Emerging Risk Factors for Recurrent Vascular Events in Patients With Embolic Stroke of Undetermined Source

Abstract

Background and Purpose-Underlying embolic causes diagnosed by transesophageal echocardiography could be implicated in mechanisms of embolic stroke of undetermined source. We aimed to explore factors, including underlying embolic causes, related to recurrent vascular events in embolic stroke of undetermined source. Methods-Patients who fulfilled the diagnostic criteria for embolic stroke of undetermined source and whose potential embolic sources were examined by transesophageal echocardiography were included. Recurrent vascular events, including ischemic stroke, cardiovascular and peripheral artery diseases, and vascular death, were retrospectively analyzed. Cox proportional hazards regression analysis was used to explore factors, including clinical characteristics, embolic causes on transesophageal echocardiography, and the Calcification in the Aortic Arch, Age, Multiple Infarction score (CAM), based on the degree of aortic arch calcification on chest radiograph (0-3 points), age (≥70 years; 1 point), and multiple infarctions on magnetic resonance imaging (multiple infarcts in 1, 2, or ≥3 territories of large intracranial arteries, 1, 2, or 3 points) associated with recurrent vascular events. Results-A total of 177 patients (age, 64.1±14.2 years; 127 men) were enrolled. Thirty-one patients had recurrent vascular events (follow-up, 3.5±2.7 years; annualized rate, 5.0% per person-year). Among embolic causes on transesophageal echocardiography, incidence of recurrent vascular events was high in patients with large aortic arch plaques (7.5% per person-year). Diabetes mellitus (hazard ratio, 2.56; 95% confidence interval, 1.23-5.32; P=0.012) and CAM score grade (hazard ratio, 2.29; 95% confidence interval, 1.11-4.72; P=0.026) predicted recurrent vascular events. Conclusions-History of diabetes mellitus and the CAM score could be novel risk factors for recurrent vascular events in embolic stroke of undetermined source.

Atrial cardiopathy in embolic stroke of undetermined source

“…There was a higher prevalence of MACI among ESUS than among LAA patients. A prior study found that 39% of ESUS patients had multiple infarcts on diffusion-weighted imaging, and multiple infarcts were more frequent among patients with recurrent vascular events (Ueno et al, 2016 (Jalini et al, 2019). However, AC-ESUS and AF-CE stroke patients had many similarities as mentioned above.…”

Spontaneous ruptured aortic plaque and injuries: insights for aging and acute aortic syndrome from non-obstructive general angioscopy

“…Most cryptogenic strokes have embolic features [27]. Atheromatous emboli were detected in the brain [28,29], and the association between atherosclerosis in the aortic arch and stroke risk have been established [30][31][32]. Stroke is known as one of the complications of endovascular aortic repair for aortic arch, and operative procedures have been improved to decrease stroke events [30,33].…”

Covert atrial fibrillation and atrial high-rate episodes as a potential cause of embolic strokes of undetermined source: Their detection and possible management strategy

“…A recent systemic review of ESUS reported that the frequency of ESUS ranged from 9% to 25% with average frequency of 17% [2,23,24]. In Japan, frequency of ESUS was reported to be 13% in the NCVC Stroke Registry between 2012 and 2013 [25], and to be 25% in the Inpatient Registry of the Department of Neurology at Juntendo University Hospital from April 2008 to March 2014 [26]. The frequency of cryptogenic stroke or ESUS varies among studies according to the patient population, the criteria for cryptogenic stroke in each hospital, and different diagnostic evaluation.…”