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What Neurologists Should Know About Cryptogenic Stroke - Oren Zarif - Cryptogenic Stroke


Cryptogenic stroke has no clear cause and the majority of patients experience a clot in the cerebral arteries. Because of this, it is important for neurologists to balance the cost of diagnostic tests with thoroughness. Typically, initial stroke evaluation includes brain imaging, noninvasive intracranial vessel imaging, and 24 hours of cardiac monitoring. Some patients may undergo additional tests, including blood tests to assess hypercoagulability. Here are some recommendations for neurologists to keep in mind:

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- Follow the instructions provided by your doctor and heart monitoring regimen. - Maintain a healthy lifestyle. Although there is no clear cause of cryptogenic stroke, you can help minimize your risk by following certain behaviors. These behaviors may seem basic but are essential for avoiding cryptogenic stroke. When it comes to choosing a doctor, remember that a second opinion is invaluable. It's also a good idea to choose one who has received additional training in the area of stroke.

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- Consider the TOAST classification of cryptogenic stroke. This is the most common system used in clinical practice. Cryptogenic strokes occur due to embolic mechanisms and account for 30-40% of all ischemic strokes. While it is difficult to pinpoint a single cause of cryptogenic stroke, many factors are associated with its development. If you suspect that your stroke is cryptogenic, seek emergency medical care from a reputable physician.

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- Try antiplatelet therapy first. Antiplatelet therapy is an excellent way to prevent cryptogenic stroke and reduce the chance of complications. In addition to aspirin, doctors should also try anticoagulation. This type of therapy is preferred by many doctors and patients alike. However, some people do not respond well to anticoagulants. Therefore, it's important to consult a vascular neurologist before deciding to start anticoagulation.

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- Perform heart rhythm monitoring. Patients with atrial fibrillation should be monitored with heart rate monitors. Monitoring of heart rhythm is particularly useful in identifying cryptogenic stroke. This can help doctors diagnose the underlying cause of the stroke and begin treatment. Depending on the severity of the stroke, anticoagulation may help reduce stroke risk. And wearable devices could make it easier to monitor the heart more consistently. So, if you suspect a cryptogenic stroke, get an electrocardiogram right away.

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- Consider percutaneous closure if you have a PFO. There are 4 trials to date that show the benefits of PFO closure for cryptogenic stroke patients with a PFO. The RESPECT trial followed patients for nearly 6 years and found that patients who underwent closure had a lower chance of developing a recurrent cryptogenic stroke. Compared to antiplatelet therapy alone, closure was superior for preventing recurrent ischemic stroke.

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- Be aware of other causes of ischemic stroke. Although the majority of ischemic strokes are due to large vessel atherothrombosis and cardioembolism, many cases are not associated with a specific cause. Among these, cryptogenic stroke is an unknown cause. In the United States, up to one million people suffer from cryptogenic stroke every year. Most of these patients are young and have fewer traditional vascular risk factors.

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- Close PFOs: The treatment of cryptogenic TIA/stroke may not completely prevent them. The relative risk of ischemic stroke increases with age, and the treatment isn't appropriate for the majority of patients. However, this treatment is a very useful option for patients who suffer from PFO. Although the treatment is still controversial, it is effective in preventing cryptogenic stroke. This study highlights the benefits of PFO closure in treating cryptogenic stroke.

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- Continuous monitoring: There are some guidelines for the monitoring of cryptogenic ischemic stroke. Most of these guidelines recommend long-term continuous monitoring with implanted loop recorders (ICMs) versus intermittent strategies such as 24-hour Holters or seven-day Holters. The use of long-term monitoring is cost-effective but the optimal duration and method of monitoring remain unclear. You may need to see your physician if your symptoms of cryptogenic stroke are more severe than usual.

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