The twilight of cryptogenic ischaemic stroke – cardio-embolism is the most frequent cause

Authors: D. Šaňák 1;  M. Hutyra 2;  M. Král 1;  M. Špaček 2;  A. Bártková 1
Authors‘ workplace: Komplexní cerebrovaskulární centrum, Neurologická klinika LF UP a FN Olomouc 1;  Komplexní kardiovaskulární centrum, I. interní klinika – kardiologická LF UP a FN Olomouc 2
Published in: Cesk Slov Neurol N 2018; 81(3): 290-297
Category: Review Article
doi: 10.14735/amcsnn2018290


Early and accurate identification of the cause of ischaemic stroke (IS) is essential for an effective and safe secondary prevention. Etiological classification systems are used to establish an optimal diagnostic management to identify the cause of IS. However, the TOAST classification is still mostly used, but the newer ASCOD system is more detailed and accurate. If the cause of IS remains unclear or is not being identified, it is classified as cryptogenic IS. About 25–30% of all IS are cryptogenic and in the population of young patients under 50 years of age, the rate of cryptogenic IS exceeds 50% of all IS. Recently published data and clinical experience show an increasing rate of cardio-embolization, which is now presented as a cause of IS in up to 45–50% of all cases and it is considered the most frequent cause of cryptogenic IS. Higher frequency of cardio-embolization is based on more accurate and extensive diagnostics focused on the detection of relevant structural or functional heart abnormities associated with risk of embolization. Atrial fibrillation (AF) is the most frequent cause of cardio-embolization. Implementation of 24h ECG-Holter monitoring in the clinical routine and using long-term ECG-Holter monitoring or implantation of a subcutaneous cardiac monitor led to increased detection of paroxysmal AF in patients with cryptogenic IS. Transesophageal echocardiography (TEE) allows reliable detection of structural heart abnormities and other rare causes of IS. An assessment of specific serum cardiac markers can also helpful; elevated values may be associated with presence of relevant heart abnormities. Currently, a comprehensive cardiologic examination should be a standard part of routine diagnostic management in most IS patients; moreover, in cryptogenic IS patients it should include TEE and long-term ECG-Holter monitoring in case of negative 24h monitoring.

Key words:
ischaemic stroke – cardio-embolization – cryptogenic – atrial fibrillation – ECG-Holter – echocardiography

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.


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