title: Embolic strokes of undetermined source: Prevalence and patient features in the ESUS Global Registry.
abstract: Recent evidence supports that most non-lacunar cryptogenic strokes are embolic. Accordingly, these strokes have been designated as embolic strokes of undetermined source (ESUS).
  
  
  
  We undertook an international survey to characterize the frequency and clinical features of ESUS patients across global regions.
  
  
  
  Consecutive patients hospitalized for ischemic stroke were retrospectively surveyed from 19 stroke research centers in 19 different countries to collect patients meeting criteria for ESUS.
  
  
  
  Of 2144 patients with recent ischemic stroke, 351 (16%, 95% CI 15% to 18%) met ESUS criteria, similar across global regions (range 16% to 21%), and an additional 308 (14%) patients had incomplete evaluation required for ESUS diagnosis. The mean age of ESUS patients (62 years; SD = 15) was significantly lower than the 1793 non-ESUS ischemic stroke patients (68 years, p ≤ 0.001). Excluding patients with atrial fibrillation (n = 590, mean age = 75 years), the mean age of the remaining 1203 non-ESUS ischemic stroke patients was 64 years (p = 0.02 vs. ESUS patients). Among ESUS patients, hypertension, diabetes, and prior stroke were present in 64%, 25%, and 17%, respectively. Median NIHSS score was 4 (interquartile range 2-8). At discharge, 90% of ESUS patients received antiplatelet therapy and 7% received anticoagulation.
  
  
  
  This cross-sectional global sample of patients with recent ischemic stroke shows that one-sixth met criteria for ESUS, with additional ESUS patients likely among those with incomplete diagnostic investigation. ESUS patients were relatively young with mild strokes. Antiplatelet therapy was the standard antithrombotic therapy for secondary stroke prevention in all global regions.
authors.affiliation: Department of Medicine (Neurology), McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada.
authors.forename: Kanjana S
authors.initials: KS
authors.lastname: Perera
authors.affiliation: Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.
authors.forename: Thomas
authors.initials: T
authors.lastname: Vanassche
authors.affiliation: Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada.
authors.forename: Jackie
authors.initials: J
authors.lastname: Bosch
authors.affiliation: Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada.
authors.forename: Mohana
authors.initials: M
authors.lastname: Giruparajah
authors.affiliation: Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada.
authors.forename: Balakumar
authors.initials: B
authors.lastname: Swaminathan
authors.affiliation: Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada.
authors.forename: Katie R
authors.initials: KR
authors.lastname: Mattina
authors.affiliation: Bayer Healthcare Pharmaceuticals, Whippany, NJ, USA.
authors.forename: Scott D
authors.initials: SD
authors.lastname: Berkowitz
authors.affiliation: Instituto Nacional de Neurologia y Neurocirugia, Mexico DF, Mexico.
authors.forename: Antonio
authors.initials: A
authors.lastname: Arauz
authors.affiliation: University of Galway, Galway, Ireland.
authors.forename: Martin J
authors.initials: MJ
authors.lastname: O'Donnell
authors.affiliation: Institute for Neurological Research, Fundacion para la Lucha contra las Enfermedades Neurologicas de la Infancia (FLENI), Buenos Aires, Argentina.
authors.forename: Sebastian F
authors.initials: SF
authors.lastname: Ameriso
authors.affiliation: School of Medicine and Pharmacology, University of Western Australia, Sir Charles Gairdner Hospital, Perth, Australia.
authors.forename: Graeme J
authors.initials: GJ
authors.lastname: Hankey
authors.affiliation: Department of Neurology, Seoul National University Hospital, Seoul, Korea.
authors.forename: Byung-Woo
authors.initials: BW
authors.lastname: Yoon
authors.affiliation: Department of Neurology, Bichat Hospital, Paris, France.
authors.forename: Philippa
authors.initials: P
authors.lastname: Lavallee
authors.affiliation: Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
authors.forename: Luis
authors.initials: L
authors.lastname: Cunha
authors.affiliation: Pirogov Russian National Research Medical University, Moscow, Russia.
authors.forename: Nikolay
authors.initials: N
authors.lastname: Shamalov
authors.affiliation: Universitair Ziekenhuis Brussel, Brussels, Belgium.
authors.forename: Raf
authors.initials: R
authors.lastname: Brouns
authors.affiliation: Irmandade da Santa Casa de Misericórdia de São Paulo, Sao Paulo, Brazil.
authors.forename: Rubens J
authors.initials: RJ
authors.lastname: Gagliardi
authors.affiliation: Department of Neurology, Hospital of the University of Pennsylvania, Philadephia, United States.
authors.forename: Scott E
authors.initials: SE
authors.lastname: Kasner
authors.affiliation: Department of Neurology and Psychiatry, "Sapienza" University of Rome, Rome, Italy.
authors.forename: Alessio
authors.initials: A
authors.lastname: Pieroni
authors.affiliation: Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Philipp
authors.initials: P
authors.lastname: Vermehren
authors.affiliation: Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan.
authors.forename: Kazuo
authors.initials: K
authors.lastname: Kitagawa
authors.affiliation: Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
authors.forename: Yongjun
authors.initials: Y
authors.lastname: Wang
authors.affiliation: Institute of Neuroscience and Physiology, University of Glasgow, Queen Elizabeth Hospital, Glasgow, United Kingdom.
authors.forename: Keith
authors.initials: K
authors.lastname: Muir
authors.affiliation: Academic Medical Center, Amsterdam, Netherlands.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Coutinho
authors.affiliation: Department of Neurology, Semmelweis University, Budapest, Hungary.
authors.forename: Ildiko
authors.initials: I
authors.lastname: Vastagh
authors.affiliation: Department of Medicine (Cardiology), Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada.
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Connolly
authors.affiliation: Department of Medicine (Neurology), McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada robert.hart@phri.ca.
authors.forename: Robert G
authors.initials: RG
authors.lastname: Hart
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000453:epidemiology*; D003430:Cross-Sectional Studies; D004617:Embolism / Q000453:epidemiology*; D005260:Female; D006801:Humans; D038622:Internationality; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology*
keywords: Stroke; atrial fibrillation; cerebral embolism; diagnostic evaluation; embolism; stroke—etiology