ABSTRACT
INTRODUCTION: The concept of embolic stroke of undetermined source (ESUS) has recently appeared to better characterise patients with cryptogenic stroke. PATIENTS AND METHODS: A systematic review of studies published since 2014 was performed to evaluate the epidemiology, clinical features and prognosis of patients with ESUS and their proportion among patients with cryptogenic stroke. RESULTS: Ten studies were identified with a total of 14,810 patients. The frequency of ESUS varied between 6% and 42%. We observed a high percentage of patients with cryptogenic stroke who met ESUS criteria (37-82%). The mean age of these patients was 65-68 years. The mean severity of the stroke, as measured using the National Institutes of Health Stroke Scale, was found to be 3-7 points. A high degree of variability was seen in the proportion of atrial fibrillation (detected during follow-up) related to the electrocardiogram monitoring technique. In five studies, some minor source of cardioembolism was observed in one out of every two patients, the most frequent being the persistence of patent foramen ovale. The risk of recurrence was 5-14.5%. CONCLUSION: The application of the new ESUS criteria provides a better definition of patients with cryptogenic stroke. Applying the concept of ESUS requires not only adequate electrocardiogram monitoring, but also routine complementary examinations to rule out the presence of minor sources of cardioembolism and other sources of embolism other than atrial fibrillation.
TITLE: Revision sistematica de las caracteristicas y pronostico de los sujetos que sufren un ictus criptogenico no lacunar de mecanismo embolico.Introduccion. Recientemente ha surgido el concepto de ictus criptogenico no lacunar de mecanismo embolico del ingles embolic stroke of undetermined source (ESUS) para caracterizar mejor a los pacientes con ictus criptogenico. Pacientes y metodos. Se realiza una revision sistematica de los estudios publicados desde 2014 hasta la actualidad, valorando la epidemiologia, las caracteristicas clinicas y el pronostico de los pacientes con ESUS y su proporcion entre los pacientes con ictus criptogenico. Resultados. Se identificaron 10 estudios con un total de 14.810 pacientes. La frecuencia de ESUS vario entre el 6 y el 42%. Se observo un porcentaje elevado de pacientes con ictus criptogenico que cumplian los criterios de ESUS (37-82%). La edad media de estos pacientes era de 65-68 años. La gravedad media del ictus, medida por la National Institutes of Health Stroke Scale, se establecio en 3-7 puntos. Se observo una alta variabilidad en la proporcion de fibrilacion auricular (detectada durante el seguimiento) relacionada con la tecnica de monitorizacion del electrocardiograma. En cinco estudios, hasta en uno de cada dos pacientes se observo alguna fuente de cardioembolismo menor, la mas frecuente, la persistencia del foramen oval permeable. El riesgo de recurrencia fue del 5-14,5%. Conclusion. La aplicacion de los nuevos criterios de ESUS define mejor a los pacientes con ictus criptogenico. La aplicacion del concepto de ESUS exige no solo una monitorizacion de electrocardiograma adecuada, sino exploraciones complementarias de rutina para descartar la presencia de fuentes de cardioembolismo menor y de otras fuentes de embolismo diferentes a la fibrilacion auricular.
Subject(s)
Intracranial Embolism/epidemiology , Aged , Aortic Diseases/complications , Arteriosclerosis/complications , Atrial Fibrillation/complications , Brain Damage, Chronic/epidemiology , Brain Damage, Chronic/etiology , Female , Humans , Intracranial Embolism/complications , Intracranial Embolism/diagnosis , Male , Plaque, Atherosclerotic/complications , Prognosis , Recovery of FunctionABSTRACT
Oral anticoagulant treatments, such as vitamin K antagonists (VKAs), are the main treatments administered to atrial fibrillation (AF) patients in order to prevent ischemic stroke (IS). However, the genes involved in the VKA metabolism can undergo variations in a single nucleotide (SNP). These SNPs may then affect the VKA target enzyme (VKORC1), VKA degradation enzyme (CYP2C9), and vitamin K bioavailability enzyme (CYP4F2). We genotyped these SNPs in a cohort of patients with non-valvular AF who were under VKA treatment after suffering an IS. Clinical variables, CHADS2-VASC score and data about the international normalized ratio (INR) within the therapeutic range were all recorded. DNA was extracted from blood and genotyping was carried out by DNA sequencing. The main endpoint was the time from VKA onset to IS. Of a total of 356 consecutive IS patients monitored, 33 were included in the study. The median time to the event was 2248.0 days (interquartile range [IQR] 896.3-3545.3). The median CHADS2-VASC score was 4.0 (IQR 3.0-6.0). When we considered the risk of IS within 2 years under VKA treatment, we found that only the rs2108622 AA genotype was significantly associated with this endpoint (early IS) (hazard ratio 6.81, 95% CI 1.37-33.92, p = 0.019). Kaplan-Meier curve analysis also showed a significant relationship between early IS and rs2108622 AA genotype (Log rank p = 0.022). The CYP4F2 gene rs2108622 polymorphism was associated with a risk of early IS in NV-AF patients under VKA treatment.
