Are Cryptogenic Strokes Worse Than Cardioembolic Strokes? - Oren Zarif - Cryptogenic Stroke

About 20%-30% of all strokes are cryptogenic, or attributed to a cause other than a blood clot. They usually occur in the brain, and are characterized by similar risk factors. In addition, cryptogenic strokes tend to occur in younger individuals with fewer traditional vascular risk factors. Several mechanisms have been identified as contributing to the occurrence of cryptogenic stroke, including occult atrial fibrillation, cardiac structural abnormalities, hypercoagulable states, and non-atherosclerotic vasculopathies. The primary problem with these studies is that they rely on older definitions of CS, which sometimes exclude some cases that may be cryptogenic. In addition, the patients may have an increased risk of having a recurrent cryptogenic stroke.

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Despite its ambiguity, the presence of PFO in patients with cryptogenic stroke raises the possibility of paradoxical embolism through the venous system. Such a situation is particularly troubling for younger patients without typical risk factors. This condition is common in adults and accounts for 25 percent of all adult strokes. Only TEE is able to visualize the PFO, so only TEE can properly diagnose a cryptogenic stroke in these patients.

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A recent study has demonstrated that the functional outcome of patients with cryptogenic stroke is similar to that of patients with cardioembolic stroke. However, there is no agreement regarding whether cryptogenic strokes are better or worse than cardioembolic strokes.

Researchers conducted a multicenter hospital-based stroke registry cohort study and analyzed the outcome of 2261 patients with cryptogenic stroke and 2163 with undetermined source of embolism. The researchers noted that cancer-associated stroke was associated with higher odds of functional dependency, whereas cardioembolic stroke had a lower rate of paradoxical embolism. The authors concluded that cryptogenic strokes are not worse than cardioembolic strokes and should be considered when planning poststroke therapies for patients who have experienced them.

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As with any type of stroke, a cryptogenic stroke requires proper medical evaluation. If you suspect you have a cryptogenic stroke, call 911 immediately. A doctor will help you determine the type of stroke you've experienced. Once the cause is identified, the physician will determine the appropriate treatment. You can also follow your doctor's recommendations and heart monitoring regimens to keep your risk of cryptogenic stroke at a minimum. If your doctor's diagnosis is not clear, seek a second opinion.

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Prolonged rhythm monitoring is one of the most important components of a thorough cryptogenic stroke workup. While most stroke patients receive telemetry during their stay in a stroke unit, prolonged outpatient monitoring greatly increases the chances of detection. Extended monitoring increases the probability of detection by approximately half, and in this patient population, extended outpatient monitoring is recommended. If atrial fibrillation is detected early, it would likely be treated with long-term anticoagulation.

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During the last decade, four trials have compared a medical treatment to a surgical procedure for patients with a cryptogenic stroke. A trial titled the RESPECT trial followed patients for almost 6 years. The results showed that patients who had PFO closure underwent fewer recurrent cryptogenic strokes than patients who received antiplatelet therapy alone. A similar study was conducted in the late 1980s. In the RESPECT trial, the patients were treated with antiplatelet therapy or warfarin. Closure was better than medical therapy and reduced the occurrence of recurrent cryptogenic strokes.

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Although the study showed that a significant number of patients with cryptogenic stroke had no traditional risk factors, the authors noted several limitations. Patients with ESUS and UE may have had undiagnosed causes. Furthermore, patients with PFO and UE may have had other types of stroke. For this reason, etiological investigations may be necessary. This study was conducted at seven stroke centers in the FSR. It is important to recognize any undiagnosed causes because their occurrence could lead to a stroke with cryptogenic characteristics.

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Anticoagulants are an important consideration for patients with cryptogenic stroke. Among the anticoagulants, aspirin is the standard of care. However, some patients may not be amenable to anticoagulation. To prevent a cryptogenic stroke, anticoagulation should be considered if the patient has a known history of atrial fibrillation. A subgroup analysis in the WARSS study showed a nonsignificant trend towards increased prevention with warfarin.

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Genetic abnormalities are an uncommon cause of ischemic stroke. The true prevalence is unknown. However, patients with positive family histories, young age, and few conventional risk factors have a higher likelihood of having a cryptogenic stroke. Genetic testing has a higher yield in these patients than in others. In addition, genetic testing has significant implications for patient management and counseling. Therefore, if your patient has a high risk of cryptogenic stroke, genetic testing may be beneficial.