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Objective The objective of this study is to find out whether gadolinium accumulation in the dentate nucleus (DN) after repeated gadolinium-based contrast agent (GBCA) administration in multiple sclerosis (MS) patients is related to tissue alteration detectable on transcranial ultrasound. Methods In this case–control study, 34 patients (17 with, and 17 age-, sex-, MS severity-, and duration-matched participants without visually rated DN T1-hyperintensity) who had received 2–28 (mean, 11 ± 7) consecutive 1.5-Tesla MRI examinations with application of linear GBCA were included. Real-time MRI-ultrasound fusion imaging was applied, exactly superimposing the DN identified on MRI to calculate its corresponding echo-intensity on digitized ultrasound image analysis. In addition, cerebellar ataxia and cognitive performance were assessed. Correlation analyses were adjusted for age, MS duration, MS severity, and time between MRI scans. Results DN-to-pons T1-signal intensity-ratios (DPSIR) were larger in patients with visually rated DN T1-hyperintensity compared to those without (1.16 ± 0.10 vs 1.09 ± 0.06; p = 0.01). In the combined group, DPSIR correlated with the cumulative linear-GBCA dose (r = 0.49, p = 0.003), as did the DPSIR change on last versus first MRI (r = 0.59, p = 0.003). Neither DPSIR nor globus pallidus internus-to-thalamus T1-signal intensity-ratios were related to echo-intensity of corresponding ROI’s. DPSIR correlated with the dysarthria (r = 0.57, p = 0.001), but no other, subscore of the International Cooperative Ataxia Rating Scale, and no other clinical score. Conclusions DN gadolinium accumulation is not associated with trace metal accumulation, calcification, or other tissue alteration detectable on ultrasound. A possible mild effect of DN gadolinium accumulation on cerebellar speech function in MS patients, suggested by present data, needs to be validated in larger study samples.

Objective. To increase the effectiveness of neurological evaluation in detecting traumatic intracranial injures in children under 18 years old with clinical criteria of mild traumatic brain injury. Materials and methods. Clinical and clinical-sonographic evaluations of 256 patients aged 0-18 years with clinical criteria of mild traumatic brain injury were performed. Depending of detected clinical and neurological risk factors and the results of the primary clinical and sonographic examination, children were divided into two groups: group I (high or medium risk of traumatic intracranial injury) – 174 (67.9%), group II (low/no risk of traumatic intracranial injury) – 82 (32.1%). Verification of important traumatic and non-traumatic intracranial changes revealed by primary sonographic exam was confirmed by using computerized tomography. Results and conclusion. Identification of traumatic intracranial injures by results of primary clinical examination is most effective when two or more higher or medium risk factors were detected. Application of primary clinical and sonographic examination increases diagnostic efficiency of neurological evaluation to 10.1% and the possibility of detecting traumatic intracranial injures to 57.1%. In 7.0% of cases emergency computed tomography were determined, dynamic observation was performed in 32.1% of cases. Significant non-traumatic brain diseases (cysts, hydrocephalus, congenital malformations) were diagnosed in 3.6% of cases by results primary clinical and sonographic examination.

Demonstrate that transcranial ultrasonography (TUS) scanning is viable and useful as a diagnostic method in experimental hydrocephalus, as well as to compare measurements of cerebral and ventricular width obtained from TUS scans of hydrocephalic rats with post-mortem anatomical specimens, aiming for the development of accurate criteria to establish ventricular enlargement and progression of hydrocephalus subsequently. Thirty-five male Wistar rats were used. Following hydrocephalus induction, they underwent a transcranial ultrasound scan to measure cerebral and ventricular dimensions, in the fourth and 21 post-induction days. By the end of the experiments, measurements obtained from TUS scans were compared with actual values as seen in the post-mortem specimens of each animal. Ventricular dilation could be clearly visualized in hydrocephalic animals. We performed intraclass correlation coefficient and linear regression analyses that have demonstrated a precise correlation between measurements of TUS scans and post-mortem specimens; we have found a similarity of 0,95 for the cerebral diameter and 0,97 for ventricular width. Transcranial ultrasonography is a useful and reliable diagnostic tool for experimental hydrocephalus; also, it can be used to assess the progression of ventriculomegaly in animal models of hydrocephalus.

