title: Embolic Stroke of Undetermined Source: A Systematic Review and Clinical Update.
abstract: Embolic stroke of undetermined source (ESUS) designates patients with nonlacunar cryptogenic ischemic strokes in whom embolism is the likely stroke mechanism. It has been hypothesized that anticoagulation is more efficacious than antiplatelet therapy for secondary stroke prevention in ESUS patients. We review available information about ESUS.
  
  
  
  Systematic literature review to assess the frequency of ESUS, patient features, and prognosis using PubMed from 2014 to present, unrestricted by language.
  
  
  
  On the basis of 9 studies, the reported frequency of ESUS ranged from 9% to 25% of ischemic strokes, averaging 17%. From 8 studies involving 2045 ESUS patients, the mean age was 65 years and 42% were women; the mean NIH stroke score was 5 at stroke onset (4 studies, 1772 ESUS patients). Most (86%) ESUS patients were treated with antiplatelet therapy during follow-up, with the annualized recurrent stroke rate averaging 4.5% per year during a mean follow-up of 2.7 years (5 studies, 1605 ESUS patients).
  
  
  
  ESUS comprises about 1 ischemic stroke in 6. Patients with ischemic stroke meeting criteria for ESUS were relatively young compared with other ischemic stroke subtypes and had, on average, minor strokes, consistent with small emboli. Retrospective methods of available studies limit confidence in stroke recurrence rates but support a substantial (>4% per year) rate of stroke recurrence during (mostly) antiplatelet therapy. There is an important need to define better antithrombotic prophylaxis for this frequently occurring subtype of ischemic stroke.
authors.affiliation: From the Department of Medicine (Neurology) (R.G.H., L.C., K.S.P.), Population Health Research Institute and Department of Medicine (Cardiology) (S.J.C.), McMaster University, Hamilton Health Sciences, Ontario, Canada; Department of Medicine, Larissa University Hospital, University of Thessaly, Larissa, Greece (G.N.). robert.hart@phri.ca.
authors.forename: Robert G
authors.initials: RG
authors.lastname: Hart
authors.affiliation: From the Department of Medicine (Neurology) (R.G.H., L.C., K.S.P.), Population Health Research Institute and Department of Medicine (Cardiology) (S.J.C.), McMaster University, Hamilton Health Sciences, Ontario, Canada; Department of Medicine, Larissa University Hospital, University of Thessaly, Larissa, Greece (G.N.).
authors.forename: Luciana
authors.initials: L
authors.lastname: Catanese
authors.affiliation: From the Department of Medicine (Neurology) (R.G.H., L.C., K.S.P.), Population Health Research Institute and Department of Medicine (Cardiology) (S.J.C.), McMaster University, Hamilton Health Sciences, Ontario, Canada; Department of Medicine, Larissa University Hospital, University of Thessaly, Larissa, Greece (G.N.).
authors.forename: Kanjana S
authors.initials: KS
authors.lastname: Perera
authors.affiliation: From the Department of Medicine (Neurology) (R.G.H., L.C., K.S.P.), Population Health Research Institute and Department of Medicine (Cardiology) (S.J.C.), McMaster University, Hamilton Health Sciences, Ontario, Canada; Department of Medicine, Larissa University Hospital, University of Thessaly, Larissa, Greece (G.N.).
authors.forename: George
authors.initials: G
authors.lastname: Ntaios
authors.affiliation: From the Department of Medicine (Neurology) (R.G.H., L.C., K.S.P.), Population Health Research Institute and Department of Medicine (Cardiology) (S.J.C.), McMaster University, Hamilton Health Sciences, Ontario, Canada; Department of Medicine, Larissa University Hospital, University of Thessaly, Larissa, Greece (G.N.).
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Connolly
mesh_terms: D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D002545:Brain Ischemia / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology; D005260:Female; D006801:Humans; D020766:Intracranial Embolism / Q000150:complications / Q000188:drug therapy / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology
chemical_list: D000925:Anticoagulants
keywords: diagnosis; embolism; prognosis; secondary prevention; stroke