20161031 embolic strokes of undetermined source
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Transcript of 20161031 embolic strokes of undetermined source
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