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Latest revision as of 03:14, 5 March 2020

In neurology, Cryptogenic stroke is stroke of undetermined source^[1].

Causes

Patent foramen ovale

One cause is paradoxical embolism that may be treated with patent foramen ovale closure^[2]^[3].

Atrial fibrillation

One cause is atrial fibrillation which may be detected by prolonged event monitors^[4] or prolonged, implantable recorders such as the LINQ^[5]^[6], or even smartphones^[7].

The various methods of diagnosis have been compared by a systematic reviews which:

recommends" sequentially combining cardiac monitoring methods"^[8]. An example of a phase 4 (second ambulatory period) consisted of mobile cardiac outpatient telemetry, external loop recording, and implantable loop recording is the http://www.tlcdiagnostics.com/healthcare-professionals/cardiac-monitoring/king-hearts
"evidence for a potential impact of PCM on secondary stroke prevention"^[9]

Clinical practice guidelines address the diagnosis strategy:

The 2019 AHA/ACC/HRS Focused Update of atrial fibrillation guidelines contain a new section, "7.12. Device Detection of AF and Atrial Flutter," which states "In patients with cryptogenic stroke (ie, stroke of unknown cause) in whom external ambulatory monitoring is inconclusive, implantation of a cardiac monitor (loop recorder) is reasonable to optimize detection of silent AF". However, the guidelines do not address alternative methods to detect atrial fibrillation^[10].
2016 Guidelines by the ESC state "In stroke patients, additional ECG monitoring by long-term noninvasive ECG monitors or implanted loop recorders should be considered to document silent atrial fibrillation."^[11]

The benefit of anticoagulation based on long-term monitoring is uncertain^[12].

Unknown source

For cryptogenic stroke on unknown source, anticoagulation may not help over aspirin^[13].

External links

References

↑ Saver JL (2016). "CLINICAL PRACTICE. Cryptogenic Stroke". N Engl J Med. 374 (21): 2065–74. doi:10.1056/NEJMcp1503946. PMID 27223148.
↑ Mas JL, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L; et al. (2017). "Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke". N Engl J Med. 377 (11): 1011–1021. doi:10.1056/NEJMoa1705915. PMID 28902593. Review in: Ann Intern Med. 2018 Jan 16;168(2):JC7
↑ Saver JL, Carroll JD, Thaler DE, Smalling RW, MacDonald LA, Marks DS; et al. (2017). "Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke". N Engl J Med. 377 (11): 1022–1032. doi:10.1056/NEJMoa1610057. PMID 28902590.
↑ Gladstone DJ, Spring M, Dorian P, Panzov V, Thorpe KE, Hall J; et al. (2014). "Atrial fibrillation in patients with cryptogenic stroke". N Engl J Med. 370 (26): 2467–77. doi:10.1056/NEJMoa1311376. PMID 24963566. Review in: Evid Based Med. 2014 Dec;19(6):235 Review in: Ann Intern Med. 2014 Nov 18;161(10):JC2 Review in: Ann Intern Med. 2014 Nov 18;161(10):JC3
↑ Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA; et al. (2014). "Cryptogenic stroke and underlying atrial fibrillation". N Engl J Med. 370 (26): 2478–86. doi:10.1056/NEJMoa1313600. PMID 24963567.
↑ Edwards SJ, Wakefield V, Jhita T, Kew K, Cain P, Marceniuk G (2020). "Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke: a systematic review and economic evaluation". Health Technol Assess. 24 (5): 1–184. doi:10.3310/hta24050. PMC 6983910 Check |pmc= value (help). PMID 31944175.
↑ Perez MV, Mahaffey KW, Hedlin H, Rumsfeld JS, Garcia A, Ferris T; et al. (2019). "Large-Scale Assessment of a Smartwatch to Identify Atrial Fibrillation". N Engl J Med. 381 (20): 1909–1917. doi:10.1056/NEJMoa1901183. PMID 31722151.
↑ Sposato LA, Cipriano LE, Saposnik G, Ruíz Vargas E, Riccio PM, Hachinski V (2015). "Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis". Lancet Neurol. 14 (4): 377–87. doi:10.1016/S1474-4422(15)70027-X. PMID 25748102.
↑ Tsivgoulis G, Katsanos AH, Grory BM, Köhrmann M, Ricci BA, Tsioufis K; et al. (2019). "Prolonged Cardiac Rhythm Monitoring and Secondary Stroke Prevention in Patients With Cryptogenic Cerebral Ischemia". Stroke. 50 (8): 2175–2180. doi:10.1161/STROKEAHA.119.025169. PMID 31216964.
↑ January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC; et al. (2019). "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons". Circulation. 140 (2): e125–e151. doi:10.1161/CIR.0000000000000665. PMID 30686041.
↑ Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B; et al. (2016). "2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS". Eur J Cardiothorac Surg. 50 (5): e1–e88. doi:10.1093/ejcts/ezw313. PMID 27663299.
↑ Martin DT, Bersohn MM, Waldo AL, Wathen MS, Choucair WK, Lip GY; et al. (2015). "Randomized trial of atrial arrhythmia monitoring to guide anticoagulation in patients with implanted defibrillator and cardiac resynchronization devices". Eur Heart J. 36 (26): 1660–8. doi:10.1093/eurheartj/ehv115. PMID 25908774.
↑ Diener HC, Sacco RL, Easton JD, Granger CB, Bernstein RA, Uchiyama S; et al. (2019). "Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source". N Engl J Med. 380 (20): 1906–1917. doi:10.1056/NEJMoa1813959. PMID 31091372.

