Abstract
In a significant proportion of stroke patients (20–40%), the exact cause of stroke cannot be clearly identified. In some, stroke risk factors are identified, but it is not possible to know definitively whether the risk factor i causally linked to the stroke. A large subgroup of patients with such “undetermined” stroke mechanisms has clinical syndromes and neuroimaging consistent with an embolic event.
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References
Bogousslavsky J, Caplan L, eds. Stroke Syndromes, 2nd ed. Cambridge, UK: Cambridge University Press, 2001.
Pullicino P. Lenticulostriate arteries. In: Bogousslavsky J, Caplan L, eds. Stroke Syndromes. Cambridge, UK: Cambridge University Press, 2001:428–438.
Caplan L, Tettenborn B. Vertebrobasilar occlusive disease: review of selected aspects. 2. Posterior circulation embolism. Cerebrovasc Dis 1992;2:320–326.
Gan R, Sacco R, Kargman J, Roberts J, Boden-Albala B, Gu Q. Testing the validity of the lacunar hypothesis: the Northern Manhattan Stroke Study experience. Neurology 1997;48:1204–1211.
Ay H, Oliveira-Filho J, Buonanno F, et al. An identifiable subset of lacunar infarctions caused by embolism. Stroke 1999;30:2644–2650.
Sacco R, Ellenberg J, Mohr J, et al. Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Ann Neurol 1989;25:382–390.
Sacco R, Shi T, Zamanillo M, Kargman D. Predictors of mortality and recurrence after hospitalized cerebral infarction in an urban population: the Northern Manhattan Stroke Study. Neurology 1994;44:626–634.
Lechat P, Mas J, Lascault G, et al. Prevalence of patent foramen ovale in patients with stroke. N Eng J Med 1988;318:1148–1152.
Kerut EK, Norfleet WT, Plotnick GD, Giles TD. Patent foramen ovale: a review of associated conditions and the impact of physiological size. J Am Coll Cardiol 2001;38:613–623.
Hagen P, Scholz D, Edwards W. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17–20.
Lamy C, Giannesini C, Zuber M, et al. Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA Study. Atrial Septal Aneurysm. Stroke 2002;33:706–711.
Bogousslavsky J, Garazi S, Jeanrenaud X, Aebischer N, Van Melle G. Stroke recurrence in patients with patent foramen ovale. Neurology 1996;46:1301–1306.
Di Tullio M, Sacco RL, Gopal A, Mohr JP, Homma S. Patent foramen ovale as a risk factor for cryptogenic stroke. Ann Intern Med 1992;117:461–465.
Webster M, Chancellor A, Smith H, et al. Patent foramen ovale in young stroke patients. Lancet 1988;2:11–12.
De Belder M, Tourikis L, Leech G, Camm A. Risk of patent foramen ovale for thromboembolic events in all age groups. Am J Cardiol 1992;69:1316–1320.
Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation 2002;105:2625–2631.
Cujec B, Mainra R, Johnson DH. Prevention of recurrent cerebral ischemic events in patients with patent foramen ovale and cryptogenic strokes or transient ischemic attacks. Can J Cardiol 1999;15:57–64.
Mas JL, Zuber M. Recurrent cerebrovascular events in patients with patent foramen ovale, atrial septal aneurysm, or both and cryptogenic stroke or transient ischemic attack. French Study Group on Patent Foramen Ovale and Atrial Septal Aneurysm. Am Heart J 1995;130:1083–1088.
Mas J, Arquizan C, Lamy C, et al. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 2001;345: 1740–1746.
De Castro S, Cartoni D, Fiorelli M, et al. Morphological and functional characteristics of patent foramen ovale and their embolic implications. Stroke 2000;31: 2407–2413.
Cabanes L, Mas JL, Cohen A, et al. Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. A study using transesophageal echocardiography. Stroke 1993;24:1865–1873.
Homma S, Di Tullio MR, Sacco RL, Mihalatos D, Li Mandri G, Mohr JP. Characteristics of patent foramen ovale associated with cryptogenic stroke. A biplane transesophageal echocardiographic study. Stroke 1994;25:582–586.
