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Review
. 2022 Jul;22(7):389-393.
doi: 10.1007/s11910-022-01202-w. Epub 2022 May 7.

Management of Patients with Embolic Stroke of Unknown Source: Interpreting the Evidence in the Light of Clinical Judgement

J David Spence  1
Affiliations
Review

Management of Patients with Embolic Stroke of Unknown Source: Interpreting the Evidence in the Light of Clinical Judgement

J David Spence. Curr Neurol Neurosci Rep. 2022 Jul.

Abstract

Purpose of review: To assess the validity of the belief that anticoagulation is not beneficial in patients with embolic stroke of unknown source (ESUS), and to asssess the benefits and safety of direct-acting oral anticoagulants (DOACs).

Recent findings: The failure of randomized trials to show benefit of anticoagulation in ESUS is probably due to misclassification of large artery atherosclerosis (LAA) as ESUS, as defined by a stenosis ≥ 50%. There are important differences among DOACs. There are a number of problems with dabigatran, and rivaroxaban and edoxaban are not suitable for once-daily dosing. Recent evidence from real-world practice indicates that apixaban is more effective and safer than rivaroxaban. Plaque burden should be included in the definition of LAA. Patients in whom a cardioembolic source is strongly suspected should be anticoagulated; antiplatelet agents are not significantly safer than DOACs, and are not effective in cardioembolic stroke.

Keywords: Anticoagulation; Carotid plaque burden; Clinical judgement; Cryptogenic stroke; ESUS; Misclassification; Stenosis.

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References

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