An elderly gentleman with a pmh of ulcerative proctitis on mesalamine and azathioprine, HTN, HLD, and DM2, who presented with cryptogenic stroke found to have a grade V aortic atheroma on TEE. He later presented with a venous sinus thrombosis – patient thought to potentially be hypercoagulable given history of ulcerative proctitis. .
Management of aortic atheromas from the American Heart Association/American Stroke Association-> for patients with an ischemic stroke or TIA and evidence of aortic arch atheroma, antiplatelet therapy is recommended (Class 1; Level of Evidence A); statin therapy is also recommended (Class 1; Level of Evidence B); the effective of anticoagulation with warfarin compared with antiplatelet therapy is unknown and surgical endarterectomy of aortic arch plaque for purposes of secondary stroke prevention is NOT recommended.
Mechanisms of cryptogenic stroke ->
1) cardiac embolism 2/2 paroxysmal atrial fibrillation, aortic atheromatous disease, or other cardiac sources
2) Paradoxical embolism
3) Undefined thrombophilia -> the patient in this case was worked up for thrombophilia!
4) Substenotic cerebrovascular disease (ie, intracranial and extracranial atherosclerotic disease causing less than 50% stenosis) and other vasculopathies (eg, dissection)
Workup of cryptogenic stroke -> the minimum workup for cryptogenic stroke includes:
-Noncontrast brain CT or brain MRI
-Serum electrolytes/renal function tests
-CBC including platelet count
-Markers of cardiac ischemia
Great link regarding workup of cryptogenic stroke: