Embolic stroke of unknown source (ESUS) in young patients
The Cryptogenic Stroke International Working Group defined a new subgroup of cryptogenic stroke – embolic stroke of undetermined source (ESUS), based on clinical and imaging findings. Minor cardioembolic and atheroembolic sources were putatively implicated, and it was hypothesized that anticoagulant therapy might be warranted 1.
We aimed to assess the role of minor embolic sources in ESUS in young stroke patients by comparing the prevalence of minor embolic sources in patients with ESUS and in patients with stroke of determined origin. Etiology was defined according to the TOAST criteria. ESUS and minor cardioembolic/atheroembolic stroke were defined according to the proposed criteria 1.
We studied 100 consecutive ischemic stroke patients (see Table 1) aged between 18 and 55 years admitted in a Neurology department between January 2010 and August 2014 (mean age 46 years, range 22–55; 56% male; mean NIHSS at admission 4). The overall prevalence of minor cardioembolic sources was 53%, and of atheroembolic sources was 32%.
| Stroke subtype (n) | ESUS (42) | CE (5) | LVD (10) | SVD (20) | CRYP (9) | OS (14) | Total (100) |
|---|---|---|---|---|---|---|---|
| Demographics | |||||||
| Age | 44·6 (7·1) | 50·2 (4·8) | 41·2 (13·3) | 50·2 (4·7) | 42·1 (11·9) | 43·2 (7·9) | 45·5 (8·1) |
| Male gender (%) | 24 (50) | 1 (20) | 2 (20) | 14 (70) | 4 | 7 | 56 |
| Clinical evaluation | |||||||
| NIHSS | 4·2 (4·9) | 4·2 (3·8) | 5·7 (5·5) | 4·3 (2·1) | 2·8 (3·7) | 3·9 (3·7) | 4·2 (4·2) |
| Minor cardioembolic sources | |||||||
| Frequent supraventricular extrassysole | 2 | 1 | 1 | 2 | 0 | 1 | 7 |
| Atrial dilatation | 10 | 4 | 3 | 5 | 2 | 1 | 25 |
| Diastolic dysfunction | 2 | 2 | 0 | 7 | 1 | 1 | 13 |
| Systolic dysfunction | 0 | 2 | 1 | 2 | 1 | 0 | 6 |
| PFO | 7 | 0 | 2 | 2 | 3 | 1 | 15 |
| Mitral/aortic regurgitation | 2 | 1 | 1 | 0 | 1 | 1 | 6 |
| Mitral/aortic calcification | 1 | 2 | 0 | 3 | 0 | 1 | 7 |
| At least one minor cardioembolic factor, n (%) | 21 (50·0) | 5 (100·0) | 6 (60·0) | 11 (50·0) | 5 (55·0) | 5 (35·7) | 53 (53) |
| Minor atheroembolic sources | |||||||
| Complex aortic atheroma | 2 | 0 | 1 | 0 | 0 | 0 | 3 |
| Noncomplex aortic atheroma | 1 | 0 | 0 | 4 | 2 | 2 | 9 |
| Mild relevant stenosis | 14 | 0 | 0 | 8 | 2 | 1 | 25 |
| At least one minor atheroembolic factor n (%) | 16 (38·1) | 0 (0·0) | 1 (10·0) | 9 (64·3%) | 3 (33·3) | 3 (21·4) | 32 |
- Continuous variables are presented as mean (standard deviation). Nominal variables are presented as absolute number (percent).
- ESUS, embolic stroke of undetermined source; CE, cardioembolic stroke; LVD, large vessel disease stroke; SVD, small vessel disease stroke; CRYP, cryptogenic stroke; OC, another determined source stroke.
Cryptogenic stroke was diagnosed in 51 patients. Among these, 42 patients were ESUS (mean age 45 years, range 26–55; 50% male; mean NIHSS at admission 4). The ESUS group neither have a higher prevalence of minor cardioembolic, 50% (21/42) vs. 50% (27/54), nor a higher prevalence of minor atheroembolic, 38·1% (16/42) vs. 30·8% (15/47), P = 0·641, sources, when compared with all strokes with a determined cause other than cardioembolic and other than large vessel disease, respectively.
Although most young patients with cryptogenic stroke fulfill ESUS criteria, minor embolic sources do not seem to be more prevalent in ESUS than in strokes of determined cause; therefore, further explanations should be sought in this group.
