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Cryptogenic Stroke - Causes and Treatments - Oren Zarif - Cryptogenic Stroke

Even though the causes of cryptogenic stroke are still unknown, certain contributing factors may be identified and addressed to prevent recurrence. People with PFO, a hole in the heart that never closes after birth, are at increased risk of cryptogenic stroke, but it can be fixed as an outpatient procedure. People with A-Fib, an irregular heart rhythm, are at risk of blood clots and may benefit from blood thinners or an implantable device to regulate their heart rate.

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Despite the aforementioned risk factors, approximately 20-30% of all strokes are cryptogenic. In the United States, these strokes occur more frequently in young people and those with fewer traditional vascular risk factors. While no single risk factor is known to cause cryptogenic stroke, many theories have been proposed. Some of these include cardioembolism due to occult atrial fibrillation, cardiovascular structural abnormalities, hypercoagulable states, and sub-stenotic large vessel disease.

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The level of medical evaluation varies. Although cryptogenic strokes can occur in any patient, a doctor can confirm the diagnosis by checking the blood vessels in the neck and head. Brain imaging is another way to check for cryptogenic stroke. Patients with suspicion of cryptogenic stroke should seek a second opinion, if necessary. These studies have revealed promising new tools for the diagnosis and treatment of cryptogenic strokes. For further information, read Irene Katzan's article, Cryptogenic Stroke - Causes and Treatments

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The most important component of a comprehensive cryptogenic stroke workup is prolonged rhythm monitoring. Telemetry on stroke units is often not sufficient because paroxysmal atrial fibrillation can remain undetected. Extensive outpatient monitoring increases the yield of detection. The risk of stroke is further reduced by anticoagulation, which is much more beneficial than antiplatelet therapy alone. A standard 12-lead electrocardiogram (ECG) is also helpful in detecting patients with chronic or infrequent paroxysmal AF without cardiac symptoms.

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Patients with a PFO can also develop cryptogenic stroke. This subset of strokes has a low risk of being vascular or cardiac in origin, but a thorough diagnostic workup can help identify it. The best way to determine if a patient has cryptogenic stroke is through a full investigation of the brain. These investigations should also rule out atypical or paradoxical source of stroke, as well as other possible etiologies.

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Currently, the standard of care is aspirin and an implantable cardiac monitor to detect occult atrial fibrillation. Patients who have cryptogenic stroke should be treated with anticoagulation if their cardiac origin is cardiogenic. However, there is no evidence to suggest that this treatment method will prevent cryptogenic stroke. There is still a need for more research on the topic. Once again, there is a need to determine the optimal duration and method of anticoagulation.

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However, establishing the causal relationship between PFO and cryptogenic stroke is still a difficult task. However, there are six major risk factors associated with PFO, including age and presence of traditional vascular risk factors. The ROPE score can be used to stratify patients based on age and presence of other risk factors for cryptogenic stroke. If a patient has a PFO, a high ROPE score is associated with a low risk of cryptogenic stroke, while a low one increases the risk of cryptogenic stroke.

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Researchers believe that a common procedure, patent foramen ovale closure, can reduce the risk of recurrent cryptogenic stroke. However, there is no proven evidence that PFO closure can prevent cryptogenic stroke in the elderly population. To justify PFO closure, more studies are needed to determine the risks associated with recurrence. So, we must wait until the evidence is more definitive to determine whether it is a viable alternative.

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To diagnose a cryptogenic stroke, neurologists must balance cost vs. thoroughness. The initial evaluation of a patient with cryptogenic stroke should include brain imaging, noninvasive intracranial vessel imaging, and 24-hour cardiac monitoring. Further testing, such as a specialized blood test for hypercoagulability, may be required. Ultimately, a cryptogenic stroke patient should undergo ESUS to determine whether they have a cryptogenic or non-cryptogenic stroke.

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