A Review of the Causes of Cryptogenic Stroke - Oren Zarif - Cryptogenic Stroke
Cryptogenic stroke is a subset of ischemic stroke with a number of putative mechanisms. The mechanism may be due to a covert structural cardiac lesion, paroxysmal atrial fibrillation, hypercoagulable state, or undiagnosed malignancy. While most cryptogenic strokes are ischemic, a small percentage of these strokes may be embolic in nature, requiring systemic anticoagulation.
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Most strokes are caused by a blood clot that blocks the flow of blood to the brain. But about one in four stroke survivors will experience another, which makes finding the cause of your previous stroke a crucial step in lowering your chances of having a repeat stroke. Fortunately, a proper diagnostic workup can help determine if you had a cryptogenic stroke and reduce your risk of a repeat attack. In addition, you can also get an early diagnosis of the cause and begin treatment as soon as possible.
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The cryptogenic stroke program is located at Scripps Memorial Hospital La Jolla, where it is complemented by other facilities including the Prebys Cardiovascular Institute and the Scripps Clinic John R. Anderson V Medical Pavilion. The Scripps Cardiovascular Institute is San Diego's premier heart care facility, and its combined PFO and ASA programs rank among the best in the nation. The institute's highly-specialized cardiology program is the largest of its kind on the West Coast.
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Aetiology of a cryptogenic stroke can be identified through a systematic evaluation of the risk factors and symptoms of the condition. In addition to reducing the risk of recurrence, identifying the underlying cause can help to target treatment and prevent future episodes. As a result, this review discusses the possible causes of cryptogenic strokes. It highlights the importance of determining the aetiology of the stroke and associated conditions such as patent foramen ovale and atheroma of the aortic arch.
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Cardiovascular testing can identify AF in approximately half of patients with cryptogenic stroke. During the initial assessment, AF can be detected with routine cardiac tests and may be prevented with a longer duration of monitoring. In addition to cardiac monitoring, basic laboratory tests may also identify coagulopathy and aetiology and identify common modifiable risk factors. If AF is detected, patients should be evaluated for these risk factors and undergo appropriate treatment.
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Using the OxVasc study cohort, researchers evaluated the risk of ischemic stroke and PFO recurrence in patients with and without PFO. The researchers calculated the odds ratio of patients recurring with ischemic stroke with cryptogenic event versus those without. These results were stratified by age and PFO. In patients with cryptogenic stroke, the relative risk of recurrence is greatest at older ages.
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Patients with cryptogenic stroke should undergo more comprehensive research to diagnose the condition. TCD is one of the most sensitive tests used for this condition, but it can be limited by its limited ability to detect cardiac structures. If TCD reveals the presence of right-to-left shunt, then TEE must be performed. Its low sensitivity and high sensitivity make it a valuable tool for identifying stroke in these patients. In addition to improving diagnosis, continuous monitoring of patients with cryptogenic stroke could lead to a reduction in the rate of cryptogenic strokes.
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A population-wide study of PFO showed a low risk of cryptogenic stroke in healthy people with PFO. However, the study authors suggested that the large anatomic separation between the primum and secundum septum and right-to-left shunt at rest may increase the risk. For example, the authors found that there were two distinct groups of patients with PFO, those with acute stroke and those with TIA, and those with a right-to-left shunt at rest.
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While CS patients are heterogeneous, many possible mechanisms of cryptogenic stroke exist. A comprehensive evaluation of the cardiac system may reveal an underlying mechanism and improve secondary prevention strategies. Cardiac imaging and cardiac monitoring are essential for this evaluation. In addition, a comprehensive evaluation of the CS mechanism may also help physicians identify specific risks associated with cryptogenic stroke. The Athens Stroke Registry reported that patients with ESUS had a high risk of recurrence of ischemic stroke, and that the risk of recurrence was similar to cardioembolic stroke.