What is the appropriate evaluation of cryptogenic stroke, and when - - PowerPoint PPT Presentation

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What is the appropriate evaluation of cryptogenic stroke, and when - - PowerPoint PPT Presentation

Feb 03, 2023 189 likes •410 views

What is the appropriate evaluation of cryptogenic stroke, and when is a hypercoagulability work-up needed? David E. Thaler, MD, PhD, FAHA Neurologist in Chief, Tufts Medical Center Professor and Chair of Neurology, Tufts University School of

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What is the appropriate evaluation of cryptogenic stroke, and when is a hypercoagulability work-up needed? David E. Thaler, MD, PhD, FAHA

Neurologist in Chief, Tufts Medical Center Professor and Chair of Neurology, Tufts University School of Medicine Boston, MA

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  • Disclosure Statement of Financial Interest
  • Grant/Research Support
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  • Major Stock Shareholder/Equity
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  • Other

Steering Committee, RESPECT Trial, Abbott

Within the past 12 months, I have had a financial affiliation with the organization(s) listed below.

Affiliation/Financial Relationship Company

All content provided by Dr David Thaler unless otherwise noted.

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What is the appropriate evaluation of cryptogenic stroke, and when is a hypercoagulability work-up needed? David E. Thaler, MD, PhD, FAHA

Neurologist in Chief, Tufts Medical Center Professor and Chair of Neurology, Tufts University School of Medicine Boston, MA

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What is the appropriate evaluation

  • f stroke, and when is a

hypercoagulability work-up needed? David E. Thaler, MD, PhD, FAHA

Neurologist in Chief, Tufts Medical Center Professor and Chair of Neurology, Tufts University School of Medicine Boston, MA

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What is the underlying mechanism?

“Stroke is an

  • bservation not a

diagnosis”

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Common mechanisms of cerebral ischemia

  • “Small vessel disease,” lacune (lipohyalinosis)
  • Embolism

– Artery-to-artery (carotid, aorta, other) – Cardiac source – Paradoxical

  • Decreased perfusion through a fixed stenosis
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Lacunar stroke (0.2-15mm3)

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Large, old stroke

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Other causes of cerebral ischemia

  • Vasculitis
  • Collagen vascular diseases: isolated angiitis of the CNS, temporal (giant cell)

arteritis, polyarteritis nodosa, Wegener's granulomatosis, Takayasu's arteritis, syphilis

  • Meningitis: tuberculosis, fungi, syphilis, bacteria, herpes zoster
  • Arterial dissection: carotid, vertebral, basal intracranial arteries
  • Hematologic disorders: polycythemia, thrombocytosis, thrombotic

thrombocytopenic purpura, disseminated intravascular coagulation, dysproteinemias, hemoglobinopathies (sickle cell disease)

  • Miscellaneous: cocaine, amphetamines, moyamoya disease, fibromuscular

dysplasia, CADASIL

  • Hypercoagulable states: secondary to systemic disease, carcinoma (especially

pancreatic), eclampsia, oral contraceptives, lupus, factor C or S deficiency, factor V mutation, etc.

  • Vasospasm: following subarachnoid hemorrhage
  • Reversible cerebral vasoconstriction: idiopathic, migraine, eclampsia, trauma
  • Venous: Dehydration, pericranial infection, postpartum and postoperative states,

systemic cancer

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<50y 51-84y

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  • Arterial hypercoagulable testing

– Lupus anticoagulant – Anticardiolipin Ab – Beta-2 glycoprotein – Homocysteine

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If venous infarction or R-L shunt identified

  • Arterial hypercoagulable testing

– Lupus anticoagulant – Anticardiolipin Ab – Beta-2 glycoprotein – Homocysteine

  • Venous hypercoagulable testing

– Protein C, protein S, anti-thrombin III (RARE!) – Prothrombin gene mutation – Factor V Leiden (activated protein C resistance) – Factor VIII

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If venous infarction or R-L shunt identified

  • Arterial hypercoagulable testing

– Lupus anticoagulant – Anticardiolipin Ab – Beta-2 glycoprotein – Homocysteine

If unexplained BILATERAL embolic infarcts…

  • Venous hypercoagulable testing

– Protein C, protein S, anti-thrombin III (RARE!) – Prothrombin gene mutation – Factor V Leiden (activated protein C resistance) – Factor VIII

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If venous infarction or R-L shunt identified

  • Arterial hypercoagulable testing

– Lupus anticoagulant – Anticardiolipin Ab – Beta-2 glycoprotein – Homocysteine

If unexplained BILATERAL embolic infarcts… …cancer?

  • Venous hypercoagulable testing

– Protein C, protein S, anti-thrombin III (RARE!) – Prothrombin gene mutation – Factor V Leiden (activated protein C resistance) – Factor VIII

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Stroke, cancer, d-dimer, and mortality

Journal of Stroke 2017 19(1) 77-87

Baseline d-dimer and mortality Treated d-dimer and mortality

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CONCLUSIONS

  • Rely on neurology to make a stroke diagnosis
  • Tailor testing to individual patient characteristics
  • Making a diagnosis is ”changing management”