Steiner MM, Di Tullio MR, Rundek T, et al. Patent foramen ovale size and embolic brain imaging findings among patients with ischemic stroke. Stroke 1998;29: 944–948.
Hausmann D, Mugge A, Daniel W. Identification of patent foramen ovale permitting paradoxic embolism. J Am Coll Cardiol 1995;26:1030–1038.
Van Camp G, Schulze D, Cosyns B, Vandenbossche J. Relation between patent foramen ovale and unexplained stroke. Am J Cardiol 1993;71:596–598.
Serena J, Segura T, Perez Ayuso MJ, Bassaganyas J, Molins A, Davalos A. The need to quantify right-to-left shunt in acute ischemic stroke: a case-control study. Stroke 1998;29:1322–1328.
Nedeltchev K, Arnold M, Wahl A, et al. Outcome of patients with cryptogenic stroke and patent foramen ovale. J Neurol Neurosurg Psychiatry 2002;72:347–350.
Stollberger C, Slany J, Schuster I, et al. The prevalence of deep venous thrombosis in patients with suspected paradoxical embolism. Ann Intern Med 1993;119: 461–465.
Ruchat P, Bogousslavsky J, Hurni M, Fischer AP, Jeanrenaud X, von Segesser LK. Systematic surgical closure of patent foramen ovale in selected patients with cerebrovascular events due to paradoxical embolism. Early results of a preliminary study. Eur J Cardiothorac Surg 1997;11:824–827.
Nighoghossian N, Perinetti M, Barthelet M, Adeleine P, Trouillas P. Potential cardioembolic sources of stroke in patients less than 60 years of age. Eur Heart J 1996;17:590–594.
Berkompas D, Sagar K. Accuracy of color Doppler transesophageal echocardiography for the diagnosis of patent foramen ovale. J Am Soc Echocardiogr 1994;7: 253–256.
Devuyst G, Bogousslavsky J, Ruchat P, et al. Prognosis after stroke followed by surgical closure of patent foramen ovale: a prospective follow-up study with brain MRI and simultaneous transesophageal and transcranial Doppler ultrasound. Neurology 1996;47:1162–1166.
Dearani J, Ugurlu B, Danielson G, et al. Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic event. Circulation 1999;100(19 Suppl):II171–II175.
Homma S, Di Tullio MR, Sacco RL, Sciacca RR, Smith C, Mohr JP. Surgical closure of patent foramen ovale in cryptogenic stroke patients. Stroke 1997;28:2376–2381.
Konstantinides S, Geibel A, Olschewski M, et al. A comparison of surgical and medical therapy for atrial septal defect in adults. N Engl J Med 1995:469–473.
Schulman S, Granqvist S, Holmstrom M, et al. The duration of oral anticoagulant therapy after a second episode of venous thromboembolism. The Duration of Anticoagulation Trial Study Group. N Engl J Med 1997;336:393–398.
Hung J, Landzberg M, Jenkins K, et al. Closure of patent foramen ovale for paradoxical emboli: intermediate-term risk of recurrent neurological events following transcatheter device placement. J Am Coll Cardiol 2000;35:1311–1316.
Bridges ND, Hellenbrand W, Latson L, Filiano J, Newburger JW, Lock JE. Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation 1992;86:1902–1908.
Windecker S, Wahl A, Chatterjee T, et al. Percutaneous closure of patent foramen ovale in patients with paradoxical embolism: long-term risk of recurrent thromboembolic events. Circulation 2000;101:893–909.
Lethen H, Flachskampf F, Schneider R, et al. Frequency of deep vein thrombosis in patients with patent foramen ovale and ischemic stroke or transient ischemic attack. Am J Cardiol 1997;80:1066–1069.
Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. The French Study of Aortic Plaques in Stroke Group. N Engl J Med 1996; 334:1216–1221.
Amarenco P, Duyckaerts C, Tzourio C, Henin D, Bousser M, Hauw J. The prevalence of ulcerated plaques in the aortic arch in patients with stroke. N Engl J Med 1992:326:221–225.
Mitusch R, Doherty C, Wucherpfennig H, et al. Vascular events during follow-up in patients with aortic arch atherosclerosis. Stroke 1997;28:36–39.
