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Unveiling ESUS: Cryptogenic Strokes Explained & Prioritizing Treatment Approaches

Learn about ESUS (Embolic Strokes of Undetermined Source) as not-so-cryptogenic anymore. Understand diagnostic criteria, potential causes, and treatment options. Explore the link between ESUS and atrial fibrillation. Discover the impact of ESUS on patient characteristics, stroke severity, and recurrence. Gain insights into ESUS treatment approaches with anticoagulants versus antiplatelets. Find out key take-home messages for managing ESUS patients effectively.

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Unveiling ESUS: Cryptogenic Strokes Explained & Prioritizing Treatment Approaches

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  1. ESUS: Embolic Strokes of Undetermined Source Not so cryptogenic anymore? George Ntaios University of Thessaly, Larissa, Greece European PFO Summit Zurich, 16/10/2015

  2. Disclosures Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis. Honoraria: Medtronic; Quintiles; Boehringer-Ingelheim. Speaker fees: Sanofi; Boehringer-Ingelheim; Galenica; Elpen; Bayer Support to attend conferences: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer-Ingelheim; Galenica;Elpen; Bristol Myers Squibb. Participation in trials: • NAVIGATE-ESUS / National Coordinator (Greece) • GLORIA-AF / Sub-investigator (Larissa). • FOURIER / Principal investigator (Larissa). • ENOS / National Coordinator (Greece). • EBBINGHAUS / Principal Investigator (Larissa). • PRECIOUS / National Coordinator (Greece). • BIOSIGNAL / Principal Investigator (Larissa). • PREVISE / Principal investigator (Larissa).

  3. Cryptogenic stroke: not rare

  4. Cryptogenic stroke: not innocent Ntaios et al. EurJ Neurol. 2014; 21:1108-14

  5. TOAST classification ?

  6. ESUS: Embolic Strokes of Undetermined Source Hart et al. Lancet Neurol 2014; 13: 429–38

  7. Cryptogenic stroke: what actually do you mean? Cryptogenic Not investigated Multiple causes Really cryptogenic

  8. ESUS: diagnostic criteria • Stroke detected by CT or MRI that is not lacunar. • Absence of extracranial or intracranial atherosclerosis causing >50% luminal stenosis in arteries supplying the area of ischemia. • No major-risk cardioembolic source of embolism(permanent or paroxysmal AF, sustained atrial flutter, intracardiac thrombus, prosthetic cardiac valve, atrial myxoma or other cardiac tumours, mitral stenosis, recent (<4 weeks) MI, LVEF<30%, valvularvegetations, or infective endocarditis). • No other specific cause of stroke identified. Hart et al. Lancet Neurol 2014; 13: 429–38

  9. ESUS: potential causes Hart et al. Lancet Neurol 2014; 13: 429–38

  10. ESUS: diagnostic algorithm • Brain CT or MRI • 12-lead ECG • Precordial echocardiography • Imaging of both extra- and intracranial arteries supplying the area of brain ischemia • Cardiac monitoring for ≥24hours with automated rhythm detection Hart et al. Lancet Neurol 2014; 13: 429–38

  11. CRYSTAL-AF Sanna et al. N Engl J Med 2014;370:2478-86

  12. CRYSTAL-AF: the more you look, the more you find 12.4% vs. 2.0% 30.0% vs. 3.0% Sanna et al. N Engl J Med 2014;370:2478-86

  13. EMBRACE: the more you look, the more you find Gladstone et al. N Engl J Med 2014;370:2467-77

  14. EMBRACE: the more you look, the more you find Gladstone et al. N Engl J Med 2014;370:2467-77

  15. EMBRACE: the more you look, the more you find Gladstone et al. N Engl J Med 2014;370:2467-77

  16. ESUS: Embolic Strokes of Undetermined Source Hart et al. Lancet Neurol 2014; 13: 429–38

  17. ESUS in the Athens Stroke Registry

  18. Ntaios et al. Stroke 2015; 46:176-81

  19. ESUS: patient characteristics Ntaios et al. Stroke 2015; 46:176-81

  20. ESUS: patient characteristics Ntaios et al. Stroke 2015; 46:176-81

  21. ESUS: patient characteristics Ntaios et al. Stroke 2015; 46:176-81

  22. ESUS: stroke severity Ntaios et al. Stroke 2015; 46:176-81

  23. ESUS & AF at follow-up: how much causality is there? • 81yrs • NIHSS:3 • Hypertensive, Non-smoker, non-diabetic • LDL: 104mg/dl • LA diameter: 42mm • mRS:0

  24. AF-related strokes are more severe Ntaios et al. Eur J Neurol. 2014; 21:1108-14

  25. ESUS & AF: how much of a causality? Ntaios et al, underreview

  26. ESUS: 5-yrs functional outcome Ntaios et al. Stroke 2015; 46:2087-93

  27. ESUS: 5-yrs stroke recurrence Ntaios et al. Stroke 2015; 46:2087-93

  28. So, how to treat my ESUS patient? Approach 1 Furie et al. Stroke 2011;42:227-76

  29. So, how to treat my ESUS patient? Approach 2

  30. So, how to treat my ESUS patient? Approach 3

  31. NAVIGATE- ESUS Rivaroxaban 15mg 1x1 R Aspirin 100mg 1x1

  32. RESPECT - ESUS Dabigatran 110/150 1x2 R Aspirin 100mg 1x1

  33. ATTICUS Apixaban R Aspirin 100mg 1x1

  34. Everybody gets happy! • Almost half stroke patients get an anticoagulant!

  35. Take-home messages • Cryptogenic  ESUS • ~10% of all stroke patients • ESUS needs a complete (?) diagnostic work-up • Covert AF is frequently detected in ESUS • Perhaps AF is over-estimated as a stroke cause • High recurrence rate • NOACs to replace antiplatelets?

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