Supplementary Material for: Diffusion-Weighted Imaging Patterns According to the Right-to-Left Shunt Amount in Cryptogenic Stroke

<b><i>Background:</i></b> Although patent foramen ovale (PFO) is considered to be the main cause of cryptogenic stroke, it is difficult to define “true” PFO-related stroke. <b><i>Objective:</i></b> In this study, we evaluated comprehensive diffusion-weighted imaging (DWI) findings in patients with cryptogenic stroke according to the right-to-left shunt (RLS) amounts on transcranial Doppler (TCD) sonography. <b><i>Methods:</i></b> We assessed consecutive patients with cryptogenic stroke between October 2010 and 2018. The RLS amount on TCD was assessed according to the International Consensus Criteria (ICC). Massive RLS was defined as the highest category of ICC (Curtain pattern). We assessed DWI findings, including the location of lesions, involved vascular territory, and DWI lesion patterns. <b><i>Results:</i></b> A total of 100 consecutive patients with cryptogenic stroke were assessed, and PFO was found in 59 patients. In multivariable analyses, massive RLS was noted to be positively associated with the presence of cortical lesion (adjusted OR [aOR] 15.75, 95% CI 1.94–127.71, <i>p</i> = 0.010), multiple territory involvement (aOR 5.24, 95% CI 1.57–17.53, <i>p</i> = 0.007), and number of DWI lesions (beta 0.713, 95% CI 0.245 to 1.181, <i>p</i> = 0.003) after adjusting for confounders. Conversely, massive RLS showed inverse correlations with posterior circulation involvement (aOR 0.22, 95% CI 0.06–0.87, <i>p</i>= 0.031) and number of large DWI lesions (beta –0.328, 95% CI –0.629 to –0.026, <i>p</i> = 0.034). <b><i>Conclusions:</i></b> We demonstrated that massive RLS on TCD was associated with multiple, small-scattered cortical lesion in patients with cryptogenic stroke. These DWI pattern is highly suggestive of PFO-related stroke.

**背景**：尽管卵圆孔未闭（patent foramen ovale, PFO）被认为是隐源性卒中的主要病因，但精准界定“真正的”PFO相关性卒中仍存在挑战。**目的**：本研究基于经颅多普勒超声（transcranial Doppler, TCD）检测的右向左分流（right-to-left shunt, RLS）程度，对隐源性卒中患者的全面扩散加权成像（diffusion-weighted imaging, DWI）特征进行评估。**方法**：本研究纳入2010年10月至2018年间连续收治的隐源性卒中患者。采用国际共识标准（International Consensus Criteria, ICC）对TCD检测的RLS程度进行分级，其中大量RLS定义为ICC分级最高级（幕帘型（Curtain pattern））。本研究对DWI影像特征进行评估，包括病灶位置、受累血管支配区及DWI病灶形态。**结果**：本研究共纳入100例连续隐源性卒中患者，其中59例检出PFO。多变量分析结果显示，在校正混杂因素后，大量RLS与皮层病灶（校正比值比（adjusted OR, aOR）=15.75，95%置信区间（95% CI）：1.94~127.71，P=0.010）、多血管支配区受累（aOR=5.24，95%CI：1.57~17.53，P=0.007）及DWI病灶总数（β=0.713，95%CI：0.245~1.181，P=0.003）呈正相关；反之，大量RLS与后循环受累（aOR=0.22，95%CI：0.06~0.87，P=0.031）及大尺寸DWI病灶数量（β=-0.328，95%CI：-0.629~-0.026，P=0.034）呈负相关。**结论**：本研究证实，隐源性卒中患者TCD检测的大量RLS与多发、散在的皮层小病灶相关。此类DWI影像特征高度提示为PFO相关性卒中。