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  • Writer's pictureOren Zarif

Neurologists Need to Balance Thoroughness and Cost in Evaluating C - Oren Zarif - Cryptogenic Stroke

While ischemic stroke accounts for approximately 30% of all cases, cryptogenic strokes are often mysterious and can be caused by a variety of factors. Neurologists need to balance thoroughness and cost in assessing cryptogenic stroke patients. Initial evaluation should include brain imaging, noninvasive intracranial vessel imaging, and 24-hour cardiac monitoring. Depending on the underlying cause, additional tests may be necessary, such as blood studies to determine hypercoagulability.

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A PFO can result from a variety of causes, such as the presence of a large PFO. This condition may occur as the result of a PFO, which is a blockage or a dissection of the aorta. While the cause of cryptogenic stroke is unknown, medical treatment alone may be effective in many patients. This is especially true for those who experience frequent or recurrent strokes. Patients with a large PFO may experience a higher risk of cryptogenic stroke than those with a smaller shunt.

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While PFOs may be associated with the risk of stroke, establishing a causal relationship is difficult. In cryptogenic stroke patients, one third of PFOs are incidental. Closing incidental PFOs exposes patients to procedural risks, leaving the cause of cryptogenic stroke unresolved. However, this increase in the risk of cryptogenic stroke is higher in patients under the age of 40, those with no clinical risk factors, and those who develop a cortical infarct, suggesting an embolic mechanism.

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While anticoagulation is often used to treat ischemic strokes, the diagnosis of atrial fibrillation remains unclear. A standard 12-lead ECG and implantable cardiac monitor are used as part of the stroke workup for patients with cryptogenic stroke. Anticoagulation should be started if the implantable cardiac monitor detects occult atrial fibrillation. But research on these treatments for cryptogenic stroke patients is incomplete.

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Researchers at the "SS Annunziata" hospital in Chieti, Italy, conducted a randomized prospective study to evaluate long-term monitoring for AF detection in patients with cryptogenic stroke. The study enrolled 450 patients who were cryptogenic stroke and had no history of AF. The patients were grouped based on the presence of AF and the time to detection within six months of the stroke. The clinical follow-up period was at least 12 months.

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Researchers have studied ischemic and nonischemic effects of cryptogenic TIA/stroke using multiple studies. One of these studies, called RESPECT, involved patients with cryptogenic TIA/stroke and patients with PFO. They studied the efficacy of this treatment, compared to medical therapy for PFO. The results indicated that closure was more beneficial than medical therapy. But there is no definitive proof to suggest that cryptogenic stroke with PFO is any less dangerous than non-cystic TIA/stroke.

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Although the association between PFO and cryptogenic stroke is unclear, there is a risk score called ROPE that has been developed that can help physicians stratify patients based on age, the presence of conventional vascular risk factors, and other criteria. The ROPE score is a standardized 10-point scale, and it is useful in stratifying patients based on their risk of developing a cryptogenic stroke. When used in conjunction with other vascular risk factors, PFO is associated with a low rate of secondary stroke.

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Researchers have classified cryptogenic stroke patients as cardioembolic in older age, despite having fewer traditional risk factors. However, younger stroke patients who had PFO were classified as cryptogenic in the past. The authors of the study state that further investigations are needed in patients with cryptogenic stroke. The results are promising. And a new study has uncovered several risk factors for cryptogenic stroke. This study demonstrates that cryptogenic strokes are not as uncommon as previously thought.

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The main differences between ESUS and cryptogenic stroke are the severity and type of risk factor. While cryptogenic stroke is a complex disease, it typically has an underlying cause that can be ruled out. It is important to determine whether CS is a primary or secondary cause of a patient's stroke. If a patient has a PFO, cryptogenic stroke is almost always due to an underlying condition. If an underlying condition is suspected, a physician should seek a diagnosis and treatment as soon as possible.

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