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Cryptogenic Stroke: Advances in Diagnosis and Treatment

This article explores the evolving understanding of cryptogenic stroke and the latest developments in its diagnosis and treatment. It discusses the concept of Embolic Strokes of Undetermined Source (ESUS), diagnostic criteria and algorithms, as well as potential causes and recurrence rates. The article also contemplates the use of novel oral anticoagulants (NOACs) as a potential alternative to antiplatelet therapy.

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Cryptogenic Stroke: Advances in Diagnosis and Treatment

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  1. Κρυπτογενή εγκεφαλικά έμφρακτα: Εξελίξεις στηνδιάγνωση και θεραπεία Γεώργιος Ντάιος Επίκουρος Καθηγητής Παθολογίας, Πανεπιστήμιο Θεσσαλίας

  2. Disclosures Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis. Honoraria: Medtronic; Quintiles; CHUV; Belgian Stroke Council; Boehringer-Ingelheim. Speaker fees: Sanofi; Boehringer-Ingelheim, Galenica Support to attend conferences: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer-Ingelheim; Galenica;Elpen; Bristol Myers Squibb. Participation in trials: • NAVIGATE-ESUS / National Coordinator (Greece) • GLORIA-AF / Sub-investigator (Larissa). • FOURIER / Principal investigator (Larissa). • ENOS / National Coordinator (Greece). • EBBINGHAUS / Principal Investigator (Larissa). • PRECIOUS / National Coordinator (Greece). • BIOSIGNAL / Principal Investigator (Larissa). • PREVISE / Principal investigator (Larissa).

  3. TOAST classification Adams. Stroke 1993

  4. TOAST classification ?

  5. Cryptogenic stroke: not rare

  6. Cryptogenic stroke: not innocent Ntaios, Vemmos. Eur J Neurol. 2014; 21:1108-14

  7. Cryptogenic stroke: what actually do you mean? Cryptogenic Not investigated Multiple causes Really cryptogenic

  8. ESUS: Embolic Strokes of Undetermined Source Hart. Lancet Neurol 2014; 13: 429–38

  9. ESUS: Embolic Strokes of Undetermined Source

  10. Lacunar strokes are not embolic

  11. ESUS: Embolic Strokes of Undetermined Source

  12. ESUS: potential causes Hart. Lancet Neurol 2014; 13: 429–38

  13. ESUS: diagnostic criteria • Stroke detected by CT or MRI that is not lacunar. • Absence of extracranial or intracranial atherosclerosis causing >50% luminal stenosis in arteries supplying the area of ischemia. • No major-risk cardioembolic source of embolism(permanent or paroxysmal AF, sustained atrial flutter, intracardiac thrombus, prosthetic cardiac valve, atrial myxoma or other cardiac tumours, mitral stenosis, recent (<4 weeks) MI, LVEF<30%, valvularvegetations, or infective endocarditis). • No other specific cause of stroke identified. Hart. Lancet Neurol 2014; 13: 429–38

  14. ESUS: diagnostic algorithm • Brain CT or MRI • 12-lead ECG • Precordial echocardiography • Imaging of both extra- and intracranial arteries supplying the area of brain ischemia • Cardiac monitoring for ≥24hours with automated rhythm detection Hart. Lancet Neurol 2014; 13: 429–38

  15. CRYSTAL-AF Sanna. N Engl J Med 2014;370:2478-86

  16. CRYSTAL-AF 8.9% vs. 1.4% 12.4% vs. 2.0% 30.0% vs. 3.0% Sanna. N Engl J Med 2014;370:2478-86

  17. CRYSTAL-AF

  18. EMBRACE Gladstone. N Engl J Med 2014;370:2467-77

  19. EMBRACE Gladstone. N Engl J Med 2014;370:2467-77

  20. EMBRACE Gladstone. N Engl J Med 2014;370:2467-77

  21. ESUS in the Athens Stroke Registry Ntaios, Vemmos. Stroke 2015; 46:176-81

  22. Ntaios, Vemmos. Stroke 2015; 46:176-81

  23. ESUS: 5-yrs stroke recurrence Ntaios, Vemmos. Stroke, underreview

  24. AHA Stroke Guidelines Furie. Stroke 2010

  25. NAVIGATE- ESUS Rivaroxaban 15mg 1x1 R Aspirin 100mg 1x1

  26. RESPECT - ESUS Dabigatran 110/150 1x2 R Aspirin 100mg 1x1

  27. Everybody gets happy! • Half stroke patients get an anticoagulant!

  28. Take-home messages • Cryptogenic  ESUS • ~10% of all stroke patients • ESUS needs a complete (?) diagnostic work-up • Covert AF is the most common underlying factor • High(est?) recurrence rate • NOACs to replace antiplatelets?

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