Aetiology of Cryptogenic Stroke - Oren Zarif - Cryptogenic Stroke
While many patients may be confused by the term "cryptogenic stroke," it is not rare. About 50% of patients may suffer a stroke due to this condition, and determining its aetiology can reduce recurrence. Therefore, neurologists should incorporate this testing in initial stroke evaluations. These tests can include noninvasive extracranial vessel imaging and 24-hour cardiac monitoring. Depending on the aetiology, additional tests and blood studies may be ordered. These tests can help identify risk factors such as hypercoagulability, AF, and stroke-related mortality.
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Cardioembolic mechanisms have been widely discussed in the past few years. Among these, the patent foramen ovale and paroxysmal atrial fibrillation are suspected as possible genesis of cryptogenic stroke. Although these conditions are common in the general population, their prevalence may make them undetected. Thus, physicians must consider the symptoms and risk factors of cryptogenic stroke before treating the patient. However, a high ROPE score does not indicate that cryptogenic stroke is caused by PFO.
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Age and PFO have been linked to risk of cryptogenic transient ischemic attack. Although both PFO and age increase the risk of cryptogenic stroke, patients with a patent foramen ovale had a higher risk of ischemic stroke compared to patients without it. In addition, patients with cryptogenic stroke were more likely to develop a PFO than those without. The researchers noted that cryptogenic stroke patients had a significantly larger PFO than those with known ischemic stroke.
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In addition to the age, another risk factor for cryptogenic stroke is the presence of the patent foramen ovale. Closing the PFO in elderly patients reduces the risk of recurrent stroke but does not prevent the onset of a second stroke. For these reasons, doctors may not recommend PFO closure for elderly patients. The primary goal is to find the cause of a cryptogenic stroke. Having the right diagnostic workup will help lower the risk of developing another stroke.
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After the symptoms of cryptogenic stroke appear, patients should contact a doctor immediately. A doctor can determine the type of stroke and recommend the right treatment for the patient. The first step in diagnosis is to obtain a TCD, a sensitive test that can identify blood vessel abnormalities in the neck and head. If the TCD shows a right-to-left shunt, TEE is necessary to rule out cryptogenic stroke. These tests require more advanced imaging.
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While it is important to identify the cause of a cryptogenic stroke, it is not always possible to pinpoint it. Because of this, a wide differential evaluation of the possible etiologies of the event may help determine the treatment and prevent a secondary stroke. This article will review the standard evaluation for ischemic stroke and suggest additional studies for better understanding the mechanism of cryptogenic stroke. So, you should always be aware of the risk of cryptogenic stroke in young patients.
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Generally, ASCO classifies ischemic strokes based on their phenotypes. Using the TOAST classification, cryptogenic stroke can be characterized as any ischemic stroke without a clear etiology. This includes stroke caused by cardiac embolism and other less-established causes of thrombotic disorders. In addition to ECG, another useful tool is the Holter device. These tests are more useful for diagnosing paroxysmal AF, the underlying cause of cryptogenic stroke.
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CS can occur in younger patients, but it can also occur in older patients. Consequently, it is important to consider the age of patients in any clinical trial of a PFO closure. Since older patients tend to have larger PFOs, randomized clinical trials may be more effective for older patients. However, if the reduction in the risk of recurrent cryptogenic stroke is small in younger patients, the study would need to be conducted in a large population.
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Aside from PFO, other causes of ischemia in patients with PFO include occult malignancy, hypercoagulable states, and aspirin. While the cause of cryptogenic stroke is unknown, there is a strong tendency for the condition to be transitory. The most common risk factors for cryptogenic stroke are cardiac embolism, vasculopathy, complex aortic plaques, and Fabry's disease.
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Since an estimated 30% to 40% of patients have cryptogenic strokes, it is important to understand the underlying etiology and determine the appropriate treatment for them. Various tests, including vascular imaging, may help determine if a cryptogenic stroke is an ischemic stroke or not. In addition to cardiac evaluation, brain imaging is also performed to determine the source of the stroke. These tests can help identify the underlying cause of the stroke and reduce the risk of recurrence.