• Utilidad del doppler transcraneal en la detección del shunt derecho-izquierdo

    La embolia paradójica secundaria a foramen oval permeable es una causa de infarto cerebral en jóvenes, y la presencia de aneurismas del septo auricular incrementan aún mas el riesgo de ictus. (Cabanes et al; 1993, Molins et al; 1996). De igual forma se ha podido demostrar una excelente correlación (mas del 95%) entre los estudios de DTC con contraste y la ecocardiografía transesofágica (ETE) para la detección de shunt derecho-izquierdo.(Molins; 1996, Mas JL; 2001). Por una parte, el DTC con contraste (solución salina agitada + aire o ecocontraste ECOVIST-molécula mayor a 9 micras de díametro-) tiene algunas ventajas sobre el ETE. En algunos estudios se ha visto que tiene una mayor sensibilidad que el ETE ya que puede detectar “shunts” derecha-izquierda cardiacos y extra-cardiacos (shunts arterio-venoso de origen pulmonar; mas raros) y con el DTC se puede tener una mejor colaboración del paciente para realizar la maniobra de valsalva (que incrementa significativamente la sensibilidad y especificidad diagnóstica), a diferencia del ETE donde habitualmente los pacientes colaboran con mas dificultad por el uso de sedantes (Medina et al; 2010, Jauss M et al; 2000). Sin embargo, El ETE aporta información anatómica mas precisa y determina la presencia o no de aneurisma del septo que puede condicionar el tratamiento preventivo en la isquemia cerebral (Fuentes B et al; 2006, Sloan; 2004). Se han descrito algunas clasificaciones que relacionan el número de microburbujas (MB) obtenidas por DTC con el mayor o menor calibre del paso a través del foramen oval (Molins et al;1996, Gauss y Zanette E; 2000). Clásicamente se aceptan 4 categorías: Negativo (ninguna MB), aisladas (1-10 MB), patrón en ducha (10-20 MB), patrón cortina(>20 MB que no se pueden distinguir adecuadamente unas de otras). Los patrones ducha y cortina se asocian a un foramen oval permeable de mayor tamaño y en ocasiones a eventos clínicamente significativos. (Figura 7) (Ver Figura 7 jpg). 

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