Clinical and Neuroimaging Characteristics in Embolic Stroke of Undetermined versus Cardioembolic Origin: A Population-Based Study

Georgios Tsivgoulis; Odysseas Kargiotis; Aristeidis H Katsanos; Athanasia Patousi; Maria Pikilidou; Theodosis Birbilis; Michael Mantatzis; Lina Palaiodimou; Sokratis Triantafyllou; Nikolaos Papanas; Panagiotis Skendros; Aikaterini Terzoudi; George S Georgiadis; Efstratios Maltezos; Charitomeni Piperidou; Aspasia Serdari; Aikaterini Theodorou; Ignatios Ikonomidis; Ioannis Heliopoulos; Konstantinos Vadikolias

doi:10.1111/jon.12660

Clinical and Neuroimaging Characteristics in Embolic Stroke of Undetermined versus Cardioembolic Origin: A Population-Based Study

J Neuroimaging. 2019 Nov;29(6):737-742. doi: 10.1111/jon.12660. Epub 2019 Aug 28.

Authors

Georgios Tsivgoulis^{1

2}, Odysseas Kargiotis³, Aristeidis H Katsanos^{2

4}, Athanasia Patousi¹, Maria Pikilidou⁵, Theodosis Birbilis⁶, Michael Mantatzis⁷, Lina Palaiodimou², Sokratis Triantafyllou², Nikolaos Papanas⁸, Panagiotis Skendros⁹, Aikaterini Terzoudi¹, George S Georgiadis¹⁰, Efstratios Maltezos⁸, Charitomeni Piperidou¹, Aspasia Serdari¹¹, Aikaterini Theodorou², Ignatios Ikonomidis¹², Ioannis Heliopoulos¹, Konstantinos Vadikolias¹

Affiliations

¹ Department of Neurology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece.
² Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
³ Stroke Unit, Metropolitan Hospital, Piraeus, Greece.
⁴ Department of Neurology, University of Ioannina, School of Medicine, Ioannina, Greece.
⁵ Excellence Center, First Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
⁶ Department of Neurosurgery, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece.
⁷ Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece.
⁸ Second Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece.
⁹ First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece.
¹⁰ Department of Vascular Surgery, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece.
¹¹ Department of Child and Adolescent Psychiatry, Democritus University of Thrace, University Hospital of Alexandroupolis.
¹² Second Department of Cardiology, "Attikon" University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.

PMID: 31463999
DOI: 10.1111/jon.12660

Abstract

Background and purpose: Evidence suggests that cardioembolism represents the underlying mechanism in the minority of embolic strokes of undetermined source (ESUS). In this population-based study, we sought to compare the clinical and imaging characteristics as well as outcomes in patients with ESUS and cardioembolic stroke (CE).

Methods: We included consecutive patients with first-ever ischemic stroke (IS) from the previously published population-based Evros-Stroke-Registry identified as ESUS or CE according to standardized criteria. Baseline characteristics, admission NIHSS scores, cerebral edema, hemorrhagic transformation, stroke recurrence, functional outcomes (determined by modified Rankin Scale [mRS] scores), and mortality rates were recorded during the 1-year follow-up period.

Results: We identified 21 ESUS (3.7% of IS) and 211 CE (37.1% of IS) cases. Patients with ESUS were younger (median age: 68 years [interquartile range [IQR]: 61-75] vs 80 years [IQR: 75-84]; P < .001), had lower median admission NIHSS scores (4 points [IQR: 2-8] vs 10 points [IQR: 5-17]; P < .001), and lower prevalence of cerebral edema on neuroimaging studies (0 vs. 33.3%, P = .002). Functional outcomes were more favorable in ESUS at 28 (median mRS score: 2 [IQR: 1-3] vs 4 [IQR: 4-5]; P < .001), 90 (median mRS score: 1 [IQR: 0-2] vs 4 [IQR: 3-5]; P < .001), and 365 days (median mRS score: 1 [IQR: 0-2] vs 4 [IQR: 2-4]; P < 0.001). At 1-year, the mortality rate was lower in ESUS (0% [95% confidence interval [CI]: 0-13.5%] vs 34.6% [95% CI: 28.2-41.0%]; P < .001); the 1-year recurrent rate was also lower numerically (0% [95% CI: 0-13.5%] vs 9.5% [95% CI: 5.5-13.4%]; P = .140) but this difference failed to reach statistical significance due to the small study population.

Conclusions: The clinical and neuroimaging profiles as well as clinical outcomes vary substantially between ESUS and CE indicating different underlying mechanisms.

Keywords: atrial fibrillation; cardioembolic stroke; embolic stroke of undetermined source; population-based study; stroke recurrence.

MeSH terms

Aged
Aged, 80 and over
Atrial Fibrillation / diagnostic imaging*
Brain / diagnostic imaging*
Brain Edema / diagnostic imaging*
Female
Humans
Intracranial Embolism / diagnostic imaging*
Male
Middle Aged
Neuroimaging*
Registries
Risk Factors
Stroke / diagnostic imaging*