[pmid27223148-1] Saver JL (2016). "CLINICAL PRACTICE. Cryptogenic Stroke". N Engl J Med. 374 (21): 2065–74. doi:10.1056/NEJMcp1503946. PMID 27223148.

[pmid28902593-2] Mas JL, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L; et al. (2017). "Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke". N Engl J Med. 377 (11): 1011–1021. doi:10.1056/NEJMoa1705915. PMID 28902593. Review in: Ann Intern Med. 2018 Jan 16;168(2):JC7

[pmid28902590-3] Saver JL, Carroll JD, Thaler DE, Smalling RW, MacDonald LA, Marks DS; et al. (2017). "Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke". N Engl J Med. 377 (11): 1022–1032. doi:10.1056/NEJMoa1610057. PMID 28902590.

[pmid24963566-4] Gladstone DJ, Spring M, Dorian P, Panzov V, Thorpe KE, Hall J; et al. (2014). "Atrial fibrillation in patients with cryptogenic stroke". N Engl J Med. 370 (26): 2467–77. doi:10.1056/NEJMoa1311376. PMID 24963566. Review in: Evid Based Med. 2014 Dec;19(6):235 Review in: Ann Intern Med. 2014 Nov 18;161(10):JC2 Review in: Ann Intern Med. 2014 Nov 18;161(10):JC3

[pmid24963567-5] Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA; et al. (2014). "Cryptogenic stroke and underlying atrial fibrillation". N Engl J Med. 370 (26): 2478–86. doi:10.1056/NEJMoa1313600. PMID 24963567.

[pmid31944175-6] Edwards SJ, Wakefield V, Jhita T, Kew K, Cain P, Marceniuk G (2020). "Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke: a systematic review and economic evaluation". Health Technol Assess. 24 (5): 1–184. doi:10.3310/hta24050. PMC 6983910 Check |pmc= value (help). PMID 31944175.

[pmid31722151-7] Perez MV, Mahaffey KW, Hedlin H, Rumsfeld JS, Garcia A, Ferris T; et al. (2019). "Large-Scale Assessment of a Smartwatch to Identify Atrial Fibrillation". N Engl J Med. 381 (20): 1909–1917. doi:10.1056/NEJMoa1901183. PMID 31722151.

[pmid25748102-8] Sposato LA, Cipriano LE, Saposnik G, Ruíz Vargas E, Riccio PM, Hachinski V (2015). "Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis". Lancet Neurol. 14 (4): 377–87. doi:10.1016/S1474-4422(15)70027-X. PMID 25748102.

[pmid31216964-9] Tsivgoulis G, Katsanos AH, Grory BM, Köhrmann M, Ricci BA, Tsioufis K; et al. (2019). "Prolonged Cardiac Rhythm Monitoring and Secondary Stroke Prevention in Patients With Cryptogenic Cerebral Ischemia". Stroke. 50 (8): 2175–2180. doi:10.1161/STROKEAHA.119.025169. PMID 31216964.

[pmid30686041-10] January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC; et al. (2019). "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons". Circulation. 140 (2): e125–e151. doi:10.1161/CIR.0000000000000665. PMID 30686041.

