Embolic strokes of undetermined source

R1 Jin-Yi Hsu

Stroke etiology

25% 25%

25% 20%

5%Lancet Neurol 2014; 13: 429–38

Lancet Neurol 2014; 13: 429–38

25%

Large artery artherosclerotic

stenosis

Stroke etiology

Lancet Neurol 2014; 13: 429–38

25%

Small artery disease

Stroke etiology

Lancet Neurol 2014; 13: 429–38

20%

Major-risk source cardiogenic embolism

Stroke etiology

Lancet Neurol 2014; 13: 429–38

Unusual5%

Stroke etiology

Lancet Neurol 2014; 13: 429–38

25%

Cryptogenic

Stroke etiology

Cryptogenic stroke

Stroke 1993;24:35-41

TOAST trial

Two or more causes identified

Negative evaluation

Incomplete evaluation

Embolic strokes of undetermined source (ESUS)

Lancet Neurol 2014; 13: 429–38

Non-lacunar infarction on imaging

Open arteries ( < 50% stenosis)

No major-risk cardioembolic source

Cryptogenic strokeESUS

Diagnostic criteria

Necessary diagnostic

assessment

Head MRI /CT

TTE Not specificHolter >= 24h

Cranial vessel

Non-lacunar infarction

Not major-risk cardioembolism

Not major-risk & medium-risk

Not large vessel stenosis

Lancet Neurol 2014; 13: 429–38

Cryptogenic strokeESUS

Diagnostic criteria

Necessary diagnostic

assessment

Head MRI /CT

TTE Not specificHolter >= 24h

Cranial vessel

Non-lacunar infarction

Not major-risk cardioembolism

Not major-risk & medium-risk

Not large vessel stenosis

Lancet Neurol 2014; 13: 429–38

Lancet Neurol 2014; 13: 429–38

25%

Cryptogenic

Stroke etiology

Lancet Neurol 2014; 13: 429–38

Stroke etiology

ESUS

Cryptogenic

Large artery artherosclerotic

stenosisSmall artery disease

Major-risk source cardiogenic embolism

Unusual

Stroke Recurrence

Stroke Mortality

Stroke Recurrence

Stroke Mortality

Risk Stratification for Recurrence and Mortality in Embolic Stroke of Undetermined Source

Stroke. 2016;47:2278-2285

Baseline characteristics

Mean age: 66.8 yrs ( 54- 77)

Female: 449 ( 41%)

N= 1095

Multi-center, Prospective

Follow-up: 31 months (14-59)

NIHSS: 5 ( 2- 10)

ESUS criteriaStroke. 2016;47:2278-2285

Baseline characteristics

Stroke. 2016;47:2278-2285

Risk factor

Baseline characteristics

Stroke. 2016;47:2278-2285

Acute treatment

Baseline characteristicsTreatment on discharge

Stroke. 2016;47:2278-2285

Stroke recurrence rateCHARS2 score

Stroke. 2016;47:2278-2285

Stroke mortality rateCHARS2 score

Stroke. 2016;47:2278-2285

‘

Stroke recurrence rateCHA2RS2-VASc score

Stroke. 2016;47:2278-2285

Stroke mortality rateCHA2RS2-VASc score

Stroke. 2016;47:2278-2285

Stroke recurrence rate

Stroke. 2016;47:2278-2285

CHA2RS2-VASc scoreControl group: CHA2DS2-VASc=0

Control group: CHA2DS2-VASc low-risk

2.94 ( 1.53- 5.65)

3.35 ( 1.94- 5.80)

Stroke mortality rate

Stroke. 2016;47:2278-2285

CHA2RS2-VASc scoreControl group: CHA2DS2-VASc=0

Control group: CHA2DS2-VASc low-risk

15.11 ( 3.7- 61.5)

13.0 ( 4.7- 35.4)

Stroke mortality rateCHA2RS2-VASc score

Time (months)

Mor

talit

ylog rank test

p< 0.001

1200

0

1.0

Low risk

Intermediate risk

High risk

Stroke. 2016;47:2278-2285

Stroke mortality rateCHA2RS2-VASc score

Time (months)

Mor

talit

y

log rank testp< 0.001

1200

0

1.0

CHA2RS2-VASc score >1

CHA2RS2-VASc score 0-1

Stroke. 2016;47:2278-2285

Stroke Recurrence rateCHA2RS2-VASc score

Time (months)

Mor

talit

ylog rank test

p< 0.001

1200

0

1.0

Low risk

Intermediate riskHigh riskR

ecur

renc

e

Stroke. 2016;47:2278-2285

Stroke Recurrence rateCHA2RS2-VASc score

Time (months)

Mor

talit

y

log rank testp< 0.001

1200

0

1.0

CHA2RS2-VASc score >1

CHA2RS2-VASc score 0-1

Rec

urre

nce

Stroke. 2016;47:2278-2285

DiscussionStroke recurrence rate

Control group: CHA2DS2-VASc=0

2.94 ( 1.53- 5.65)

Stroke mortality rateControl group: CHA2DS2-VASc=0

15.11 ( 3.7- 61.5)

DiscussionSecondary prevention choice

Mor

talit

ylog rank test

p< 0.001

1200

0

1.0

Low risk

Intermediate risk

High risk

Time (months)

DiscussionSecondary prevention choice

Mor

talit

ylog rank test

p< 0.001

1200

0

1.0

Low risk

Intermediate risk

High risk

Time (months)

Anti-platelets Anti-coagulants

Baseline characteristics

Stroke. 2016;47:2278-2285

Acute treatment

DiscussionSecondary prevention choice

Mor

talit

ylog rank test

p< 0.001

1200

0

1.0

Low risk

Intermediate risk

High risk

Time (months)

Anti-platelets Anti-coagulants

DiscussionOngoing ESUS trials

ATTICUS

NAVIGATE-ESUS

RE-SPECT ESUS

Dabigatran V.S. Aspirin

Rivaroxaban V.S. Aspirin

Apixaban V.S. Aspirin

Discussion

Mean age: 66.8 yrs ( 54- 77)

Female: 449 ( 41%)

N= 1095

Multi-center, Prospective

Follow-up: 31 months (14-59)

NIHSS: 5 ( 2- 10)

✔✔

✔

ESUS criteria✔

Summary

Summary

Anti-platelets Anti-coagulants

Summary

Anti-platelets Anti-coagulants

ATTICUS NAVIGATE-ESUS RE-SPECT ESUS

Thanks for your attention

R1 Jin-Yi Hsu