OBJECTIVES Transcranial ultrasonography (US) is a relatively new neuroimaging modality proposed for early diagnostics of Parkinson disease (PD). The main limitation of transcranial US image-based diagnostics is a high degree of subjectivity caused by low quality of the transcranial images. The article presents a developed image analysis system and evaluates the potential of automated image analysis on transcranial US. METHODS The system consists of algorithms for the segmentation and assessment of informative brain regions (midbrain and substantia nigra) and a decision support subsystem, which is equipped with 64 classification algorithms. Transcranial US images of 191 participants (118 patients with a clinical PD diagnosis and 73 healthy control participants) were analyzed. RESULTS The diagnostic sensitivity and specificity achieved by the proposed system were 85% and 75%, respectively. CONCLUSIONS Digital transcranial US image analysis is challenging, and the application of a such system as the sole instrument for decisions in clinical practice remains inconclusive. However, the proposed system could be used as a supplementary tool for automated assessment of US parameters for decision support in PD diagnostics and to reduce observer variability.

Background. The intracranial changes in children with mild traumatic brain injury in acute period are identified by a combination of clinical-neurological and ultrasonographic evaluations of the condition severity. Aim. The aim of the study was to assess the possibility of performing comprehensive clinical and ultrasonographic evaluations in for determining the severity of the neurological condition of children with mild traumatic brain injury in an acute phase. Materials and Methods. Clinical and ultrasonographic assessment of the severity of the neurological condition was performed on 256 patients with clinical criteria suggesting mild traumatic brain injury. Ultrasonography was used as the main neuroimaging. Results. We found that the diagnostic sensitivity of clinical and ultrasonographic examination for detecting traumatic structural intracranial changes in children with mild traumatic brain injury was 90% (95% confidence interval [CI] 0.71–0.98), diagnostic specificity was 97% (95% CI 0.96–0.98), and diagnostic efficiency was 94.9% (95% CI 0.918–0.971). Conclusions. A comprehensive clinical ultrasonographic approach can be effectively used to assess the severity of the neurological condition of children with mild traumatic brain injury in the acute phase.

Objective: Current study aimed toward the early prediction of neonatal intraventricular hemorrhage (IVH) for better management and prognosis. Methods: This prospective study was conducted on forty neonates at the Neonatal Intensive Care Unit of Pediatrics and Medical Biochemistry department (Tanta University, Egypt) from July 2016 to June 2017. Cord blood erythropoietin and venous blood Activin A were assayed within the first hour of life. Neonates were divided into 2 groups: Group 1 (with IVH) included twenty neonates who developed IVH proved by transcranial ultrasonography (u/s) and Group 2 (without IVH) included twenty neonates who were admitted to the NICU but did not develop IVH, also proved by transcranial u/s. Data were analyzed using Chi Square and t-test. Results: Group 1 had a significantly higher cord blood erythropoietin concentration than group 2 (46.75±27.98 mIU/mL vs. 18.82±8.91 mIU/mL), respectively (p

Introduction A number of pre-hospital clinical assessment tools have been developed to triage subjects with acute stroke due to large vessel occlusion (LVO) to a specialised endovascular centre, but their false negative rates remain high leading to inappropriate and costly emergency transfers. Transcranial ultrasonography may represent a valuable pre-hospital tool for selecting patients with LVO who could benefit from rapid transfer to a dedicated centre. Methods Diagnostic accuracy of transcranial ultrasonography in acute stroke was subjected to systematic review. Medline, Embase, PubMed, Scopus, and The Cochrane Library were searched. Published articles reporting diagnostic accuracy of transcranial ultrasonography in comparison to a reference imaging method were selected. Studies reporting estimates of diagnostic accuracy were included in the meta-analysis. Results Twenty-seven published articles were selected for the systematic review. Transcranial Doppler findings, such as absent or diminished blood flow signal in a major cerebral artery and asymmetry index ≥ 21% were shown to be suggestive of LVO. It demonstrated sensitivity ranging from 68 to 100% and specificity of 78–99% for detecting acute steno-occlusive lesions. Area under the receiver operating characteristics curve was 0.91. Transcranial ultrasonography can also detect haemorrhagic foci, however, its application is largely restricted by lesion location. Conclusions Transcranial ultrasonography might potentially be used for the selection of subjects with acute LVO, to help streamline patient care and allow direct transfer to specialised endovascular centres. It can also assist in detecting haemorrhagic lesions in some cases, however, its applicability here is largely restricted. Additional research should optimize the scanning technique. Further work is required to demonstrate whether this diagnostic approach, possibly combined with clinical assessment, could be used at the pre-hospital stage to justify direct transfer to a regional thrombectomy centre in suitable cases.

