national-clinical-guidelines-for-stroke-fourth-edition

5.8 Treatment of unusual causes of stroke
In about 25% of stroke cases, and more commonly in younger patients, no cause is
evident on initial screening. Other causes that should be considered include
paroxysmal atrial fibrillation, which may require 3- or 7-day cardiac monitoring to
detect, intracranial arterial disease, cervical artery dissection, antiphospholipid
syndrome and other prothrombotic conditions, and patent foramen ovale (PFO). In
patients where no cause is identified and particularly where there is a history of
venous or arterial thrombosis or early miscarriage, a thrombophilia screen should be
performed.
5.8.1 Vertebral artery disease
5.8.1.1 Recommendation
5.8.1.2 Source
A Angioplasty and stenting of the vertebral artery should only be performed in the
context of a clinical trial.
A Consensus
5.8.2 Intracranial arterial disease
5.8.2.1 Recommendations
5.8.2.2 Source
A Patients with symptomatic intracranial stenosis should be offered an intensive
antiplatelet regime (eg aspirin and clopidogrel) for 3 months in addition to usual
recommendations for secondary prevention intervention and lifestyle modification.
B Endovascular intervention for intracranial stenosis should not be performed except in
the context of a clinical trial.
A–B Chimowitz et al 2011
5.8.3 Patent foramen ovale
Evidence to recommendation
5 Secondary prevention
Patent foramen ovale is found in 25% of the healthy population and it is therefore difficult
to know whether the finding of a PFO is relevant in a patient with cryptogenic stroke. It is
more likely if there is a good history of the stroke occurring during or shortly after a
Valsalva manoeuvre or where there are recurrent strokes in different arterial territories. No
adequate trials have been performed to indicate whether treatment should be antiplatelet
drugs, anticoagulation or closure of the PFO. Natural history studies would suggest a low
recurrence rate that probably does not justify the risk of closure unless there is recurrent
© Royal College of Physicians 2012 75