BACKGROUND: Stroke is the leading cause of adult disability worldwide, with approximately 30% of strokes remaining cryptogenic. One potential important etiology is a patent foramen ovale (PFO), which may contribute to stroke through paradoxical thromboembolism or METHODS: We conducted a retrospective quality improvement project at our regional stroke center to compare the performance of TTE and raTCD in identifying RLS in ischemic stroke patients. The study involved 148 patients admitted between February 2021 and February 2023. All patients underwent TTE and raTCD with agitated saline bubble contrast, with additional transesophageal echocardiography (TEE) at the treatment team's discretion. The primary metrics analyzed included differences in overall RLS detection and large RLS detection rates for raTCD, TTE and TEE. RESULTS: raTCD detected RLS in 60.1% of patients compared to 37.2% with TTE ( CONCLUSION: raTCD significantly outperforms TTE in detecting RLS and large shunts, suggesting its integration into standard PFO workup protocols may enhance secondary stroke prevention. These findings support the adoption of raTCD as a complementary diagnostic tool alongside TTE and TEE for more accurate PFO detection and risk stratification.