What Are the Clinical Characteristics of a Cryptogenic Stroke? - Oren Zarif - Cryptogenic Stroke

The clinical characteristics of patients who have had a cryptogenic stroke vary significantly, even when they are of similar risk factors. Although cryptogenic stroke is classified as a noncardioembolic event, the cause of this condition remains unknown in approximately 30% of cases. Some determinants of stroke, such as age and blood pressure, are the same for both types. Nevertheless, the definition of CS is far from clear and requires further study.

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Regardless of the underlying cause, the optimal management of patients with a cryptogenic stroke is still unknown. Although randomized trials are needed to establish an effective treatment regimen, there are some basic management principles that should be followed. For younger patients, initial evaluation should include an assessment of secondary causes, TEE, survey for hypercoagulable states, and a look at cervicocephalic vessels. Among these, age was the greatest risk factor for recurrence.

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The American Heart Association has a program called the Cryptogenic Stroke Initiative to educate patients and health care providers about this disease. It also offers resources for stroke survivors to recognize changes in their health and help their healthcare providers identify the condition. In addition, the American Heart Association offers a toolkit to patients that can help them understand possible causes of stroke and how to minimize the risk of another one. There are a variety of lifestyle and treatment options to consider.

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In the United States, more than 200,000 strokes are classified as "cryptogenic" or undetermined causes. Cryptogenic stroke is more likely to be fatal than other strokes because the underlying cause is unknown. For this reason, prevention is the key to survival. Sadly, this task becomes more difficult if the underlying cause of the first stroke is not known. It is important to be aware of the risk factors to reduce the chance of cryptogenic stroke.

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The high prevalence of PFO may be the primary reason behind the association between PFO and cryptogenic stroke. However, the low likelihood of identifying the underlying cause of thrombus may make the association between PFO and cryptogenic stroke unlikely. Also, patients with PFOs with traditional vascular risk factors are more likely to have deep infarcts than younger patients. However, only TEE is able to visualize the PFO.

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Prolonged monitoring of rhythm is an important part of the workup for cryptogenic stroke. Although telemetry is typically used on a stroke unit, extended outpatient monitoring may increase the odds of detecting atrial fibrillation. If detected, atrial fibrillation may require long-term anticoagulation treatment. If detected, however, patients may have to undergo anticoagulation in the event of a cryptogenic stroke. The CrysTAL AF trial is a randomized prospective study. It will enroll 450 patients with cryptogenic stroke who do not have a history of AF. The study will also evaluate the time to detect AF within 6 months of stroke and continue to follow patients for at least 12 months.

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Anticoagulation is an important component of the treatment for patients with cryptogenic stroke. Generally, patients are treated with aspirin and an implantable cardiac monitor, and if anticoagulation is detected, anticoagulation is initiated. While there have been no studies comparing the use of anticoagulation with aspirin for cryptogenic stroke, future research is underway in a subgroup of patients who may benefit from it. Although the treatment options are still not clear, the most important aspect of this review is to formulate a practical diagnostic and treatment algorithm for patients with PFO and cryptogenic stroke.

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Cardioembolic mechanisms have been the subject of extensive research and are thought to be a possible etiology for cryptogenic stroke. However, some of these mechanisms have not been identified as primary causes, possibly due to the lack of research. In addition to the risk for CS associated with paroxysmal atrial fibrillation and other cardiac structural abnormalities, aortic valve stenosis may also be the cause.

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While the causes of a cryptogenic stroke may not be clear, an ESUS is often necessary to rule out other conditions. ESUS is a procedure that requires a specific workup and has high-risk implications for the diagnosis of stroke. The etiology of the stroke should be considered carefully and a vascular neurologist should perform the workup. Antiplatelet therapy (ACEI) may be indicated in selected patients who have paradoxical embolization of the PFO.