Recurrent Stroke Incidence and Etiology in Patients with Embolic Stroke of Undetermined Source and Other Stroke Subtypes

Abstract

This study aimed at clarifying the incidence of recurrent stroke and its etiology in patients with embolic stroke of undetermined source (ESUS) and other stroke subtypes in both the acute and chronic periods. Methods: A total of 645 patients who were admitted with acute ischemic stroke (IS) between March 2015 and August 2019 were enrolled. Among them, 511 patients with ESUS, cardioembolism (CE), large artery atherosclerosis (LAA), or small vessel disease (SVD) were analyzed in this study. After discharge, 391 patients who visited the outpatient clinic were followed up until August 2020. The outcome was stroke recurrence. Results: In the acute admission, recurrence rates were 7.6%, 8.1%, 18.8%, and 2.2% in patients with ESUS, CE, LAA, and SVD, respectively, and there were significant differences between the groups. The subtype of recurrence was almost identical to that of the index stroke. In the outpatient clinic, the annual recurrence rates were 4.4%, 4.3%, 6.0%, and 2.9% in ESUS, CE, LAA, and SVD, respectively, and no difference was observed. Subtypes of recurrence in outpatients with ESUS included ESUS, intracerebral hemorrhage (ICH), and SVD. Patients with ESUS and SVD had a higher risk of ICH during follow-up. Conclusions: Although the risk of recurrence was comparable between patients with ESUS and CE and intermediate between patients with LAA and SVD, in the acute admission unit, the risk in outpatients was similar among all subtypes. ESUS was the most recurrent stroke subtype in outpatients with ESUS. The risk of hemorrhagic stroke was significant in patients with SVD and ESUS. atherosclerosis (LAA) 3) ; however, the recurrence risk of other stroke subtypes after the acute period remains controversial 4). Physicians usually start to see patients in the outpatient clinic within 6 months of their index stroke and administer medical treatments, including appropriate antithrombotic therapy, for patients with cardioembolic (CE) stroke and non-CE stroke to prevent secondary stroke. Both NAVIGATE ESUS 5) and RESPECT ESUS 6) studies reported that recurrent stroke incidence in outpatients with ESUS ranged from 4.0% to 5.0% in outpatient clinics, irrespective of the use of direct oral anticoagulant or aspirin. On the basis of nine cohort studies, a systematic review of ESUS also reported an average Copyright©2021 Japan Atherosclerosis Society This article is distributed under the terms of the latest version of CC BY-NC-SA defined by the Creative Commons Attribution License.

The Relationship Between Aortic Arch Calcification and Recurrent Stroke in Patients With Embolic Stroke of Undetermined Source—A Case-Control Study

“…According to data from the China National Stroke Screening and Prevention Project (CNSSPP), the standardized prevalence of AF among Chinese adults aged ≥40 years was 2.31%. Notably, the rate of stroke recurrence in our patients with ESUS was quite close to that reported in patients with large artery atherosclerosis (LAA) ( 25 , 26 ), further supporting that large artery non-stenosing plaque might be the potential etiology of stroke and stroke recurrence in this ESUS population in China.…”

Long-Term Trends in The 5-Year Risk of Recurrent Stroke over A Half Century in A Japanese Community: The Hisayama Study

“…In the present study, we examine the secular trends in the 5-year risk of recurrent stroke from the date of first onset using the data from four cohorts covering different time periods, which were established from an epidemiological study for stroke in a Japanese community conducted over a half century. In addition, since the risk of stroke recurrence is considered to be different among the subtypes 20,21) , we separately estimated the trends in the risk of stroke recurrence among the subjects with ischemic stroke, among the subjects with hemorrhagic stroke, and among the subjects with each ischemic stroke subtype.…”

Detection of atrial fibrillation and sinus pause in embolic stroke of undetermined sources by chest strap‐style 7‐day Holter monitoring

“…In our institute, all patients with acute ischemic stroke were admitted to stroke care unit under standard ECG monitoring system, and 5 percent of ESUS patients showed PAF in 24-h ECG monitor or standard monitor system. 6 ECG monitoring of stroke unit uncovered PAF in some ESUS patients before 7-day ECG monitoring, 17,18 resulting in low detection rated of PAF in 7-day ECG monitoring in our study. After 1 month since index stroke, 7-day ECG monitoring may be meaningless due to low detection rate.…”

“…UMIN00031913), which included those who were admitted to our hospital within 7 days of onset of ischemic stroke or transient ischemic attack (TIA). 6 Between March 1, 2015, and January 2021, a total of 738 patients were enrolled in this registry.…”

“…Around 10% of patients with ESUS showed PAF in ILR during the first year 4 ; however, etiology of recurrent stroke in ESUS was mostly ESUS, and very few CE. 5,6 Furthermore, recent studies showed that around 10% of patients with noncardioembolic stroke such as large artery atherosclerosis or small vessel showed PAF in ILR during a year. 7,8 Therefore, it is unclear whether PAF detected in ILR in ESUS patients is responsible for index stroke or not.…”