Identifying the Cause of a Cryptogenic Stroke - Oren Zarif - Cryptogenic Stroke

If you are experiencing symptoms of a cryptogenic stroke, call 911 right away. Only a physician can diagnose the cause of your stroke, and determine the appropriate treatment. While the exact cause is not always known, some lifestyle factors can increase the risk of cryptogenic stroke. Smoking, high-fat diet, and major stress are just a few of the risk factors. Other risk factors may include pregnancy, birth control pills, and post-menopausal hormone therapy for women. Men may also experience a stroke after testosterone therapy. Finding the root cause of your stroke may help you avoid the symptoms of the condition.

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Although most cryptogenic strokes are caused by an embolic mechanism, the exact cause is unknown. Because this type of stroke is rare, there is no consensus on a specific diagnosis. As such, clinical studies have been limited by the lack of a standardized definition and necessary diagnostic assessment. A new subclassification of cryptogenic stroke has been proposed by the Cryptogenic Stroke/ESUS International Working Group. However, more research is needed to understand the cause of cryptogenic stroke.

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A common underlying cause of cryptogenic stroke is atrial fibrillation. Although most patients receive telemetry during their stay in a stroke unit, prolonged outpatient cardiac monitoring may improve the odds of detection. Identifying atrial fibrillation during the initial evaluation is also helpful in preventing additional strokes. However, identifying atrial fibrillation would require a long-term anticoagulant. The 30-day Cardiac Event Monitor Belt for Recording Atrial Fibrillation After Cerebral Ischemia (EMBRACE) study examined patients with atrial fibrillation for 30 days. The results showed that 16.1% of patients with cryptogenic stroke underwent extended monitoring, compared with just 3.2% of controls.

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Patients with a PFO have higher rates of deep venous thrombosis than those with known strokes. Several studies have suggested a role for anticoagulation over antiplatelet therapy in patients with cryptogenic stroke. Although no studies have shown a definitive role for anticoagulation over antiplatelets in this subgroup, the PICSS trial compared the use of warfarin to aspirin in patients with a cryptogenic stroke.

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AF detection in patients with cryptogenic stroke has a low rate with routine cardiac monitoring. With the help of Holter monitoring, physicians can detect AF even when the patient has symptoms that are not obvious to the naked eye. The device can be useful in detecting paroxysmal AF, but other factors must be considered. A thorough diagnostic evaluation of cryptogenic stroke patients is essential for the proper treatment of this condition. Only then can physicians recommend the right treatment.

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Current treatment for cryptogenic stroke is based on a series of randomized controlled trials. The ARCADIA trial, which compares the effectiveness of aspirin and a DOAC in cryptogenic stroke patients, is the biggest example of a positive impact on outcomes. The trial aims to confirm the hypothesis that DOACs are more effective than aspirin for the prevention of cryptogenic stroke. The primary endpoint of the study is PTFV1 > 5,000 mV* ms and left atrial diameter index.

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A recent trial in the US randomized patients with a PFO and cryptogenic stroke found that closure of the PFO significantly reduced the risk of a recurrent episode of cryptogenic stroke. The trial also showed that patients with PFO were less likely to develop a TIA or a subsequent stroke when PFO was repaired. Those who were left without a diagnosis or treatment may also experience a TIA or a cryptogenic stroke.

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The TOAST subtype classification system divides acute ischemic stroke into five subtypes: cardioembolic, vascular, cryptogenic, and undetermined. Generally, cryptogenic stroke has a higher risk and requires more thorough diagnostic testing. However, there are several lower risk emboli that can be caused by a cryptogenic stroke. For this reason, correct identification of the cause of the cryptogenic stroke is critical. It is important to avoid the CS if possible.

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Cardioembolic mechanisms of CS can include valvular heart disease, aortic valve stenosis, aortic calcification, or aortic valve calcification. Other causes of cryptogenic stroke may include occult malignancy or substenotic atherosclerosis. A comprehensive evaluation of the cardiovascular system will determine the underlying cause of a cryptogenic stroke and help physicians improve the prevention and treatment of this condition.