Characteristics and outcomes of Embolic Stroke of Undetermined Source according to stroke severity

Abstract

Background and aims Patients with embolic strokes of undetermined source (ESUS) usually present with mild symptoms. We aimed to compare the baseline characteristics between mild and severe ESUS, identify predictors for severe ESUS, and assess outcomes of patients with severe ESUS. Methods In the AF-ESUS (AF-ESUS) dataset, we stratified ESUS severity using the median National Institutes of Health Stroke Scale (NIHSS) score on admission as cut-off. We performed multivariable stepwise regression analyses to identify independent predictors of severe ESUS and to assess the association between ESUS severity and stroke recurrence, death, and new incident atrial fibrillation (AF) on follow-up. The 10-year cumulative probabilities of outcome incidence were estimated by the Kaplan–Meier product limit method. Results In 772 patients (median NIHSS: 6 (interquartile range: 3–12)), 414 (53.6%) patients had severe ESUS (i.e. NIHSS ≥6). Female sex was the only independent predictor for severe ESUS (odds ratio: 1.72 (1.27–2.33)). The rates of recurrence (3.3%/year vs. 3.4%/year, adjusted-hazard ratio: 1.09 (0.73–1.62)) and new incident AF (13.5% vs. 17.0%, adjusted odds ratio: 0.67 (0.44–1.03)) were similar between severe and mild ESUS, but mortality was higher (5.4%/year vs. 3.7%/year, adjusted-hazard ratio: 1.51 (1.05–2.16)) in severe ESUS. The 10-year cumulative probability for stroke recurrence was similar between severe and mild ESUS (38.1% (29.2–48.6) vs. 36.6% (27.8–47.0), log-rank test: 0.01, p = 0.920). The 10-year cumulative probability of death was higher in patients with severe ESUS compared with mild ESUS (40.5% (32.5–50.0) vs. 34.0% (26.0–43.6) respectively; log-rank test: 4.54, p = 0.033). Conclusions Women have more severe ESUS compared with men. Patients with severe ESUS have similar rates of stroke recurrence and new incident AF, but higher mortality compared with mild ESUS.

Gender Predicts Differences in Acute Ischemic Cardioembolic Stroke Profile: Emphasis on Woman-Specific Clinical Data and Early Outcome—The Experience of Sagrat Cor Hospital of Barcelona Stroke Registry

“…Other clinical predictors related to the severity of CE stroke, such as limb weakness, altered consciousness, or advanced age, are consistent with data reported in other general studies of acute stroke [66][67][68][69][70][71][72][73][74].…”

Atrial Cardiopathy and Likely Pathogenic Patent Foramen Ovale in Embolic Stroke of Undetermined Source

“…The analysis was performed in the AF-ESUS (Prediction of Atrial Fibrillation in ESUS) data set, an international multicenter registry of ESUS patients. The AF-ESUS is registered at Clinicaltrials.gov (NCT02766205) and its methodology was described previously 10,11 and was approved by the local ethics committees, where necessary. All patients were registered prospectively and data were collected and analyzed in a prespecified manner using prespecified definitions.…”

Markers of Atrial Cardiopathy in Severe Embolic Strokes of Undetermined Source

“…Moreover, patients with severe ESUS are also characterized by additional and specific clinical characteristics, such as older age and higher prevalence of female sex, according to a previous study ( 6 ), that demonstrated that women have more severe ESUS compared with men.…”

“…Although clinical characteristics alone cannot reliably classify the underlying cause of ischemic stroke ( 4 ), higher National Institutes of Health Stroke Scale (NIHSS) score is usually associated with cardioembolic etiology ( 5 ). Furthermore, patients with severe ESUS (NIHSS score >5) have different clinical characteristics and outcome with higher mortality rate in comparison with patients with mild ESUS ( 6 ). These findings suggest a possible role of cardioembolic mechanisms (especially due to atrial cardiopathy) in determining severe ESUS.…”