Kanjana S Perera1, Thomas Vanassche2, Jackie Bosch3, Mohana Giruparajah3, Balakumar Swaminathan3, Katie R Mattina3, Scott D Berkowitz4, Antonio Arauz5, Martin J O'Donnell6, Sebastian F Ameriso7, Graeme J Hankey8, Byung-Woo Yoon9, Philippa Lavallee10, Luis Cunha11, Nikolay Shamalov12, Raf Brouns13, Rubens J Gagliardi14, Scott E Kasner15, Alessio Pieroni16, Philipp Vermehren17, Kazuo Kitagawa18, Yongjun Wang19, Keith Muir20, Jonathan Coutinho21, Ildiko Vastagh22, Stuart J Connolly23, Robert G Hart24. 1. Department of Medicine (Neurology), McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada. 2. Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium. 3. Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada. 4. Bayer Healthcare Pharmaceuticals, Whippany, NJ, USA. 5. Instituto Nacional de Neurologia y Neurocirugia, Mexico DF, Mexico. 6. University of Galway, Galway, Ireland. 7. Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la Infancia (FLENI), Buenos Aires, Argentina. 8. School of Medicine and Pharmacology, University of Western Australia, Sir Charles Gairdner Hospital, Perth, Australia. 9. Department of Neurology, Seoul National University Hospital, Seoul, Korea. 10. Department of Neurology, Bichat Hospital, Paris, France. 11. Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal. 12. Pirogov Russian National Research Medical University, Moscow, Russia. 13. Universitair Ziekenhuis Brussel, Brussels, Belgium. 14. Irmandade da Santa Casa de Misericórdia de São Paulo, Sao Paulo, Brazil. 15. Department of Neurology, Hospital of the University of Pennsylvania, Philadephia, United States. 16. Department of Neurology and Psychiatry, "Sapienza" University of Rome, Rome, Italy. 17. Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany. 18. Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan. 19. Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. 20. Institute of Neuroscience and Physiology, University of Glasgow, Queen Elizabeth Hospital, Glasgow, United Kingdom. 21. Academic Medical Center, Amsterdam, Netherlands. 22. Department of Neurology, Semmelweis University, Budapest, Hungary. 23. Department of Medicine (Cardiology), Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada. 24. Department of Medicine (Neurology), McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada robert.hart@phri.ca.
Abstract
BACKGROUND: Recent evidence supports that most non-lacunar cryptogenic strokes are embolic. Accordingly, these strokes have been designated as embolic strokes of undetermined source (ESUS). AIMS: We undertook an international survey to characterize the frequency and clinical features of ESUS patients across global regions. METHODS: Consecutive patients hospitalized for ischemic stroke were retrospectively surveyed from 19 stroke research centers in 19 different countries to collect patients meeting criteria for ESUS. RESULTS: Of 2144 patients with recent ischemic stroke, 351 (16%, 95% CI 15% to 18%) met ESUS criteria, similar across global regions (range 16% to 21%), and an additional 308 (14%) patients had incomplete evaluation required for ESUS diagnosis. The mean age of ESUS patients (62 years; SD = 15) was significantly lower than the 1793 non-ESUS ischemic stroke patients (68 years, p ≤ 0.001). Excluding patients with atrial fibrillation (n = 590, mean age = 75 years), the mean age of the remaining 1203 non-ESUS ischemic stroke patients was 64 years (p = 0.02 vs. ESUS patients). Among ESUS patients, hypertension, diabetes, and prior stroke were present in 64%, 25%, and 17%, respectively. Median NIHSS score was 4 (interquartile range 2-8). At discharge, 90% of ESUS patients received antiplatelet therapy and 7% received anticoagulation. CONCLUSIONS: This cross-sectional global sample of patients with recent ischemic stroke shows that one-sixth met criteria for ESUS, with additional ESUS patients likely among those with incomplete diagnostic investigation. ESUS patients were relatively young with mild strokes. Antiplatelet therapy was the standard antithrombotic therapy for secondary stroke prevention in all global regions.