Kessler C, Mitusch R, Guo Y, Rosengart A, Sheikhzadeh A. Embolism from the aortic arch in patients with cerebral ischemia. Thromb Res 1996;84:145–155.
Kronzon I, Tunick PA. Atheromatous disease of the thoracic aorta: pathologic and clinical implications. Ann Intern Med 1997;126:629–637.
Toyoda K, Yasaka M, Nagata S, Yamaguchi T. Aortogenic embolic stroke: a transesophageal echocardiographic approach. Stroke 1992;23:1056–1061.
Karalis D, Chandrasekaran K, Victor M, Ross J, Mintz G. Recognition and embolictia1of tarttc1oti d TAC 11 Cadi 99 .1 7 . 7 7Qaasois. J 1 .J11 9 1 I . 3 I O.
Amarenco P, Cohen A, Tzourio C, et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med 1994;1994:1474–1479.
Tunick P, Rosenzweig B, Katz E, Freedberg R, Perez J, Kronzon I. High risk for vascular events in patients with protruding aortic atheromas: a prospective study. J Am Coll Cardiol 1994;23:1085–1090.
Tunick PA, Kronzon I. Atheromas of the thoracic aorta: clinical and therapeutic update. J Am Coll Cardiol 2000;35:545–554.
Stone DA, Hawke MW, LaMonte M, et al. Ulcerated atherosclerotic plaques in the thoracic aorta are associated with cryptogenic stroke: a multiplane transesophageal echocardiographic study. Am Heart J 1995;130:105–108.
Agmon Y, Khandheria BK, Meissner I, et al. Independent association of high blood pressure and aortic atherosclerosis: a population-based study. Circulation 2000; 102:2087–2093.
Tribouilloy CM, Peltier M, Iannetta Peltier MC, Trojette F, Andrejak M, Lesbre JP. Plasma homocysteine and severity of thoracic aortic atherosclerosis. Chest 2000; 118:1685–1689.
Sen S, Oppenheimer SM, Lima J, Cohen B. Risk factors for progression of aortic atheroma in stroke and transient ischemic attack patients. Stroke 2002;33:930–935.
Guo Y, Jiang X, Zhang S, Chen S, Li G. Application of transesophageal echocardiography to aortic embolic stroke. Chin Med J (Engl) 2002;115:525–528.
Collaboration AT. Collaborative overview of randomised trials of antiplatelet therapy. I. Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ 1994;308:81–106.
Hacke W. From CURE to MATCH: ADP receptor antagonists as the treatment ot choice for high-risk atherothrombotic patients. Cerebrovasc Dis 2002;13(Suppl 1): 22–26.
Ferrari E, Vidal R, Chevallier T, Baudouy M. Atherosclerosis of the thoracic aorta and aortic debris as a marker of poor prognosis: benefit of oral anticoagulants. J Am Coll Cardiol 1999;33:1317–1322.
Tunick P, Lackner H, Katz E, Culliford A, Giangola G, Kronzon I. Multiple emboli from a large aortic arch thrombus in a patient with thrombotic diathesis. Am Heart J 1992;124:239–241.
Tunick P, Culliford A, Lamparello P, Kronzon I. Atheromatosis of the aortic arch as an occult source of multiple systemic emboli. Ann Intern Med 1991;114:391–392.
Nihoyannopoulos P, Joshi J, Athanasopoulos G, Oakley C. Detection of atherosclerotic lesions in the aorta by transesophageal echocardiography. Am J Cardiol 1993;71:1208–1212.
Freedberg R, Tunick P, Culliford A, Tatelbaum R, Kronzon I. Disappearance of a large intraaortic mass in a patient with prior systemic embolization. Am Heart J 1993;125:1445–1447.
Bansal R, Pauls G, Shankel S. Blue digit syndrome: transesophageal echocardiographic identification of thoracic aortic plaque-related thrombi and successful outcome with warfarin. J Am Soc Echocardiogr 1993;6:319–323.
Bruns F, Segel D, Adler S. Control of cholesterol embolization by discontinuation of anticoagulant therapy. Am J Med Sci 1978;275:105–108.
