sonography. The application of ultrasound contrast media and the performance of a provocation manoeuvre to invert the intracardial pressure gradient are prerequisites for the evaluation of right-to-left shunts. The optimal protocol of performing transcranial Doppler investigation is a matter of debate. Protocols using different contrast media, provocation maneuvers, and evaluation criteria have been recommended. This paper addresses the pros and cons of the various technical approaches and provides practical recommendations for identifying right-to-left shunts using by transcranial Doppler ultrasound.

Ischaemic stroke - Paradoxical embolism - Right-to-left shunt - Transcranial Doppler ultrasound

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