Cryptogenic stroke. Part 4: Antiphospholipid syndrome and cancer

Abstract

Cryptogenic embolic stroke (embolic strokes of undetermined source, ESUS) is an intermediate diagnosis in patients with unknown etiology of stroke and implies the absence of large sources of cardioembolism and significant extra- and intracranial stenoses and probably embolic pathogenesis of cerebral infarction. In the previous parts of the article, we discussed the issues of diagnosis and secondary prevention of ESUS with underlying potential aortoaortic sources of embolism, paradoxical embolism and atrial cardiopathy. This article discusses the issues of epidemiology, pathogenesis, diagnosis and secondary prevention of ischemic stroke with underlying antiphospholipid syndrome (APS) and cancer-associated stroke (RAI). Both mechanisms of stroke are associated with hypercoagulability, often manifest as multifocal cortical brain lesions, and respond to anticoagulant therapy. While APS should be suspected primarily in young women with pathology of pregnancy, arterial and venous thrombosis, as well as livedo reticularis (racemosa), RAI does not have a specific clinical picture, but can manifest as diffuse cortical infarcts (symptom of three pools) combined with increased D-dimer level. If APS is suspected, appropriate haematological screening is required, followed by the use of the Sydney diagnostic criteria. Possible diagnosis of RAI often requires transesophageal echocardiography (ruling out non-bacterial thromboendocarditis) and oncological screening. Secondary prevention of APS consists in prescribing warfarin with the target international normalized ratio (INR) of 2.0 to 3.0. RAI is treated with anticoagulants, but the choice of a drug and dose is determined by the balance between thrombotic/thromboembolic and hemorrhagic risks.