[pmid27663299-11] Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B; et al. (2016). "2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS". Eur J Cardiothorac Surg. 50 (5): e1–e88. doi:10.1093/ejcts/ezw313. PMID 27663299.

[pmid25908774-12] Martin DT, Bersohn MM, Waldo AL, Wathen MS, Choucair WK, Lip GY; et al. (2015). "Randomized trial of atrial arrhythmia monitoring to guide anticoagulation in patients with implanted defibrillator and cardiac resynchronization devices". Eur Heart J. 36 (26): 1660–8. doi:10.1093/eurheartj/ehv115. PMID 25908774.

[pmid31091372-13] Diener HC, Sacco RL, Easton JD, Granger CB, Bernstein RA, Uchiyama S; et al. (2019). "Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source". N Engl J Med. 380 (20): 1906–1917. doi:10.1056/NEJMoa1813959. PMID 31091372.

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@@ Line 3: / Line 3: @@
 {{SI}}
-In [[neurology]], '''{{PAGENAME}}''' is [[stroke]] of undetermined source.
+In [[neurology]], '''{{PAGENAME}}''' is [[stroke]] of undetermined source<ref name="pmid27223148">{{cite journal| author=Saver JL| title=CLINICAL PRACTICE. Cryptogenic Stroke. | journal=N Engl J Med | year= 2016 | volume= 374 | issue= 21 | pages= 2065-74 | pmid=27223148 | doi=10.1056/NEJMcp1503946 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27223148  }} </ref>.
+==Causes==
+===Patent foramen ovale===
 One cause is [[paradoxical embolism]] that may be treated with patent [[foramen ovale]] closure<ref name="pmid28902593">{{cite journal| author=Mas JL, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L et al.| title=Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke. | journal=N Engl J Med | year= 2017 | volume= 377 | issue= 11 | pages= 1011-1021 | pmid=28902593 | doi=10.1056/NEJMoa1705915 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28902593  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=29335719 Review in: Ann Intern Med. 2018 Jan 16;168(2):JC7] </ref><ref name="pmid28902590">{{cite journal| author=Saver JL, Carroll JD, Thaler DE, Smalling RW, MacDonald LA, Marks DS et al.| title=Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke. | journal=N Engl J Med | year= 2017 | volume= 377 | issue= 11 | pages= 1022-1032 | pmid=28902590 | doi=10.1056/NEJMoa1610057 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28902590  }} </ref>.
-One cause is [[Atrial fibrillation]] with may be detected by prolonged, implantable recorders such as the LINQ<ref name="pmid24963567">{{cite journal| author=Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA et al.| title=Cryptogenic stroke and underlying atrial fibrillation. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 26 | pages= 2478-86 | pmid=24963567 | doi=10.1056/NEJMoa1313600 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24963567  }} </ref><ref name="pmid31944175">{{cite journal| author=Edwards SJ, Wakefield V, Jhita T, Kew K, Cain P, Marceniuk G| title=Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke: a systematic review and economic evaluation. | journal=Health Technol Assess | year= 2020 | volume= 24 | issue= 5 | pages= 1-184 | pmid=31944175 | doi=10.3310/hta24050 | pmc=6983910 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31944175  }} </ref>.
+===Atrial fibrillation===
+One cause is [[atrial fibrillation]] which may be detected by prolonged event monitors<ref name="pmid24963566">{{cite journal| author=Gladstone DJ, Spring M, Dorian P, Panzov V, Thorpe KE, Hall J et al.| title=Atrial fibrillation in patients with cryptogenic stroke. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 26 | pages= 2467-77 | pmid=24963566 | doi=10.1056/NEJMoa1311376 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24963566  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=25185267 Review in: Evid Based Med. 2014 Dec;19(6):235]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=25402535 Review in: Ann Intern Med. 2014 Nov 18;161(10):JC2]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=25402536 Review in: Ann Intern Med. 2014 Nov 18;161(10):JC3] </ref> or prolonged, implantable recorders such as the LINQ<ref name="pmid24963567">{{cite journal| author=Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA et al.| title=Cryptogenic stroke and underlying atrial fibrillation. