Highlights
- •Cryptogenic stroke is not a diagnostic entity, but includes strokes of many different aetiologies.
- •Potential aetiologies include occult atrial fibrillation, patent foramen ovale, atrial cardiopathy, and aortic arch atheroma.
- •Embolic stroke of unknown source (ESUS) is a recently developed concept, and diagnostic subgroup of cryptogenic stroke.
- •New potential investigative strategies include long-term cardiac monitoring, and new cardiac MR-imaging techniques.
- •The best preventive strategies for many of the potential causes of cryptogenic stroke are currently unknown.
Abstract
Secondary preventive strategies in ischaemic stroke depend on the underlying aetiology.
However, approximately one-third of ischaemic strokes remain unexplained, or ‘cryptogenic’.
There is a wide range of possible underlying causes in cryptogenic stroke, and the
best approach to secondary prevention of these may differ. To date, though, the widely
accepted and uniform secondary preventive strategy in this group consists of modification
of vascular risk factors, and of treatment with a combination of antiplatelet therapy
and antihypertensive and lipid-lowering medication.
Among the potential causes for cryptogenic stroke are occult atrial fibrillation,
patent foramen ovale, atrial cardiopathy, aortic arch atheroma and hypercoagulable
states. While it is possible to diagnose these conditions, in individual patients
there is often uncertainty over whether they have a directly causative role, are markers
of disease, or are innocent bystanders. Similarly, even if the cause is found, the
best secondary preventive strategies remain uncertain, which questions the benefit
of extensive investigations in a clinical setting. More recently, the concept of “embolic
stroke of unknown source (ESUS)” has been introduced, in the hope that anticoagulation
may offer better secondary prevention than antiplatelet therapy, but trials so far
have been negative.
At present, there is little justification for introducing extensive new investigative
strategies into the management of patients with cryptogenic stroke. Investigations
should be targeted at identifying those high-risk conditions which lead to a change
in management. Further investigations need to be tailored individually, according
to clinical circumstances. This should include identifying patients for participation
in clinical trials, as the significance and best management of many of the potential
causes for cryptogenic stroke require further research.
Keywords
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Article info
Publication history
Published online: January 11, 2019
Accepted:
January 10,
2019
Received:
January 2,
2019
Identification
Copyright
© 2019 Elsevier B.V. All rights reserved.
