Cryptogenic Stroke: Diagnostic Workup and Management

AbstractPurpose of reviewCryptogenic stroke describes a subset of ischemic stroke for which no cause can be found despite a structured investigation. There are a number of putative mechanisms of cryptogenic ischemic stroke including a covert structural cardiac lesion, paroxysmal atrial fibrillation, hypercoagulable state or undiagnosed malignancy. Because many of these proposed mechanisms are embolic – and based on studies of thrombus history showing commonalities between thrombus composition between cardioembolic and cryptogenic strokes – the concept of embolic stroke of undetermined source (ESUS) (Hart et al. Lancet Neurol. 13(4):429–38,2014; Stroke. 48(4):867 –72,2017) has been proposed to describe cryptogenic strokes that may warrant systemic anticoagulation. In this review, we discuss the phenomena of cryptogenic stroke, ESUS and a proposed management pathway.Recent findings1. The concept of ESUS was proposed in 2014 as a potentially useful therapeutic entity. Two recent trials – NAVIGATE-ESUS (Hart et al. N Engl J Med. 378(23):2191–201,2018) and RESPECT-ESUS (Diener2018) were proposed based on this concept. They were negative for their primary endpoint and for the secondary endpoint of ischemic stroke recurrence. Post-hoc analysis of the WARSS trial (Longstreth et al. Stroke. 44(3):714 –9,2013) suggested that people with elevated pro-BNP benefited from systemic anticoagulation whereas those with a normal pro-BNP did not. This led to the hypothesis that a s...
Source: Current Treatment Options in Cardiovascular Medicine - Category: Cardiology Source Type: research