BACKGROUND: Recent evidence supports that most non-lacunar cryptogenic strokes are embolic. Accordingly, these strokes have been designated as embolic strokes of undetermined source (ESUS). AIMS: We undertook an international survey to characterize the frequency and clinical features of ESUS patients across global regions. METHODS: Consecutive patients hospitalized for ischemic stroke were retrospectively surveyed from 19 stroke research centers in 19 different countries to collect patients meeting criteria for ESUS. RESULTS: Of 2144 patients with recent ischemic stroke, 351 (16%, 95% CI 15% to 18%) met ESUS criteria, similar across global regions (range 16% to 21%), and an additional 308 (14%) patients had incomplete evaluation required for ESUS diagnosis. The mean age of ESUS patients (62 years; SD = 15) was significantly lower than the 1793 non-ESUS ischemic strokepatients (68 years, p ≤ 0.001). Excluding patients with atrial fibrillation (n = 590, mean age = 75 years), the mean age of the remaining 1203 non-ESUS ischemic strokepatients was 64 years (p = 0.02 vs. ESUS patients). Among ESUS patients, hypertension, diabetes, and prior stroke were present in 64%, 25%, and 17%, respectively. Median NIHSS score was 4 (interquartile range 2-8). At discharge, 90% of ESUS patients received antiplatelet therapy and 7% received anticoagulation. CONCLUSIONS: This cross-sectional global sample of patients with recent ischemic stroke shows that one-sixth met criteria for ESUS, with additional ESUS patients likely among those with incomplete diagnostic investigation. ESUS patients were relatively young with mild strokes. Antiplatelet therapy was the standard antithrombotic therapy for secondary stroke prevention in all global regions.
Authors: James E Siegler; Jesse M Thon; John H Woo; David Do; Steven R Messé; Brett Cucchiara Journal: J Stroke Cerebrovasc Dis Date: 2019-07-26 Impact factor: 2.136
Authors: Victor J Del Brutto; Seemant Chaturvedi; Hans-Christoph Diener; Jose G Romano; Ralph L Sacco Journal: J Am Coll Cardiol Date: 2019-08-13 Impact factor: 24.094
Authors: Kanjana S Perera; Danielle de Sa Boasquevisque; Purnima Rao-Melacini; Amanda Taylor; Anna Cheng; Graeme J Hankey; Sarah Lee; Joan Marti Fabregas; Sebastian F Ameriso; Thalia S Field; Antonio Arauz; Shelagh B Coutts; Marcel Arnold; Robert Mikulik; Danilo Toni; Jennifer Mandzia; Roland C Veltkamp; Elena Meseguer; Karl Georg Haeusler; Robert G Hart Journal: JAMA Neurol Date: 2022-05-01 Impact factor: 29.907
Authors: Kanjana S Perera; Balakumar Swaminathan; Roland Veltkamp; Antonio Arauz; Sebastian Ameriso; Joan Marti-Fabregas; Marcel Arnold; Graeme J Hankey; Helmi Lutsep; Robert G Hart Journal: Eur Stroke J Date: 2018-01-24
Authors: Robert G Hart; Mukul Sharma; Hardi Mundl; Ashkan Shoamanesh; Scott E Kasner; Scott D Berkowitz; Guillaume Pare; Bodo Kirsch; Janice Pogue; Calin Pater; Gary Peters; Antoni Davalos; Wilfried Lang; Yongjun Wang; Yilong Wang; Luis Cunha; Jens Eckstein; Turgut Tatlisumak; Nikolay Shamalov; Robert Mikulik; Pablo Lavados; Graeme J Hankey; Anna Czlonkowska; Danilo Toni; Sebastian F Ameriso; Rubens J Gagliardi; Pierre Amarenco; Daniel Bereczki; Shinichiro Uchiyama; Arne Lindgren; Matthias Endres; Raf Brouns; Byung-Woo Yoon; George Ntaios; Roland Veltkamp; Keith W Muir; Serefnur Ozturk; Antonio Arauz; Natan Bornstein; Alan Bryer; Martin J O'Donnell; Jeffrey Weitz; Frank Peacock; Ellison Themeles; Stuart J Connolly Journal: Eur Stroke J Date: 2016-08-03