Objective Several studies have shown an increased prevalence of right-to-left shunt (RLs) in migraine patients, particularly those with aura. However, the prevalence of RLs and its relation to Japanese patients with migraine are unknown. We investigated the prevalence of RLs in Japanese patients with migraine. Methods In total, 112 consecutive patients with migraine were recruited from our headache outpatient clinic. Migraine with aura (MA) and migraine without aura (MWOA) were diagnosed according to the International Classification of Headache Disorders, 3rd edition (beta-version). Contrast transcranial Doppler ultrasound was used to detect RLs, including patent foramen ovale (PFO). Then, the associations between RLs and patients' backgrounds and presence of aura were assessed. Results The overall prevalence of RLs and PFO in migraine patients was 54.5% and 43.8%, respectively. The prevalence of RLs and PFO in the MA group were significantly higher than in the MWOA group (RLs, 62.9% vs. 44.0%, p=0.046; PFO, 54.8% vs. 30.0%, p=0.008). There were no marked differences in the prevalence of large, middle and small shunts between MA and MWOA patients. Compared with the MWOA patients, the MA patients were younger (p=0.013) and had early onset age (p=0.013) and increased prevalence of photophobia (p=0.008). Conclusion RLs were found in over half of the Japanese patients with migraine. Our study suggests a possible link between RLs and MA.

Introduction:Midline shift (MLS) in the brain is a life-threatening emergency, which requires immediate surgical intervention following diagnosis. Currently, CT Brain is accepted as the gold standard in detection of MLS. Unfortunately, the diagnosis may be delayed when the patient is unable to undergo a CT Brain immediately due to several reasons. This has led to a constant endeavor to identify and develop other methods for detection of MLS, among which Transcranial Sonography (TCS) is included.Aim:To validate point-of-care TCS for detection of MLS in neuro-emergency patients in the Emergency Department, and compare it to CT values of MLS.Methods:This double-blinded prospective study was conducted from March 2018 to August 2018 in the Emergency Department of VIMS Hospital, Salem. All patients above the age of 18 who required a CT Brain were included, and a TCS was performed. MLS on TCS was calculated by measuring the distance between the outer table of the skull and the third ventricle on both sides, through the temporal window using a 2.8 MHz Sector Probe. MLS on CT was defined as the difference between ideal midline and septum pellucidum.Results:A total of 87 patients were included in this study. The MLS (mean ± SD) was 0.21cm ± 0.31cm using TCS, and 0.20cm ± 0.34cm using CT. The Pearson’s correlation coefficient between CT and TCS was 0.97 (p < 0.01). The area under the ROC curve for detection of a significant MLS using TLS was 83.7%. Using 0.5cm as a cut-off, the sensitivity, specificity, and positive likelihood ratio were 86.7%, 98.6%, and 61.92, respectively.Discussion:This study concludes that Transcranial Sonography could detect Midline Shift with reasonable accuracy, and can be used as a point-of-care tool in the Emergency Department to facilitate early diagnosis of MLS and intervene accordingly in neuro-emergencies.

