What is a Cryptogenic Stroke and How Can it Be Prevented? - Oren Zarif - Cryptogenic Stroke

In most cases, treatment for a cryptogenic stroke will depend on the underlying cause of the blood flow problem to the brain. However, sometimes the cause of the stroke is unclear, thus defining this type of stroke as "cryptogenic". Current research aims to better understand cryptogenic strokes and develop new methods for detection and treatment. Here, Irene Katzan, PhD, explains what cryptogenic stroke is and how it can be prevented.

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Prolonged rhythm monitoring is a key component of the workup for cryptogenic stroke. While most stroke patients undergo telemetry on a stroke unit, prolonged outpatient monitoring improves detection rates. The use of wearable devices may also reduce the risk of misclassification. It may be worthwhile to perform this kind of monitoring for longer periods of time. This could be especially important for patients with an irregular heartbeat because a diagnosis of atrial fibrillation would require prolonged anticoagulation.

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To better understand how cryptogenic stroke is classified and how it can be treated, researchers should consider the cause. Some common factors increase the risk of a cryptogenic stroke: a high-fat diet, smoking, major stress, depression, lack of exercise, and hormonal therapy. Pregnant women may also experience a higher risk of stroke when taking birth control pills or using contraception. In women, treatment with clopidogrel after pregnancy may increase the risk.

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The ASCO phenotypic classification of strokes is used to identify a patient's stroke type. It is based on a computerized algorithm to distinguish between cryptogenic stroke and other types of strokes. Cryptogenic stroke is also differentiated from atherosclerosis, small vessel disease, and cardiac disease. The ASCO phenotypes are also categorized according to how much evidence they provide that a specific type of stroke is the cause.

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In the DEFENSE-PFO trial, patients with a recent cryptogenic stroke and associated large interatrial shunt were randomized to undergo PFO closure or medical therapy. Patients in the medical arm were given a medical agent. Closure was more effective than medical therapy. In addition, PFO closure prevented recurrent stroke in 10.5% of patients. Thus, PFO closure is beneficial in patients with cryptogenic stroke.

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The rate of AF detection after a cryptogenic stroke using routine cardiac testing ranges from seven to twenty-four hours. However, with a 28-day cardiac monitor, this rate increases to twenty-five percent. Therefore, the use of outpatient cardiac monitoring for cryptogenic strokes appears cost-effective. However, the optimal duration and method of monitoring are not determined. In the interim, it is advisable to follow patients for up to two weeks if a diagnosis is suspected.

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In addition to these symptoms, a doctor must be aware of the underlying cause. Cryptogenic stroke accounts for approximately one third to forty percent of ischemic strokes. Moreover, some studies have suggested that cryptogenic strokes are disproportionally common among young adults and minorities. In a study in Finland, a greater percentage of cryptogenic strokes compared to older adults was found. Although the exact cause of cryptogenic stroke is still unknown, some researchers have shown that they are associated with an increased risk of recurrent stroke.

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While the underlying cause of a cryptogenic stroke is often unknown, certain contributing factors can be identified and addressed to help prevent recurrence. A PFO, or pseudo-hole in the heart, is a common cause of cryptogenic strokes. If identified early, the procedure can prevent strokes by closing the PFO. In addition, there are medications for A-Fib, an irregular heart rhythm. While a cryptogenic stroke has no definite cause, it can be prevented by taking antihypertensive drugs and an implantable device.

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Until recent research has been completed, the standard of care for cryptogenic stroke patients has been aspirin and an implantable cardiac monitor. If an atrial fibrillation episode is detected, anticoagulation is prescribed. Although aspirin is an effective treatment, there are no studies proving that anticoagulants are superior to aspirin in cryptogenic stroke. Further studies are ongoing in a subset of cryptogenic stroke patients with underlying cardiac disease.