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  • Writer's pictureOren Zarif

Anticoagulation May Be Beneficial in Patients With ESUS - Oren Zarif - Cryptogenic Stroke

Anticoagulation may be beneficial in some patients with ESUS, although a subset of these patients may be ineligible for anticoagulation. The Warfarin-Aspirin Recurrent Stroke Study (WARSS) showed no benefit of warfarin for prevention of cryptogenic stroke, and the RESPECT ESUS trial found that aspirin was inferior to dabigatran for secondary stroke prevention.

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While standard of care recommends dual antiplatelet therapy (Aspirin plus clopidogrel) to prevent secondary stroke, there are few studies on the efficacy of dual antiplatelet therapy in this population. Several studies, including the EmBRACE trial, have also shown that dual antiplatelet therapy reduces the risk of cryptogenic stroke. For this reason, it is important to monitor patients with ACS and consider treatment options for these individuals.

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Once the onset of cryptogenic stroke is suspected, it's important to seek medical attention as soon as possible. While the exact cause of the stroke isn't determined, the doctor's diagnosis will depend on the level of medical evaluation. In addition to blood tests and CT scans, doctors can examine brain tissue and conduct brain imaging. However, if a doctor is unsure about the diagnosis, a second opinion is always recommended.

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In the recent RESPECT trial, patients with cryptogenic stroke with PFO were randomized to antiplatelet therapy alone or PFO closure plus an antiplatelet agent. Antiplatelet therapy alone or closure with a PFO shunt decreased the risk of recurrent ischemic stroke. After the study, PFO closure was more effective than antiplatelet therapy alone. A large proportion of patients enrolled in the trial remained stroke-free for years afterward.

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The PFO-induced clots were more resistant to antiplatelet therapy than other patients with ESUS. ESUS also occurs in younger patients without typical stroke risk factors. The use of agitated saline contrast in the PFO is critical for diagnosing paradoxical embolism through the vena cava. However, only TEE can visualize the PFO. As such, important questions about management should be answered by determining if the PFO closure will reduce the risk of stroke in these patients.

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Generally, strokes are caused by a blood clot that blocks the blood flow to the brain. Patients who have survived one cryptogenic stroke will most likely suffer another one at some point in their lives. However, if it can be prevented, the risk of another stroke is decreased if the cause of the first one can be identified. By getting a proper diagnostic workup, the chances of a second stroke are greatly reduced.

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All patients who were admitted to the Neurological Clinic at "SS Annunziata" hospital in Chieti, Italy, were evaluated for AF. The workup included a complete neurological examination, 24-hour ECG monitoring, screening for thrombophilic states, and magnetic resonance angiography. Each patient was followed for four months after the device was inserted. If AF was present, the patient was classified into the AF group.

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Despite the wide variety of etiologies of ESUS, poststroke outcomes are similar and can be influenced by embolic source. Moreover, ESUS may be a significant factor in predicting a patient's outcome. Nevertheless, the clinical outcome of cryptogenic stroke is still unknown. In addition, the treatment for patients with cryptogenic stroke may need to consider underlying vascular disease, cardiac arrhythmias, and structural abnormalities.

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In addition to this, the study also included some limitations. Patients with ESUS did not always receive all of their diagnostic tests, and there may be other underlying causes of UE. Also, patients with ESUS were sometimes referred to other treatment centers after an initial diagnosis of cryptogenic stroke. The high proportion of ESUS cases may have been due to other, lower-risk sources. Furthermore, in patients with ESUS, antiplatelet therapy has been the standard of care for this subset of stroke. Some patients with cryptogenic ESUS may benefit from percutaneous closure.

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