Uvod: Depresija je poremećaj raspoloženja koji izaziva perzistentno osećanje tuge i gubitka interesovanja. Uzrok depresije nije poznat, ali su populacione genetske studije pokazale da genetika ima uticaj na pojavu poremećaja. Do sada su izučavani mnogi polimorfizmi i nekoliko ih je pokazalo obećavajuće rezultate, tj. da verovatno utiču na povećanje podložnost za razvoj depresije. Među njima su i 5-HTTLPR polimorfizam gena za serotoninski transporter, Val66Met funkcionalni polimorfizam neurotropnog faktora dobijenog iz mozga (BDNF) i Val158Met funkcionalni polimorfizam katehol-Ometiltransferaze (COMT). Heterogenost rezultata dosadašnjih istraživanja depresije govori u prilog tome da aktuelna dijagnostička kategorija obuhvata više etiološki različitih poremećaja koji imaju sličnu kliničku sliku. Izučavanje interakcije polimorfizama i njihov uticaj na morfologiju može biti jedan od pristupa distinkciji među potencijalnim etiopatogenetskim tipovima depresije. Cilj: (1)Utvrđivanje da li postoje specifične interakcije ili akumulacije alela BDNF Val66Met, COMT Val158Met i SERT 5-HTTLPR funkcionalnih polimorfizama koje su češće kod pacijenata sa depresivnim poremećajem nego kod kontrola. (2) Utvrđivanje specifičnih kliničkih, sociodemografskih karakteristika ili specifičnih morfoloških (VBM, traktografija, debljina sive mase, transkranijalna ultrasonografija) parametara koji bi definisali patološke ili kliničke specifičnosti grupa pacijenata oformljenih prema njihovom genetskom profilu. Metod:Istraživanje je koncipirano kao hibridna studija, koja se zasnivala na studiji preseka i studiji slučajeva i kontrola. U studijsku grupu uključeno je 85 konsekutivnih, hospitalizovanih pacijenata Instituta za mentalno zdravlje (Beograd), kojima je postavljena klinička dijagoza prve depresivne epizode ili rekurentnog depresivnog poremećaja (F32 i F33 prema MKB-10 klasifikaciji), starosti od 18 do 65 godina... Introduction: Depression is a mood disorder caused by persistent feeling of sadness and loss of interest. The cause of depression has not yet been elucidated, but the population genetic studies have shown the impact of genetics on the occurrence of this disorder. So far numerous polymorphisms have been investigated and several yielded positive results, i.e. they probably increase the proneness to development of depression. Among them are the 5-HTTLPR functional polymorphism for serotonin transporter, Val66Met functional polymorphism of brain-derived neurotrophic factor (BDNF) and Val158Met functional polymorphism of catechol-O-methyl-transferase (COMT). Heterogeneity of results of previous depression studies suggests that the current diagnostic category comprises several etiologically different disorders with similar clinical presentation. Study of interaction of the polymorphisms and their impact on morphology can be an approach to differentiate among the potential etiopathogenetic types of depression. Aim: (1) To establish possible specific interactions or accumulation of alleles BDNF Val66Met, COMT Val158Met and SERT 5-HTTLPR of functional polymorphisms that are more common in patients with depressive disorder than in controls. (2) To establish specific clinical, sociodemographic features or specific morphological (VBM, tractography, gray matter thickness, transcranial ultrasonography) parameters that may define pathological or clinical specificities of groups of patients composed by their respective genetic profiles. Method: The study has been designed as a hybrid one, based on cross-sectional study, case study and controls. The study group comprised 85 consecutive, in-patients at the Institute of Mental Health (Belgrade), diagnosed with the first depressive episode or recurrent depressive disorder (F32 and F33 acc. to ICD-10 classification), aged 18 to 65 years...

Streszczenie Rutynowo stosowane metody obrazowania ukladu nerwowego, takie jak tomografia komputerowa i tomografia rezonansu magnetycznego, sluzą glownie do wykluczania wtornych przyczyn schorzen pozapiramidowych. Nie są jednak istotnie przydatne w wykrywaniu zmian w obrebie jąder podstawy i pnia mozgu, szczegolnie we wczesnym okresie wystąpienia objawow idiopatycznych postaci tych chorob. Ostatnio podjeto proby stosowania przezczaszkowej ultrasonografii metodą duplex w diagnostyce obrazowej jąder podstawy. Metoda ta, z powodzeniem wykorzystywana w chorobach naczyn mozgu, pozwala takze uwidocznic niektore struktury miązszowe mozgowia. W pracy przedstawiono najwazniejsze odkrycia dotyczące obserwowanych w badaniu ultrasonograficznym zaburzen określonych struktur, w szczegolności hiperechogeniczności w obrebie istoty czarnej towarzyszącej chorobie Parkinsona.

Extracranial and transcranial colour-coded duplex sonography (TCCD) are used routinely in clinical practice to assess physiologic and pathologic arterial blood flow to the brain. Such investigations are straightforward, safe, and cost effective, and can be repeated frequently for patient follow-up. In addition, the portability of extracranial colour-coded duplex sonography and TCCD provides the option of bedside investigations, particularly useful for evaluation of the critically ill patient. However, duplex ultrasound can be hampered by insufficient acoustic penetration, an unfavourable insonation angle, or by conditions of low or no flow. Echocontrast agents capable of surviving pulmonary and capillary transit have been developed, and such agents increase the Doppler signal and, therefore, the success rate of neurosonographic investigations. Approximately 20% of TCCD studies involve poor insonation conditions and, therefore, the use of echocontrast agents is of particular interest for this application. Levovist® and SonoVue® are the two agents currently approved for use in neurosonography. Such agents have a relatively long-lasting effect (up to 7 min), and can be administered as a single injection or, alternatively, a fractionated injection protocol can be used, depending on the quality of the window.