Hyman B, Landas S, Ashman R, Schelper R, Robinson K. wartarin-related purple toes syndrome and cholesterol microembolization. Am J Med 1987;82:1233–1237.
Culliford A, Tunick P, Katz E, et al. Initial experience with removal of protruding atheroma from the aortic arch: diagnosis by transesophageal echo, operative techniaue, and follow-up. J Am Coll Cardiol 1993;21:342A.
Hogue CW, Sundt TM, Goldberg M, Barner H, Davila Roman VG. Neurological complications of cardiac surgery: the need for new paradigms in prevention and treatment. Sem Thorac Cardiovasc Surg 1999;11:105–115.
Bushnell C, Goldstein L. Diagnostic testing for coagulopathies in patients with ischemic stroke. Stroke 2000;31:3067–3078.
Goldstein L, Adams R, Becker K, et al. AHA scientific statement: primary prevention of ischemic stroke. A statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke 2001;32:280–299.
Barinagarrementeria F, Cantu-Brito C, De La Pena A, Izaguirre R. Prothrombotic states in young people with idiopathic stroke. A prospective study. Stroke 1994;25: 287–290.
Barinagarrementeria F, Gonzalez-Duarte A, Cantu-Brito C. Prothrombotic states and cerebral ischemia [in Spanish]. Rev Neurol 1998;26:85–91.
Chan AK, deVeber G. Prothrombotic disorders and ischemic stroke in children. Sem Pediatr Neurol 2000;7:301–308.
Bauer K. The thrombophilias: well-defined risk factors with uncertain therapeutic implications. Ann Intern Med 2001;135:367–373.
Fihn S, Callahan C, Martin D, McDonnel M, Henikoff J, White R. The risk for and severity of bleeding complications in elderly patients treated with warfarin. The National Consortium of Anticoagulation Clinics. Ann Intern Med 1996;124: 970–979.
Hughes G. Thrombosis, abortion, cerebral disease and lupus anticoagulant. BMJ 1983;187:1088–1091.
Cervera R, Piette JC, Font J, et al. Antiphospholipid syndrome: clinical and immunologic manifestations and patterns of disease expression in a cohort of 1000 patients. Arthritis Rheum 2002;46:1019–1027.
Petri M. Epidemiology of the antiphospholipid antibody syndrome. J Autoimmun 2000;15:145–151.
Vila P, Hernandez M, Lopez-Fernandez M, Battle J. Prevalence, follow-up and clinical significance of the anticardiolipin antibodies in normal subjects. Thromb Haemost 1994;72:209–213.
Blohorn A, Guegan Massardier E, Triquenot A, et al. Antiphospholipid antibodies in the acute phase of cerebral ischaemia in young adults: a descriptive study of 139 patients. Cerebrovasc Dis 2002;13:156–162.
Nencini P, Baruffi MC, Abbate R, Massai G, Amaducci L, Inzitari D. Lupus anticoagulant and anticardiolipin antibodies in young adults with cerebral ischemia. Stroke 1992;23:189–193.
Group A. Anticardiolipin antibodies are an independent risk factor for first ischemic stroke. The Antiphospholipid Antibodies in Stroke Study (APASS) Group. Neurology 1993;43:2069–2073.
Mohr J, Thompson J, Lazar R, et al. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 2001;345:1444–1451.
Mohr JP. Prevention of recurrent ischemic stroke: recent clinical trial results [in Spanish]. Neurologia 2002;17:378–382.
Levine S, Brey R, Tilley B, et al. APL and stroke study (APASS). Presented at: 10th International Congress on Antiphospholipid Antibodies, Sept. 29-Oct. 3,2002, Giardini Naxos, Taormina, Sicily, Italy. Abstract 258.
Levine SR, Brey RL, Sawaya KL, et al. Recurrent stroke and thrombo-occlusive events in the antiphospholinid syndrome. Ann Neurol 1995;3R :119–194
Kittner SJ, Gorelick PB. Antiphospholipid antibodies and stroke: an epidemiological perspective. Stroke 1992;23:119–122.
Futrell N, Millikan C. Frequency, etiology and prevention of stroke in patients with systemic lupus erythematosus. Stroke 1989;20:583–591.
