Embolic Strokes of Undetermined Source in the Athens Stroke Registry: An Outcome Analysis

George Ntaios; Vasileios Papavasileiou; Haralampos Milionis; Konstantinos Makaritsis; Anastasia Vemmou; Eleni Koroboki; Efstathios Manios; Konstantinos Spengos; Patrik Michel; Konstantinos Vemmos

doi:10.1161/STROKEAHA.115.009334

Embolic Strokes of Undetermined Source in the Athens Stroke Registry: An Outcome Analysis

Stroke. 2015 Aug;46(8):2087-93. doi: 10.1161/STROKEAHA.115.009334. Epub 2015 Jul 9.

Affiliations

¹ From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Comprehensive Stroke Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford Royal Foundation Trust, Manchester, UK (V.P.); 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 (A.V., E.K., 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.
² From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Comprehensive Stroke Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford Royal Foundation Trust, Manchester, UK (V.P.); 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 (A.V., E.K., 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.).

PMID: 26159795
DOI: 10.1161/STROKEAHA.115.009334

Abstract

Background and purpose: Information about outcomes in Embolic Stroke of Undetermined Source (ESUS) patients is unavailable. This study provides a detailed analysis of outcomes of a large ESUS population.

Methods: Data set was derived from the Athens Stroke Registry. ESUS was defined according to the Cryptogenic Stroke/ESUS International Working Group criteria. End points were mortality, stroke recurrence, functional outcome, and a composite cardiovascular end point comprising recurrent stroke, myocardial infarction, aortic aneurysm rupture, systemic embolism, or sudden cardiac death. We performed Kaplan-Meier analyses to estimate cumulative probabilities of outcomes by stroke type and Cox-regression to investigate whether stroke type was outcome predictor.

Results: 2731 patients were followed-up for a mean of 30.5±24.1months. There were 73 (26.5%) deaths, 60 (21.8%) recurrences, and 78 (28.4%) composite cardiovascular end points in the 275 ESUS patients. The cumulative probability of survival in ESUS was 65.6% (95% confidence intervals [CI], 58.9%-72.2%), significantly higher compared with cardioembolic stroke (38.8%, 95% CI, 34.9%-42.7%). The cumulative probability of stroke recurrence in ESUS was 29.0% (95% CI, 22.3%-35.7%), similar to cardioembolic strokes (26.8%, 95% CI, 22.1%-31.5%), but significantly higher compared with all types of noncardioembolic stroke. One hundred seventy-two (62.5%) ESUS patients had favorable functional outcome compared with 280 (32.2%) in cardioembolic and 303 (60.9%) in large-artery atherosclerotic. ESUS patients had similar risk of composite cardiovascular end point as all other stroke types, with the exception of lacunar strokes, which had significantly lower risk (adjusted hazard ratio, 0.70 [95% CI, 0.52-0.94]).

Conclusions: Long-term mortality risk in ESUS is lower compared with cardioembolic strokes, despite similar rates of recurrence and composite cardiovascular end point. Recurrent stroke risk is higher in ESUS than in noncardioembolic strokes.

Keywords: ESUS; embolic stroke of undetermined source; mortality; outcome; stroke recurrence.

MeSH terms

Embolism / diagnosis*
Embolism / mortality*
Follow-Up Studies
Greece / epidemiology
Humans
Mortality / trends
Prospective Studies
Registries*
Risk Factors
Stroke / diagnosis*
Stroke / mortality*
Treatment Outcome