Avaliaram-se 55 cães com distúrbios neurológicos e verificou-se a ocorrência de afecções neurológicas de origem central, detectadas pela ultra-sonografia transcraniana (USTC). Vinte e nove (52,9%) animais apresentaram diagnóstico compatível com hidrocefalia, e destes, 16 (55,1%) eram fêmeas e 15 (51,7%) tinham menos de dois anos. Quinze (27,3%) cães apresentaram lesões focais, quatro (7,2%), alterações difusas e quatro (7,2%) apresentavam imagens sugestivas de lissencefalia; em três (5,4%) não foram detectadas alterações pela USTC. A hidrocefalia foi o distúrbio neurológico de origem central mais freqüente e a USTC é uma alternativa viável para auxiliar na rotina clínica veterinária como ferramenta diagnóstica na detecção de alterações morfológicas e estruturais do cérebro no cão. In this work, 55 dogs with neurologycal disorder were examined and central neurological affections were detected by transcranial ultrasonography (TCUS). They were classifyed in hydrocephaly, lissencephaly, focal and difuse parenchimal disorders, and none changes. From the examinated dogs, 52.9% presented diagnosis compatible with hydrocephaly, being 55.1% female and 51.7% younger than 2 year-old. Fifteen dogs (27.3%) presented focal lesions, 7.2% diffuse lesions, 7.2% images that suggested lissencephaly, and in 5.4% no changes were detected by TCUS. It was concluded that hydrocephaly was the most frequent central neurologycal disorder and TCUS is a valuable alternative to be used in clinical routine as a tool of diagnostic to detect morphological and structural cerebral disorders in dogs.

Autism spectrum disorders (ASDs) are now recognized as urgent public health concerns with dramatically increased frequencies seen across Western countries for more than 2 decades (Baio, 2014). ASDs significantly impact on the quality of life for both patients and their families (Siniscalco et al., 2013). It has been estimated that the total lifetime societal cost of caring for one individual with ASDs is about $3.2 million US dollars (Siniscalco, 2013). The diagnosis of ASDs is based on the evaluation of social communication skills and behavior; currently there is no specific biomarker rendering a diagnosis potentially subjective. Recent changes with the DSM-5 diagnostic criteria illustrate the challenges clinicians face due to the lack of quantifiable diagnostic markers. The search for biomarkers is a priority in autism research and care (Siniscalco et al., 2012). The authors Bradstreet et al. (2014) used a novel imaging approach to detect abnormalities in the central nervous system of autistic subjects. The authors used a transcranial ultrasonography (TUS) imaging technique, that allowed the detection of abnormalities in extra-axial fluid production and cortical structures. Alternative brain imaging technologies such as MRI are generally expensive and invasive, especially for children with ASDs who need sedation to undergo such investigation. TUS resolution is potentially capable of observing structures as small as 0.1 mm and can detect a cortical abnormality up to a depth of several cm in order of magnitude. Using this approach the authors were able to identify a cortical dysplasia and increased extra-axial fluid presence in brains of autistic patients. These brain abnormalities correlated with autism severity. In addition, this study raised the possibility that the detected cortical abnormalities may be associated with impaired neurotransmissions which could underlie some of the cognitive abnormalities seen in ASDs. This very interesting technique is simple, reproducible, safe, and effective. It is non-invasive and presents the advantage of being inexpensive. It further has the potentials to enable real-time analysis of sub-arachnoidal and cortical brain regions. Functional imaging studies conducted in autism have shown consistently abnormalities of hypo-perfusion in the temporal lobe areas which may correlate with the degree of impairment. Unfortunately most ASD subjects do not have access to such analysis, due to limited access and cost. Clinicians are in need of fast, non-invasive, accurate and safe means to evaluate any potential structural brain abnormality, especially if such abnormalities correlate with mental and neurological dysfunctions. 2D TUS might offer such fast analysis of the upper brain anatomy. Whether this can assist with regard to diagnosis remains to be shown with larger scale investigations and comparison with age matched individuals suffering from other developmental abnormalities.

A widely under-recognized brain-death confirming transcranial ultrasonography pattern resembling the red-blue beacon signal was demonstrated. Familiarity to this distinct and characteristic ultrasonic pattern seems to be important in the perspective of point-of-care neurological ultrasound use and knobology.

