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Underlying causes of cryptogenic stroke and TIA in the nordic atrial fibrillation and stroke (NOR-FIB) study : the importance of comprehensive clinical evaluation

Ratajczak-Tretel, B ; Lambert, A Tancin ; Al-Ani, R ; Arntzen, K ; Bakkejord, G K ; Bekkeseth, H M O ; Bjerkeli, V ; Eldøen, G ; Gulsvik, A K and Halvorsen, B , et al. (2023) In BMC Neurology 23(1).
Abstract

BACKGROUND: Cryptogenic stroke is a heterogeneous condition, with a wide spectrum of possible underlying causes for which the optimal secondary prevention may differ substantially. Attempting a correct etiological diagnosis to reduce the stroke recurrence should be the fundamental goal of modern stroke management.

METHODS: Prospective observational international multicenter study of cryptogenic stroke and cryptogenic transient ischemic attack (TIA) patients clinically monitored for 12 months to assign the underlying etiology. For atrial fibrillation (AF) detection continuous cardiac rhythm monitoring with insertable cardiac monitor (Reveal LINQ, Medtronic) was performed. The 12-month follow-up data for 250 of 259 initially... (More)

BACKGROUND: Cryptogenic stroke is a heterogeneous condition, with a wide spectrum of possible underlying causes for which the optimal secondary prevention may differ substantially. Attempting a correct etiological diagnosis to reduce the stroke recurrence should be the fundamental goal of modern stroke management.

METHODS: Prospective observational international multicenter study of cryptogenic stroke and cryptogenic transient ischemic attack (TIA) patients clinically monitored for 12 months to assign the underlying etiology. For atrial fibrillation (AF) detection continuous cardiac rhythm monitoring with insertable cardiac monitor (Reveal LINQ, Medtronic) was performed. The 12-month follow-up data for 250 of 259 initially included NOR-FIB patients were available for analysis.

RESULTS: After 12 months follow-up probable stroke causes were revealed in 43% patients, while 57% still remained cryptogenic. AF and atrial flutter was most prevalent (29%). In 14% patients other possible causes were revealed (small vessel disease, large-artery atherosclerosis, hypercoagulable states, other cardioembolism). Patients remaining cryptogenic were younger (p < 0.001), had lower CHA
2DS
2-VASc score (p < 0.001) on admission, and lower NIHSS score (p = 0.031) and mRS (p = 0.016) at discharge. Smoking was more prevalent in patients that were still cryptogenic (p = 0.014), while dyslipidaemia was less prevalent (p = 0.044). Stroke recurrence rate was higher in the cryptogenic group compared to the group where the etiology was revealed, 7.7% vs. 2.8%, (p = 0.091).

CONCLUSION: Cryptogenic stroke often indicates the inability to identify the cause in the acute phase and should be considered as a working diagnosis until efforts of diagnostic work up succeed in identifying a specific underlying etiology. Timeframe of 6-12-month follow-up may be considered as optimal.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02937077, EudraCT 2018-002298-23.

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organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Humans, Atrial Fibrillation/complications, Ischemic Attack, Transient/complications, Stroke/epidemiology, Ischemic Stroke/complications, Causality, Electrocardiography, Ambulatory/adverse effects
in
BMC Neurology
volume
23
issue
1
article number
115
pages
10 pages
publisher
BioMed Central (BMC)
external identifiers
  • pmid:36944929
  • scopus:85150903439
ISSN
1471-2377
DOI
10.1186/s12883-023-03155-0
language
English
LU publication?
yes
id
92b2cd04-08bb-4486-b4c2-7557586ffc03
date added to LUP
2023-03-27 15:39:17
date last changed
2024-06-15 01:43:08
@article{92b2cd04-08bb-4486-b4c2-7557586ffc03,
  abstract     = {{<p>BACKGROUND: Cryptogenic stroke is a heterogeneous condition, with a wide spectrum of possible underlying causes for which the optimal secondary prevention may differ substantially. Attempting a correct etiological diagnosis to reduce the stroke recurrence should be the fundamental goal of modern stroke management.</p><p>METHODS: Prospective observational international multicenter study of cryptogenic stroke and cryptogenic transient ischemic attack (TIA) patients clinically monitored for 12 months to assign the underlying etiology. For atrial fibrillation (AF) detection continuous cardiac rhythm monitoring with insertable cardiac monitor (Reveal LINQ, Medtronic) was performed. The 12-month follow-up data for 250 of 259 initially included NOR-FIB patients were available for analysis.</p><p>RESULTS: After 12 months follow-up probable stroke causes were revealed in 43% patients, while 57% still remained cryptogenic. AF and atrial flutter was most prevalent (29%). In 14% patients other possible causes were revealed (small vessel disease, large-artery atherosclerosis, hypercoagulable states, other cardioembolism). Patients remaining cryptogenic were younger (p &lt; 0.001), had lower CHA<br>
 2DS<br>
 2-VASc score (p &lt; 0.001) on admission, and lower NIHSS score (p = 0.031) and mRS (p = 0.016) at discharge. Smoking was more prevalent in patients that were still cryptogenic (p = 0.014), while dyslipidaemia was less prevalent (p = 0.044). Stroke recurrence rate was higher in the cryptogenic group compared to the group where the etiology was revealed, 7.7% vs. 2.8%, (p = 0.091).<br>
 </p><p>CONCLUSION: Cryptogenic stroke often indicates the inability to identify the cause in the acute phase and should be considered as a working diagnosis until efforts of diagnostic work up succeed in identifying a specific underlying etiology. Timeframe of 6-12-month follow-up may be considered as optimal.</p><p>TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02937077, EudraCT 2018-002298-23.</p>}},
  author       = {{Ratajczak-Tretel, B and Lambert, A Tancin and Al-Ani, R and Arntzen, K and Bakkejord, G K and Bekkeseth, H M O and Bjerkeli, V and Eldøen, G and Gulsvik, A K and Halvorsen, B and Høie, G A and Ihle-Hansen, H and Ingebrigtsen, S and Kremer, C and Krogseth, S B and Kruuse, C and Kurz, M and Nakstad, I and Novotny, V and Naess, H and Qazi, R and Rezaj, M K and Rørholt, D M and Steffensen, L H and Sømark, J and Tobro, H and Truelsen, T C and Wassvik, L and Ægidius, K L and Atar, D and Aamodt, A H}},
  issn         = {{1471-2377}},
  keywords     = {{Humans; Atrial Fibrillation/complications; Ischemic Attack, Transient/complications; Stroke/epidemiology; Ischemic Stroke/complications; Causality; Electrocardiography, Ambulatory/adverse effects}},
  language     = {{eng}},
  month        = {{03}},
  number       = {{1}},
  publisher    = {{BioMed Central (BMC)}},
  series       = {{BMC Neurology}},
  title        = {{Underlying causes of cryptogenic stroke and TIA in the nordic atrial fibrillation and stroke (NOR-FIB) study : the importance of comprehensive clinical evaluation}},
  url          = {{http://dx.doi.org/10.1186/s12883-023-03155-0}},
  doi          = {{10.1186/s12883-023-03155-0}},
  volume       = {{23}},
  year         = {{2023}},
}