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PFO and Cryptogenic Stroke - Oren Zarif - Cryptogenic Stroke

Writer's picture: Oren ZarifOren Zarif

A patient with a PFO is at higher risk of a cryptogenic stroke. This condition may be triggered by a PFO and can be symptomatic or fatal. A standardized cryptogenic stroke score is available. A high score means that a PFO is the probable mechanism, while a low score indicates that the PFO is an incidental cause. The role of the PFO in the pathogenesis of cryptogenic stroke is not fully understood, but it can be a useful diagnostic tool in cases of this type.

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Although a PFO may be an early sign of a cryptogenic TIA/stroke, the risk of having a subsequent ischemic stroke is still unknown. The prevalence of PFOs and ischemic stroke is highest in patients with a higher age. Researchers are now investigating the role of the PFO in the development of stroke in patients with a PFO. However, these studies are limited by the need to gather large sample sizes.

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One in three ischemic strokes is cryptogenic. The risk of cryptogenic stroke is five times greater in African-Americans than in whites. People with an irregular heartbeat (AFib) are at a five-fold higher risk for a cryptogenic stroke. If you suspect that you are at risk, discuss your symptoms with your doctor. Depending on the cause of the cryptogenic stroke, your doctor may recommend diagnostic testing, blood workups, and lifestyle changes.

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A computerized algorithm (ASCOD) enables neurologists to grade the severity of strokes and the likelihood of causation. The criteria used for this assessment include age, gender, and the type of patient. There are five main categories of strokes: cryptogenic stroke, known ischemic stroke, and aortic artery occlusion. After using the ASCOD algorithm, a patient will be classified as either a cryptogenic or a vascular stroke.

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The standard of care for patients with cryptogenic stroke is aspirin and the use of an implantable cardiac monitor. If the device detects occult atrial fibrillation, anticoagulation is initiated. Anticoagulation has not been proven to be any more effective than aspirin in cryptogenic stroke patients, although future studies are needed to identify subgroups of patients who may benefit from anticoagulation. Moreover, the clinical significance of brief episodes of atrial fibrillation and threshold for duration of atrial fibrillation remain unclear.

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The incidence of cryptogenic stroke is high, and it accounts for approximately one-quarter of all ischemic strokes. Cryptogenic stroke is also more prevalent among young adults and people of color. The risk of recurrent cryptogenic stroke is particularly high, so understanding the causes of the disease is important to prevent it. A systematic evaluation of the risk of ischemic stroke in Finland found that this subtype accounted for a higher percentage of young adults than older people. In Finland, the incidence of cryptogenic stroke was higher among minorities than in whites.

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Besides the underlying mechanism, there are also several risk factors that are associated with cryptogenic stroke. In particular, atrial fibrillation and intermittent AF may make it more difficult to detect a cryptogenic stroke. Continuous monitoring of patients with AF may help to classify less cases as cryptogenic. Wearable devices may be used to monitor patients more efficiently and without invasive procedures. In addition to the above, continuous monitoring of the patient may also help in identifying fewer cryptogenic strokes.

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Although most cryptogenic strokes are symptomatic, some thrombotic complications can cause it. Despite the risk factors, the ESUS must be confirmed by a vascular neurologist to determine if anticoagulation is appropriate. In these cases, anticoagulation is an option but should only be used in patients with a cardiac source. Moreover, anticoagulation should not be used as a primary treatment of a cryptogenic stroke.

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Researchers have identified a risk factor for a cryptogenic stroke based on a patient's age and a patient's risk for a PFO. These patients must also have a PFO of greater than a 0.7-mm in size or an atrial septal aneurysm. They were randomized to receive a surgery or medical therapy. The results from the RESPECT trial showed that patients who underwent a PFO closure had a significantly lower risk of a recurrent cryptogenic stroke compared to those who received a medical therapy.

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Although the rate of cryptogenic stroke remains low, there is no consensus on which treatment is most effective. In recent studies, surgical stenting has been used to close PFOs. While the procedure is not effective for all patients, it has been shown to reduce the risk of cryptogenic stroke and TIA. Therefore, PFO surgery is recommended for individuals with a high risk of cryptogenic stroke. But in these cases, a surgical procedure may not be the best option.

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