Research advances in embolic stroke of undetermined source_West China Medical Journal

Authors：

PENG Chao , ZHANG Yanan ,  HE Li

Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

HE Li, Email: heli2003new@126.com

Keywords：

Embolic stroke of undetermined source; Research advance; Cryptogenic stroke

DOI：

10.7507/1002-0179.201907149

Video：

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In 2014, the new concept of embolic stroke of undetermined source (ESUS) was first proposed by cryptogenic stroke/ESUS International Working Group. In the past 5 years, related clinical researches of ESUS have been deepened, and the results of many large clinical studies have been published. However, the guiding significance of this new concept to clinical practice is still controversial. By reviewing the background, diagnostic criteria, assessment, common emboli sources, anticoagulant therapy research advances and related limitations of ESUS, and analyzing the possible causes of negative anticoagulant therapy results, we explored the clinical value of this new classification.

Citation： PENG Chao, ZHANG Yanan, HE Li. Research advances in embolic stroke of undetermined source. West China Medical Journal, 2019, 34(10): 1175-1178. doi: 10.7507/1002-0179.201907149 Copy

1.	Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. trial of org 10172 in acute stroke treatment. Stroke, 1993, 24(1): 35-41.
2.	Eckerle B, Massaro A. Lumpers or splitters: evaluation and management of embolic stroke of undetermined source. Neurology, 2016, 87(10): 972-973.
3.	Hart RG, Catanese L, Perera KS, et al. Embolic stroke of undetermined source: a systematic review and clinical update. Stroke, 2017, 48(4): 867-872.
4.	Paciaroni M, Kamel H. Do the results of RE-SPECT ESUS call for a revision of the embolic stroke of undetermined source definition?. Stroke, 2019, 50(4): 1032-1033.
5.	Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 2014, 45(7): 2160-2236.
6.	Hart RG, Diener HC, Coutts SB, et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol, 2014, 13(4): 429-438.
7.	Kamel H, Merkler AE, Iadecola C, et al. Tailoring the approach to embolic stroke of undetermined source: a review. JAMA Neurol, 2019, 76(7): 855-861.
8.	Hart RG, Sharma M, Mundl H, et al. Rivaroxaban for stroke prevention after embolic stroke of undetermined source. N Engl J Med, 2018, 378(23): 2191-2201.
9.	Diener HC, Sacco RL, Easton JD, et al. Dabigatran for prevention of stroke after embolic stroke of undetermined source. N Engl J Med, 2019, 380(20): 1906-1917.
10.	Geisler T, Poli S, Meisner C, et al. Apixaban for treatment of embolic stroke of undetermined source (ATTICUS randomized trial): rationale and study design. Int J Stroke, 2017, 12(9): 985-990.
11.	Geisler T, Mengel A, Ziemann U, et al. Management of embolic stroke of undetermined source (ESUS). Drugs, 2018, 78(8): 823-831.
12.	Hart RG, Sharma M, Mundl H, et al. Rivaroxaban for secondary stroke prevention in patients with embolic strokes of undetermined source: design of the NAVIGATE ESUS randomized trial. Eur Stroke J, 2016, 1(3): 146-154.
13.	Kasner SE, Swaminathan B, Lavados P, et al. Rivaroxaban or aspirin for patent foramen ovale and embolic stroke of undetermined source: a prespecified subgroup analysis from the NAVIGATE ESUS trial. Lancet Neurol, 2018, 17(12): 1053-1060.
14.	Diener HC, Bernstein R, Hart R, et al. Secondary stroke prevention in cryptogenic stroke and embolic stroke of undetermined source (ESUS). Curr Neurol Neurosci Rep, 2017, 17(9): 64.
15.	Amarenco P, Albers GW, Denison H, et al. Ticagrelor versus aspirin in acute embolic stroke of undetermined source. Stroke, 2017, 48(9): 2480-2487.
16.	Bembenek JP, Karlinski MA, Kurkowska-Jastrzebska I, et al. Embolic strokes of undetermined source in a cohort of Polish stroke patients. Neurol Sci, 2018, 39(6): 1041-1047.
17.	Cantú-Brito C, Sampaio Silva G, Ameriso SF. Embolic stroke of undetermined source in Latin America: a review. Neurologist, 2017, 22(5): 171-181.
18.	Dennis M. Embolic stroke of undetermined source: a therapeutic target?. Lancet Neurol, 2014, 13(4): 344-346.
19.	Gladstone DJ, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med, 2014, 370(26): 2467-2477.
20.	Katsanos AH, Bhole R, Frogoudaki A, et al. The value of transesophageal echocardiography for embolic strokes of undetermined source. Neurology, 2016, 87(10): 988-995.
21.	Homma S, Sacco RL, Di Tullio MR, et al. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in cryptogenic stroke study. Circulation, 2002, 105(22): 2625-2631.
22.	Amarenco P, Davis S, Jones EF, et al. Clopidogrel plus aspirin versus warfarin in patients with stroke and aortic arch plaques. Stroke, 2014, 45(5): 1248-1257.
23.	Nouh A, Hussain M, Mehta T, et al. Embolic strokes of unknown source and cryptogenic stroke: implications in clinical practice. Front Neurol, 2016, 7: 37.
24.	Umemura T, Nishizawa S, Nakano Y, et al. Importance of finding embolic sources for patients with embolic stroke of undetermined source. J Stroke Cerebrovasc Dis, 2019, 28(7): 1810-1815.
25.	Tirschwell DL, Taylor BL. Is embolic stroke of undetermined source shrinking?. Stroke, 2019, 50(9): 2290-2291.

1. Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. trial of org 10172 in acute stroke treatment. Stroke, 1993, 24(1): 35-41.
2. Eckerle B, Massaro A. Lumpers or splitters: evaluation and management of embolic stroke of undetermined source. Neurology, 2016, 87(10): 972-973.
3. Hart RG, Catanese L, Perera KS, et al. Embolic stroke of undetermined source: a systematic review and clinical update. Stroke, 2017, 48(4): 867-872.
4. Paciaroni M, Kamel H. Do the results of RE-SPECT ESUS call for a revision of the embolic stroke of undetermined source definition?. Stroke, 2019, 50(4): 1032-1033.
5. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 2014, 45(7): 2160-2236.
6. Hart RG, Diener HC, Coutts SB, et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol, 2014, 13(4): 429-438.
7. Kamel H, Merkler AE, Iadecola C, et al. Tailoring the approach to embolic stroke of undetermined source: a review. JAMA Neurol, 2019, 76(7): 855-861.
8. Hart RG, Sharma M, Mundl H, et al. Rivaroxaban for stroke prevention after embolic stroke of undetermined source. N Engl J Med, 2018, 378(23): 2191-2201.
9. Diener HC, Sacco RL, Easton JD, et al. Dabigatran for prevention of stroke after embolic stroke of undetermined source. N Engl J Med, 2019, 380(20): 1906-1917.
10. Geisler T, Poli S, Meisner C, et al. Apixaban for treatment of embolic stroke of undetermined source (ATTICUS randomized trial): rationale and study design. Int J Stroke, 2017, 12(9): 985-990.
11. Geisler T, Mengel A, Ziemann U, et al. Management of embolic stroke of undetermined source (ESUS). Drugs, 2018, 78(8): 823-831.
12. Hart RG, Sharma M, Mundl H, et al. Rivaroxaban for secondary stroke prevention in patients with embolic strokes of undetermined source: design of the NAVIGATE ESUS randomized trial. Eur Stroke J, 2016, 1(3): 146-154.
13. Kasner SE, Swaminathan B, Lavados P, et al. Rivaroxaban or aspirin for patent foramen ovale and embolic stroke of undetermined source: a prespecified subgroup analysis from the NAVIGATE ESUS trial. Lancet Neurol, 2018, 17(12): 1053-1060.
14. Diener HC, Bernstein R, Hart R, et al. Secondary stroke prevention in cryptogenic stroke and embolic stroke of undetermined source (ESUS). Curr Neurol Neurosci Rep, 2017, 17(9): 64.
15. Amarenco P, Albers GW, Denison H, et al. Ticagrelor versus aspirin in acute embolic stroke of undetermined source. Stroke, 2017, 48(9): 2480-2487.
16. Bembenek JP, Karlinski MA, Kurkowska-Jastrzebska I, et al. Embolic strokes of undetermined source in a cohort of Polish stroke patients. Neurol Sci, 2018, 39(6): 1041-1047.
17. Cantú-Brito C, Sampaio Silva G, Ameriso SF. Embolic stroke of undetermined source in Latin America: a review. Neurologist, 2017, 22(5): 171-181.
18. Dennis M. Embolic stroke of undetermined source: a therapeutic target?. Lancet Neurol, 2014, 13(4): 344-346.
19. Gladstone DJ, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med, 2014, 370(26): 2467-2477.
20. Katsanos AH, Bhole R, Frogoudaki A, et al. The value of transesophageal echocardiography for embolic strokes of undetermined source. Neurology, 2016, 87(10): 988-995.
21. Homma S, Sacco RL, Di Tullio MR, et al. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in cryptogenic stroke study. Circulation, 2002, 105(22): 2625-2631.
22. Amarenco P, Davis S, Jones EF, et al. Clopidogrel plus aspirin versus warfarin in patients with stroke and aortic arch plaques. Stroke, 2014, 45(5): 1248-1257.
23. Nouh A, Hussain M, Mehta T, et al. Embolic strokes of unknown source and cryptogenic stroke: implications in clinical practice. Front Neurol, 2016, 7: 37.
24. Umemura T, Nishizawa S, Nakano Y, et al. Importance of finding embolic sources for patients with embolic stroke of undetermined source. J Stroke Cerebrovasc Dis, 2019, 28(7): 1810-1815.
25. Tirschwell DL, Taylor BL. Is embolic stroke of undetermined source shrinking?. Stroke, 2019, 50(9): 2290-2291.

West China Medical Journal

Research advances in embolic stroke of undetermined source

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