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From the Department of Neurology (Drs. Hamann, Strittmatter, Jost, and Schimrigk) and Cardiology (Drs. Schätzer-Klotz, Fröhlig, and Schieffer, G. Berg and M. Stopp), University of the Saarland, Homburg-Saar, Germany.
Address correspondence and reprint requests to Dr. Gerhard F. Hamann, Department of Neurology, Klinikum Großhadern, Ludwig-Maximilians-University, Marchioninistr. 15, D-83177 Munich, Germany.
Objective: The diagnosis of a patent foramen ovale (PFO) as a cause of stroke is of increasing interest especially in young (<45 years) patients.
Methods: We studied potential right-to-left shunting using transesophageal echocardiography (TEE) and bilateral transcranial Doppler sonography (TCD) of the middle cerebral artery (MCA) simultaneously in 44 patients. All patients were younger than age 45 and suffered from an acute ischemic stroke or transient ischemic attack. Other possible etiologies were excluded. Echo contrast medium was injected in an alternating mode via antecubital or femoral veins. Tests were performed with and without the Valsalva maneuver. The criteria for a PFO were that the contrast pass from the right to the left atrium (TEE) and early detection (<10 seconds) of more than 10 micro air bubbles in at least one MCA by TCD.
Results: A PFO was diagnosed in 22 patients (50%). The detection rate with TEE/TCD was 11.4%/4.5% via antecubital injection, 18%/13.6% via antecubital injection plus the Valsalva maneuver, 38.6%/36% via femoral injection alone, and 50%/50% via femoral injection plus the Valsalva maneuver. The difference between femoral and antecubital injections was significant with and without the Valsalva maneuver (p < 0.01, 
2 test). There were no differences between TEE and TCD after femoral injection with the Valsalva maneuver. The brain transit time was 4.6 ± 2.1 seconds for femoral injection and 6.3 ± 4.1 seconds for antecubital injection.
Conclusions: The sensitivity in detecting a PFO was markedly increased by femoral injection. This may be caused by different inflow patterns to the right atrium: inferior vena caval flow is directed to the right atrial septum, whereas superior vena caval flow is directed to the tricuspid valve. Thus, femoral injection may help to improve the detection of PFO and may explain the differences between TEE and TCD findings in previous studies.
Supported by an institutional grant from the Departments of Neurology and Cardiology, University of the Saarland, Germany.
Received May 5, 1997. Accepted in final form September 19, 1997.
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