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 26 | pages= 2478-86 | pmid=24963567 | doi=10.1056/NEJMoa1313600 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24963567  }} </ref><ref name="pmid31944175">{{cite journal| author=Edwards SJ, Wakefield V, Jhita T, Kew K, Cain P, Marceniuk G| title=Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke: a systematic review and economic evaluation. | journal=Health Technol Assess | year= 2020 | volume= 24 | issue= 5 | pages= 1-184 | pmid=31944175 | doi=10.3310/hta24050 | pmc=6983910 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31944175  }} </ref>, or even smartphones<ref name="pmid31722151">{{cite journal| author=Perez MV, Mahaffey KW, Hedlin H, Rumsfeld JS, Garcia A, Ferris T et al.| title=Large-Scale Assessment of a Smartwatch to Identify Atrial Fibrillation. | journal=N Engl J Med | year= 2019 | volume= 381 | issue= 20 | pages= 1909-1917 | pmid=31722151 | doi=10.1056/NEJMoa1901183 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31722151  }} </ref>.
+The various methods of diagnosis have been compared by a [[systematic review]]s which:
+* recommends" sequentially combining cardiac monitoring methods"<ref name="pmid25748102">{{cite journal| author=Sposato LA, Cipriano LE, Saposnik G, Ruíz Vargas E, Riccio PM, Hachinski V| title=Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. | journal=Lancet Neurol | year= 2015 | volume= 14 | issue= 4 | pages= 377-87 | pmid=25748102 | doi=10.1016/S1474-4422(15)70027-X | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25748102  }} </ref>. An example of a phase 4 (second ambulatory period) consisted of mobile cardiac outpatient telemetry, external loop recording, and implantable loop recording is the http://www.tlcdiagnostics.com/healthcare-professionals/cardiac-monitoring/king-hearts
+* "evidence for a potential impact of PCM on secondary stroke prevention"<ref name="pmid31216964">{{cite journal| author=Tsivgoulis G, Katsanos AH, Grory BM, Köhrmann M, Ricci BA, Tsioufis K | display-authors=etal| title=Prolonged Cardiac Rhythm Monitoring and Secondary Stroke Prevention in Patients With Cryptogenic Cerebral Ischemia. | journal=Stroke | year= 2019 | volume= 50 | issue= 8 | pages= 2175-2180 | pmid=31216964 | doi=10.1161/STROKEAHA.119.025169 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31216964  }} </ref>
+[[Clinical practice guideline]]s address the diagnosis strategy:
+* The 2019 AHA/ACC/HRS Focused Update of atrial fibrillation guidelines contain a new section, "7.12. Device Detection of AF and Atrial Flutter," which states "In patients with cryptogenic stroke (ie, stroke of unknown cause) in whom external ambulatory monitoring is inconclusive, implantation of a cardiac monitor (loop recorder) is reasonable to optimize detection of silent AF". However, the guidelines do not address alternative methods to detect atrial fibrillation<ref name="pmid30686041">{{cite journal| author=January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC et al.| title=2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. | journal=Circulation | year= 2019 | volume= 140 | issue= 2 | pages= e125-e151 | pmid=30686041 | doi=10.1161/CIR.0000000000000665 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30686041  }} </ref>.
+* 2016 Guidelines by the ESC state "In stroke patients, additional ECG monitoring by long-term noninvasive ECG monitors or implanted loop recorders should be considered to document silent atrial fibrillation."<ref name="pmid27663299">{{cite journal| author=Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B et al.| title=2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. | journal=Eur J Cardiothorac Surg | year= 2016 | volume= 50 | issue= 5 | pages= e1-e88 | pmid=27663299 | doi=10.1093/ejcts/ezw313 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27663299  }} </ref>
+The benefit of anticoagulation based on long-term monitoring is uncertain<ref name="pmid25908774">{{cite journal| author=Martin DT, Bersohn MM, Waldo AL, Wathen MS, Choucair WK, Lip GY et al.| title=Randomized trial of atrial arrhythmia monitoring to guide anticoagulation in patients with implanted defibrillator and cardiac resynchronization devices. | journal=Eur Heart J | year= 2015 | volume= 36 | issue= 26 | pages= 1660-8 | pmid=25908774 | doi=10.1093/eurheartj/ehv115 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25908774  }} </ref>.
+===Unknown source===
 For cryptogenic stroke on unknown source, anticoagulation may not help over aspirin<ref name="pmid31091372">{{cite journal| author=Diener HC, Sacco RL, Easton JD, Granger CB, Bernstein RA, Uchiyama S et al.| title=Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source. | journal=N Engl J Med | year= 2019 | volume= 380 | issue= 20 | pages= 1906-1917 | pmid=31091372 | doi=10.1056/NEJMoa1813959 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31091372  }} </ref>.