Embolic Stroke of Unknown Source - Oren Zarif - Embolic Stroke
Embolic stroke of unknown source (ESUS) is a relatively rare complication of cryptogenic stroke. Approximately 20% of all strokes have cryptogenic origins, and the term is relatively new, but it aims to describe a large subgroup of these cases. The term includes patients with non-lumen infarcts and excludes patients with cardiogenic emboli. Its causes are unclear, and the best treatment options are multidisciplinary.
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Cryptogenic or paradoxical causes are believed to account for one-third of all strokes, with the number increasing among younger patients. Such strokes can be the result of inadequate diagnostic workups, multiple causes, or under-recognized etiologies. A patient with suspected embolic stroke of unknown source requires an individualized treatment plan, including investigations to rule out established vascular and cardiac causes. Although a thorough clinical and diagnostic evaluation is required, there are some ways to identify a cryptogenic or undetermined source of embolic stroke.
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Symptoms of embolic stroke include difficulty moving limbs or performing simple manipulations. The occurrence of these symptoms depends on the part of the brain affected and the functions it affects. Regardless of the cause, this is a medical emergency requiring immediate medical attention. The symptoms of an embolic stroke vary widely, and it is important to seek medical attention right away. If you notice any of these symptoms, call an ambulance immediately. Diagnosis of this type of stroke is complicated and difficult to predict.
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An embolic stroke is a potentially devastating type of stroke caused by a blood clot traveling from somewhere else in the body. The embolus, or piece of clot, breaks loose and is carried through the bloodstream to the brain. However, the larger arteries branch off into smaller vessels, and the embolus becomes wedged, cutting off the flow of blood to the brain. In this case, the patient will experience a stroke, and it will be irreversible.
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An embolic stroke can be caused by a number of cardiac conditions. High-risk conditions include atrial fibrillation, recent myocardial infarction, calcific aortic valve stenosis, or mechanical prosthetic valve. Even minor causes can be the culprit of an embolic stroke, such as a ruptured aneurysm. Nevertheless, an embolic stroke is not an indication of the end of the world.
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Although there is no specific treatment for ESUS, current guidelines recommend antiplatelet therapy for noncardioembolic ischemic stroke. Anticoagulation is also being studied in clinical trials for ESUS. Although the etiology of ESUS remains unclear, it appears to be closely related to heart-related embolism. And while the two types of stroke share similarities in their presentation, ESUS is a much more serious type of stroke.
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Emergency procedures may be performed to treat an embolic stroke. Emergency procedures include a carotid endarterectomy, in which the plaque lining the carotid artery is removed, and mechanical clot removal, in which a catheter is inserted into the brain and breaks up the clot. Dedicated neurologists and neurosurgeons provide 24-hour care for patients with embolic stroke. These highly experienced doctors also offer rehabilitation services.
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Preventing embolic stroke is an important part of managing chronic conditions. Tobacco use has been linked to stroke in both men and women. However, studies have shown that it is possible to reduce the risk of stroke by following your doctor's recommendations. In addition to tobacco use, smoking and pregnancy are known risk factors for embolic stroke in women. And if you have a history of heart attacks, your risk of having a stroke increases dramatically.
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The causes of embolic stroke vary widely and are complicated by the underlying pathology. For example, while AF is often considered the etiology, there is also a possible risk of PFO being the actual cause of a stroke. A multivariate regression analysis revealed six risk factors that were associated with PFO. These variables can be stratified on a 10-point scale. The majority of patients with deep infarcts had low ROPE scores, which is consistent with a PFO.
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Although the frequency of genetic abnormality as a cause of ischemic stroke remains low, early identification of a disease causing factor may have implications for management and counseling of these patients. While the true prevalence of genetic abnormality is not known, those patients with a positive family history or no conventional risk factors are at higher risk for a recurrent stroke. While this finding is not conclusive, it does suggest that genetic testing is necessary to identify any potential risk factor.
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The NAVIGATE-ESUS trial yielded three major findings. The majority of recurrent ischemic strokes after ESUS were recurrent, and a significant percentage had no underlying source of embolic disease. The location of recurrences also underscores the coexistence of several embolic mechanisms. However, the association of atrial fibrillation with recurrences was only rarely significant. Although rivaroxaban prevented recurrences associated with atrial fibrillation, it was an uncommon complication of the trial.