Stroke of undetermined source most commonly followed by another embolic stroke

If this is you, you are pretty much on your own since researchers seem to have given up.

Stroke of undetermined source most commonly followed by another embolic stroke

After an initial embolic stroke of undetermined source, or ESUS, the most prevalent recurrent infarct was another ESUS, according to an analysis of the NAVIGATE-ESUS trial.
Researchers also noted that atrial fibrillation was strongly associated with morbidity and mortality among patients with recurrent ischemic stroke.

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“The predominance of embolic features in most of the recurrent strokes after ESUS found in our analysis supports the validity of the ESUS construct in terms of embolism as the pathogenic mechanism,” Roland Veltkamp, MD, of the department of neurology at Alfried Krupp Krankenhaus, Germany, and colleagues wrote. “However, even with the additional knowledge of recurrent stroke subtype in the present analysis, it is not possible to identify patient characteristics that are associated with the mechanism of recurrence at the time of the qualifying ESUS.”
The NAVIGATE-ESUS trial was a randomized controlled trial that assessed the safety and efficacy of rivaroxaban (Xarelto, Janssen) compared with aspirin in patients with recent ESUS.
For this secondary analysis, published in JAMA Neurology, investigators assessed the data of patients who experienced ischemic stroke during the median 11-month follow-up after initial ESUS (n = 309; 66% men; mean age, 68 years).
Of the classifiable cases of ischemic strokes, researchers determined that 58% were ESUS and the other 42% were identified as cardioembolic (32%), atherosclerotic (23%), lacunar (31%) or other determined cause (14%). The risk for stroke recurrence did not differ by subtype between patients who received rivaroxaban or aspirin, according to the study.
Although AF was identified in 9% of cohort, it was associated with greater morbidity (median change in modified Rankin Scale score, 2 vs. 0) and mortality (15% vs 1%) compared with other causes.
“Although covert atrial fibrillation may not underlie most recurrent strokes after ESUS, its particularly grave consequences warrant a more extensive search for atrial fibrillation in patients with ESUS than mandated in the originally proposed criteria for ESUS,” the researchers wrote.
In other findings, for both the index and recurrent strokes, location of infarct was more often in the left hemisphere (46% index; 54% recurrent) compared with the right hemisphere (40% index; 37% recurrent) or brain stem or cerebellum (14% index; 9% recurrent).
“The persisting uncertainty regarding the embolic source after stroke recurrence in a large proportion of our patients with ESUS suggests that the search for an underlying source may remain futile in many cases with ESUS, given the limitations of widely used diagnostic testing at present,” the researchers wrote. “Consequently, addressing a specific embolic source by targeted antithrombotic stroke prevention remains an unresolved dilemma for many patients with ESUS.”