Khamashta M, Guadrado M, Mujic F, Taub N, Hunt B, Hughes G. The management of thrombosis in the antiphospholipid-antibody syndrome. N Engl J Med 1995; 332:993–1027.
Levine S, Salowich-Palm L, Sawaya K, et al. IgG anticardiolipin antibody titer > 40 GPL and the risk of subsequent thrombo-occlusive events and death. A prospective cohort study. Stroke 1997;28:1660–1665.
Tanne D, D’Olhaberriague L, Schultz LR, Salowich-Palm L, Sawaya KL, Levine SR. Anticardiolipin antibodies and their associations with cerebrovascular risk factors. Neurology 1999;52:1368–1373.
Heinzlet O, Abuat N, Conen A, Amarenco r. ecurrent stroke anu vascular cven ts in elderly patients with anticardiolipin antibodies: a prospective study. J Neurol 2001;248:373–379.
The Antiphospholipid Antibodies in Stroke Study (APASS) Group. Anticardiolipin antibodies and the risk of recurrent thrombo-occlusive events and death. Neurology 1997;48:91–94.
Toghi H, Takahashi H, Kashiwaya M, Watanabe K, Hayama K. The anticardiolipin antibody in elderly stroke patients: its effects on stroke types, recurrence, and the coagulation-fibrinolysis system. Acta Neurol Scand 1994;90:86–90.
Levine SR, Brey RL, Joseph CL, Havstad S. Risk of recurrent thromboembolic events in patients with focal cerebral ischemia and antiphospholipid antibodies. The Antiphospholipid Antibodies in Stroke Study Group. Stroke 1992;23:129–132.
Khamashta MA. Primary prevention of thrombosis in subjects with positive antiphospholipid antibodies. J Autoimmun 2000;15:249–253.
Love P, Santoro S. Antiphospholipid antibodies: anticardiolipin and the lupus anticoagulant in systemic lupus erythematosus (SLE) and in non-SLE disorders. Ann Intern Med 1990;112:682–698.
Rosove M, Brewer P. Antiphospholipid thrombosis: clinical course after the first thrombotic event in 70 patients. Ann Intern Med 1992;117:303–308.
Ruiz-Irastorza G, Khamashta MA, Hunt BJ, Escudero A, Cuadrado MJ, Hughes GR. Bleeding and recurrent thrombosis in definite antiphospholipid syndrome: analysis of a series of 66 patients treated with oral anticoagulation to a target international normalized ratio of 3.5. Arch Intern Med 2002;162:1164–1169.
Prandoni P, Simioni P, Girolami A. Antiphospholipid antibodies, recurrent thromboembolism and intensity of warfarin anticoagulation. Thromb Haemost 1996;75: 859.
Schulman S, Svenungsson E, Granqvist S. Anticardiolipin antibodies predict early recurrence of thromboembolism and death among patients with venous thromboembolism following anticoagulant therapy. Duration of Anticoagulation Study Group. Am J Med 1998;104:332–338.
Derksen RH, de Groot PG. Do we know which patients with the antiphospholipid syndrome should receive long-term high dose anti-coagulation? J Autoimmun 2000; 15:255–259.
Brey R, Levine S, Thompson J, et al. Baseline frequencies, isotypes, and titers of antiphospholipid antibodies in the Warfarin-Aspirin Recurrent Stroke Study/Antiphospholipid Antibody Stroke Study (WARSS/APASS) collaboration; preliminary results. Stroke 2000;31:280.
Knic-Barrie S, Reister O, Connor C, Looney S, Pieriangeli S, Harris E. A retrospective review of 61 patients with antiphospholipid syndrome. Arch Intern Med 1997; 157:2101–2108.
Kalashnikova L, Nasonov E, Kushekbaeva A, Gracheva L. Anticardiolipin antibodies in Sneddon’s syndrome. Neurology 1990;40:464–467.
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Smirnakis, S.M., Koroshetz, W.J. (2004). Cryptogenic Emboli and Other Elusive Causes of Stroke. In: Furie, K.L., Kelly, P.J. (eds) Handbook of Stroke Prevention in Clinical Practice. Current Clinical Neurology. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-59259-769-7_13
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