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Potential Causes of Cryptogenic Stroke

Potential causes i Stock 641236100

A cryptogenic stroke is known as a stroke of “unknown cause”; however, awareness of the possible causes is important in reducing the risk of recurring stroke.

Icon pfo 1 2x

Patent Foramen Ovale (PFO)

Patent foramen ovale (PFO) is an embryonic defect, seen in up to 25% of adults¹, that has been associated with increased risk of ischemic, cryptogenic stroke. PFO is defined as an opening in the septum between the atria that acts as a conduit for emboli from the deep veins of the pelvis or legs to the brain.

The foramen ovale remains open post birth

Pfo figure 1 2x Before birth Open foramen ovale
Pfo figure 2 2x Post birth Natural closure of the foramen ovale
Pfo figure 3 2x Post birth Foramen ovale remains open, creating a PFO

Other potential causes

Occult paroxysmal atrial fibrillation

Atrial fibrillation puts the patient at a 5x greater risk of stroke.² Detection of AF is important in the workup of cryptogenic stroke in order to identify patients who might benefit from anticoagulant over antiplatelet therapy. Paroxysmal atrial fibrillation (AF) is often paroxysmal and asymptomatic, and thus may not be detected by standard short or intermediate-term cardiac monitoring.³

A number of technologies are available for extended cardiac monitoring, including continuous telemetry, ambulatory electrocardiography, serial ECGs, transtelephonic ECG monitoring, and insertable cardiac monitors. A complete review of the sensitivity of various modalities for detecting AF can be found in Glotzer et al., 2015.

Inherited thrombophilias

Thrombophilia is a predisposition to form blood clots inappropriately and is characterized by deficiencies and mutations in endogenous anticoagulants². Thrombophilia can cause a cryptogenic stroke; among patients in whom other causes have not been found, screening for inherited thrombophilias may be worthwhile.

Aortic arch atheroma

Some evidence from retrospective studies suggests a causal association between atherosclerotic disease of the aortic arch (atheroma or plaque) and increased risk of ischemic stroke. Aortic arch plaque has been shown independently with an increased risk of stroke.

Understand the options for PFO treatment

If your patient has had a cryptogenic stroke and has also been diagnosed with a PFO, it’s important to talk to them about the benefits and risks of available treatment options to reduce their risk of another stroke.

Treatment options
  1. Kent, D.M and Thaler, D.E. Is Patent Foramen Ovale a Modifiable Risk Factor for Stroke Recurrence? Stroke, 2010. DOI:10.1161/STROKEAHA.110.595140.
  2. Mahmood, Levy; Vasan, Wang (2013). "The Framingham Heart Study and the epidemiology of cardiovascular disease: a historical perspective" Lancet. 383 (9921): 999–1008
  3. Lewalter T and Boriani, G. Relevance of Monitoring Atrial Fibrillation in Clinical Practice Arrythmia & Electrophysiology Review 2012:1:54-8.
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