Right-to-Left Shunt in Divers with Neurological Decompression Sickness: A Systematic Review and Meta-Analysis

Spyros Peppas, Leonidas Palaiodimos, Sanjana Nagraj, Damianos G. Kokkinidis, Nidhish Tiwari, Amrin Kharawala, Mohammad K. Mojadidi, Sanauallah Mojaddedi, George Ntaios, Robert T. Faillace, Jonathan M. Tobis

Research output: Contribution to journalReview articlepeer-review

1 Scopus citations


Objective: The aim of this study was to assess the association between the presence of a right-to-left shunt (RLS) and neurological decompression sickness (NDCS) and asymptomatic brain lesions among otherwise healthy divers. Background: Next to drowning, NDCS is the most severe phenotype of diving-related disease and may cause permanent damage to the brain and spinal cord. Several observational reports have described the presence of an RLS as a significant risk factor for neurological complications in divers, ranging from asymptomatic brain lesions to NDCS. Methods: We systematically reviewed the MEDLINE, Embase, and CENTRAL databases from inception until November 2021. A random-effects model was used to compute odds ratios. Results: Nine observational studies consisting of 1830 divers (neurological DCS: 954; healthy divers: 876) were included. RLS was significantly more prevalent in divers with NDCS compared to those without (62.6% vs. 27.3%; odds ratio (OR): 3.83; 95% CI: 2.79–5.27). Regarding RLS size, high-grade RLS was more prevalent in the NDCS group than the no NDCS group (57.8% versus 18.4%; OR: 4.98; 95% CI: 2.86–8.67). Further subgroup analysis revealed a stronger association with the inner ear (OR: 12.13; 95% CI: 8.10–18.17) compared to cerebral (OR: 4.96; 95% CI: 2.43–10.12) and spinal cord (OR: 2.47; 95% CI: 2.74–7.42) DCS. RLS was more prevalent in divers with asymptomatic ischemic brain lesions than those without any lesions (46.0% vs. 38.0%); however, this was not statistically significant (OR: 1.53; 95% CI: 0.80–2.91). Conclusions: RLS, particularly high-grade RLS, is associated with greater risk of NDCS. No statistically significant association between RLS and asymptomatic brain lesions was found.

Original languageEnglish (US)
Article number1407
JournalHealthcare (Switzerland)
Issue number10
StatePublished - May 2023
Externally publishedYes


  • diving
  • neurological decompression sickness
  • right-to-left shunt
  • silent brain lesions

ASJC Scopus subject areas

  • Leadership and Management
  • Health Policy
  • Health Informatics
  • Health Information Management


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