The aim of the study was to assess the correlation between the levels of catecholamines and cerebral hemodynamics in patients with chronic post-traumatic stress disorder (PTSD). The study included 50 patients with chronic PTSD hospitalized for psychiatric treatment for the first time, and 50 healthy control subjects. All study subjects were in the 30-50 age group. In PTSD group, determination of vanllylmandelic acid (VMA), an epinephrine and norepinephrine metabolite, in 24-h urine and transcranial Doppler (TCD) sonography of the circle of Willis vasculature were performed on the first day of hospital stay. The same diagnostic procedures were repeated upon the completion of 21-day medicamentous psychiatric treatment. Initial analysis revealed concurrently elevated 24-h VMA in 29 (58.00%) patients and increased values of the mean blood flow velocity (MBFV) in the circle of Willis vasculature in 34 (68.00%) patients, indicating a high correlation of the respective parameters (p = 0.3290). Second analysis performed after 21-day psychiatric treatment showed concurrently elevated 24-h VMA in eight (16.00%) patients and increased MBFV in the circle of Willis vasculature in nine (18.00%) patients, also pointing to a high correlation of the parameters observed (p = 0.7906). In the control group, only two (4.00%) subjects had elevated MBFV in the circle of Willis vessels, whereas the level of 24-h VMA was normal in all control subjects. Study results pointed to a significant association between elevated levels of stress hormones and increased MBFV in the circle of Willis vasculature caused by cerebral vasospasm. Medicamentous psychiatric treatment for PTSD administered for three weeks significantly reduced the proportion of PTSD patients with elevated levels of the catecholamine metabolite and cerebral vasospasm. Study results showed a high correlation between diurnal VMA level and elevated MBFV in the circle of Willis vessels, clearly demonstrating the effect of prolonged elevation of catecholamine levels on cerebral hemodynamics.

The aim of the study was to assess the possible correlation between catecholamine and cortisol levels and changes in cerebral hemodynamics in patients with chronic posttraumatic stress disorder (PTSD). The study included 50 patients with chronic PTSD first ever hospitalized for psychiatric treatment and 50 healthy control subjects. All study subjects were aged 30-50. In PTSD patients, 24-h urine levels of the epinephrine and norepinephrine metabolites vanillylmandelic acid (VMA) and cortisol were determined and transcranial Doppler ultrasonography was performed on day 1 of hospital stay and repeated after 21-day psychiatric medicamentous treatment. On initial testing, increased level of 24-h VMA, decreased cortisol level and elevated mean blood flow velocity (MBFV) in the circle of Willis vessels were recorded in 25 (50.00%) patients. Repeat findings obtained after 21-day psychopharmaceutical therapy showed increased 24-h VMA, decreased cortisol and elevated MBFV in the circle of Willis vessels in seven (14.00%) patients (initial vs. repeat testing, P=0.0002). Such parameters were not recorded in any of the control subjects (initial PTSD patient testing vs. control group, P=0.0000). Study results pointed to a significant correlation between increased catecholamine levels, decreased cortisol level and elevated MBFV in the circle of Willis vessels caused by cerebral vasospasm. Psychiatric medicamentous therapy administered for three weeks significantly reduced the proportion of patients with concurrently altered cerebral hemodynamics, increased levels of catecholamine metabolites and decreased level of cortisol.

Transcranial ultrasonography is an established and reliable method for the evaluation of the arteries of the circle of Willis, even at the patient’s bedside. Examination of cerebral veins and sinuse

Background: Transesophageal echocardiography (TEE) and transcranial Doppler sonography (TCD) can identify right-to-left-shunts that predispose to paradoxical embolism. In a large cohort we compared the results of both techniques. Methods: 222 patients were investigated by both techniques using the contrast agent Echovist®-300 and performing each test once without and once with the Valsalva maneuver (VM). Results: TEE-proven right-to-left-shunts were detected by TCD with a high sensitivity of 94%. In addition, TCD revealed shunts not noted during TEE in about 20% of all patients studied. These shunts are in general smaller than those concordantly identified; however, 9% of the patients without a TEE-proven shunt presented with a shunt that allows a considerable amount of contrast medium to pass. There were 12% more microbubbles detected in the right middle cerebral artery than in the left middle cerebral artery during the TCD test performed with VM, but not during the TCD test performed without VM. Conclusions: Contrast-enhanced TEE and TCD are complementary methods in the assessment of stroke and stroke-prone patients. The side difference of microbubbles may indicate a selective streaming of cardiac emboli during VM.