Embolic strokes of undetermined source in the Athens stroke registry: a descriptive analysis.
OBJECTIVE
A new clinical construct termed embolic stroke of undetermined source (ESUS) was recently introduced, but no such population has been described yet. Our aim is to provide a detailed descriptive analysis of an ESUS population derived from a large prospective ischemic stroke registry using the proposed diagnostic criteria.


METHODS
The criteria proposed by the Cryptogenic Stroke/ESUS International Working Group were applied to the Athens Stroke Registry to identify all ESUS patients. ESUS was defined as a radiologically confirmed nonlacunar brain infarct in the absence of (a) extracranial or intracranial atherosclerosis causing ≥50% luminal stenosis in arteries supplying the ischemic area, (b) major-risk cardioembolic source, and (c) any other specific cause of stroke.


RESULTS
Among 2735 patients admitted between 1992 and 2011, 275 (10.0%) were classified as ESUS. In the majority of ESUS (74.2%), symptoms were maximal at onset. ESUS were of moderate severity (median National Institute Health Stroke Scale score, 5). The most prevalent risk factor was arterial hypertension (64.7%), and 50.9% of patients were dyslipidemic. Among potential causes of the ESUS, covert atrial fibrillation (AF) was the most prevalent: in 30 (10.9%) patients, AF was diagnosed during hospitalization for stroke recurrence, whereas in 50 (18.2%) patients AF was detected after repeated ECG monitoring during follow-up. Also, covert AF was strongly suggested in 38 patients (13.8%) but never recorded.


CONCLUSIONS
About 10% of patients with first-ever ischemic stroke met criteria for ESUS; covert paroxysmal AF seems to be a frequent cause of ESUS.
From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece (E.M., K.V.); Department of Neurology, Eginition Hospital, University of Athens Medical School, Athens, Greece (K.S.); and Stroke Center, Neurology Service, CHUV, University of Lausanne, Lausanne, Switzerland (P.M.). gntaios@med.uth.gr.
George
G
Ntaios
From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece (E.M., K.V.); Department of Neurology, Eginition Hospital, University of Athens Medical School, Athens, Greece (K.S.); and Stroke Center, Neurology Service, CHUV, University of Lausanne, Lausanne, Switzerland (P.M.).
Vasileios
V
Papavasileiou
From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece (E.M., K.V.); Department of Neurology, Eginition Hospital, University of Athens Medical School, Athens, Greece (K.S.); and Stroke Center, Neurology Service, CHUV, University of Lausanne, Lausanne, Switzerland (P.M.).
Haralambos
H
Milionis
From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece (E.M., K.V.); Department of Neurology, Eginition Hospital, University of Athens Medical School, Athens, Greece (K.S.); and Stroke Center, Neurology Service, CHUV, University of Lausanne, Lausanne, Switzerland (P.M.).
Konstantinos
K
Makaritsis
From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece (E.M., K.V.); Department of Neurology, Eginition Hospital, University of Athens Medical School, Athens, Greece (K.S.); and Stroke Center, Neurology Service, CHUV, University of Lausanne, Lausanne, Switzerland (P.M.).
Efstathios
E
Manios
From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece (E.M., K.V.); Department of Neurology, Eginition Hospital, University of Athens Medical School, Athens, Greece (K.S.); and Stroke Center, Neurology Service, CHUV, University of Lausanne, Lausanne, Switzerland (P.M.).
Konstantinos
K
Spengos
From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece (E.M., K.V.); Department of Neurology, Eginition Hospital, University of Athens Medical School, Athens, Greece (K.S.); and Stroke Center, Neurology Service, CHUV, University of Lausanne, Lausanne, Switzerland (P.M.).
Patrik
P
Michel
From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Athens, Greece (E.M., K.V.); Department of Neurology, Eginition Hospital, University of Athens Medical School, Athens, Greece (K.S.); and Stroke Center, Neurology Service, CHUV, University of Lausanne, Lausanne, Switzerland (P.M.).
Konstantinos
K
Vemmos
D000368:Aged; D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000150:complications* / Q000175:diagnosis; D020520:Brain Infarction / Q000209:etiology*; D015331:Cohort Studies; D050171:Dyslipidemias / Q000150:complications; D004562:Electrocardiography; D005260:Female; D006115:Greece; D006801:Humans; D006973:Hypertension / Q000150:complications; D020766:Intracranial Embolism / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012042:Registries; D012307:Risk Factors; D020521:Stroke / Q000209:etiology
ESUS; covert atrial fibrillation; cryptogenic; embolic stroke of undetermined cause; embolism