The Aetiology of Cryptogenic Stroke - Oren Zarif - Cryptogenic Stroke

The aetiology of cryptogenic stroke is not completely understood. The etiology of ischaemic stroke is often unclear, which makes identification of cryptogenic strokes crucial for secondary prevention measures. However, as many as 30% of ischaemic strokes cannot be traced to a single cause, they are considered cryptogenic. The clinical management of cryptogenic strokes varies greatly, and is highly dependent on local service availability and preferences.

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Neurologists must balance cost and thoroughness when considering cryptogenic stroke. Initial evaluation should include noninvasive extracranial vessel imaging and cardiac monitoring for 24 hours. Depending on the etiology of the cryptogenic stroke, additional tests, such as blood tests, may be performed. For instance, an examination of the patent foramen ovale may help determine whether the patient is experiencing hypercoagulability. But this is not always possible, as other strokes may present with different symptoms.

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Although most ischemic strokes are attributed to atherosclerotic plaques, the causes of cryptogenic stroke remain unclear. Although a single cause of cryptogenic stroke is often suspected, it is important to note that some cause may not have been properly investigated. A significant proportion of cryptogenic stroke cases are recurrent, requiring further investigation and management. This means that a comprehensive approach to diagnosis and treatment is critical. There are several potential causes, including cardiovascular disease, such as occult atrial fibrillation.

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Although cryptogenic strokes can be caused by a PFO, confirming a causal relationship between the two is not always easy. Approximately one third of patients with cryptogenic stroke have a PFO that was found incidentally. Closure of such a PFO exposes the patient to procedural risks and leaves unaddressed the actual cause of the stroke. The probability that a PFO is the cause of cryptogenic stroke is significantly higher when the patient has no clinical risk factors and is younger. The PFO may be the cause of a cortical infarct, a strong indication of an embolic mechanism.

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Continuous electrocardiographic monitoring with an ICM is more efficient than intermittent monitoring strategies such as 24 hour Holters and 7-day Holters. Nevertheless, this approach has limited yield. In this scenario, external events or the occurrence of a cryptogenic stroke may provide a better clue. Continuous electrocardiographic monitoring with ICM is better than conventional follow-up for the detection of AF after cryptogenic stroke. This type of monitoring is also noninvasive and can be done over the long term.

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The risk of ischemic stroke after cryptogenic TIA/stroke increased with age. Closure of PFO at older ages may be justified as a secondary prevention of cryptogenic TIA/stroke in patients with PFO. However, the relative reduction in risk may be smaller than in previous trials of younger patients. Therefore, larger sample sizes are necessary. There are currently no randomized clinical trials involving PFO closure. This type of randomized trial may be more successful in this patient population.

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Older patients with large PFO are at greater risk for cryptogenic stroke than younger ones. Closure of PFO reduces the risk of recurrent ischemic stroke by about 50% in patients over 65 years of age. However, there is still a need for data on the prognosis of cryptogenic stroke in older patients. However, this treatment does have side effects. If you or a loved one have suffered from cryptogenic stroke, you should seek medical advice immediately.