Embolic stroke of undetermined source: A cardiovascular approach to diagnostic uncertainty
Adishwar Rao1, Hammad Rahman2, Hitesh Bhatia1
1Department of Internal Medicine, Guthrie Robert Packer Hospital, Sayre, PA 18840, USA.
Insights
Embolic stroke of undetermined source (ESUS) requires thorough cardiac and hypercoagulable state evaluation. While antiplatelet therapy is common, oral anticoagulants are reserved for specific conditions, emphasizing shared decision-making.
Area of Science:
- Neurology
- Cardiology
- Hematology
Background:
- Embolic stroke of undetermined source (ESUS) presents an undiagnosed embolic cause post-stroke workup.
- Identifying the embolic source is crucial for appropriate patient management and secondary stroke prevention.
Purpose of the Study:
- To outline the comprehensive evaluation process for patients diagnosed with ESUS.
- To delineate appropriate therapeutic strategies, including antiplatelet therapy and oral anticoagulation, for ESUS patients.
Main Methods:
- Systematic review of diagnostic criteria and etiological workup for ESUS.
- Analysis of current therapeutic guidelines and evidence for antiplatelet and anticoagulant use in ESUS.
- Emphasis on shared decision-making in managing ESUS patients.
Main Results:
- ESUS evaluation necessitates investigation of rhythm disorders (e.g., atrial fibrillation), cardiac pathologies, and hypercoagulable states.
- Most ESUS patients benefit from antiplatelet therapy.
- Oral anticoagulation is discouraged unless specific indications like atrial fibrillation, cancer-related thrombosis, or cardiac thrombosis are present.
Conclusions:
- A structured diagnostic approach is essential for identifying potential causes of ESUS.
- Therapeutic decisions in ESUS should be individualized, balancing risks and benefits.
- Shared decision-making is paramount due to uncertainties in ESUS management and limited high-quality data.
Abstract:
Embolic stroke of undetermined source (ESUS) is a clinical event with an undelineated embolic etiology after the initial stroke workup. Once stroke specialists confirm ESUS, evaluation of rhythm disorders such as atrial fibrillation, specific cardiac pathologies (cardiomyopathy, left atrial cardiopathy, left-atrial septal pouch, aortic or mitral valve disease, cardiac neoplasm, right-to-left shunts, or device-related thrombus), and acquired hypercoagulable states, which may occasionally be related to malignancy, should be performed. While most ESUS patients require appropriate antiplatelet therapy, certain subsets may require oral anticoagulation. However, routine prescription of oral anticoagulants in the absence of documented atrial fibrillation, cancer-related thrombosis, or cardiac thrombosis is discouraged. Shared decision-making between the patient and the physician about additional diagnostic and therapeutic decisions is particularly encouraged in this condition, given the limited availability of high-quality clinical data and considerable uncertainty about the safety and efficacy of therapeutic options and clinical outcomes.
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