Clinical Study Of Embolic Stroke Of Undetermined Source

Purpose Retrospective review hospital records of patients with premiere acute ischemic stroke, filtering an embolic stroke of undetermined source(ESUS)[1] population among these patients by applying the diagnostic criteria of ESUS, and study the demographics, risk factors and treatments of them. Our aim is to investigate whether the newly proposed diagnostic criteria have an effect on the traditional classification of acute ischemic stroke, which is called The Trial of Org 10172 in acute stroke treatment(TOAST) classification, and on the treatment strategy.Methods 1. Retrospective review of hospital records between Jan 2003 and Dec 2014, Patients with diagnosis of premiere acute ischemic stroke were included. 2. The include criteria and exclude criteria are as follow: include criteria:(1) Patients must be admitted in Anzhen hospital with diagnosis of premiere acute ischemic stroke between Jan 2003 and Dec 2014;(2) Age ≥18 years old, gender and level of education is not limited;(3) Patients must meet the diagnostic criteria of ischemic cerebrovascular disease made in Fourth National Conference on cerebrovascular disease [3];(4) selected cases must completed necessary examines for diagnosing ESUS during hospitalization, including head computed tomography(CT) and / or magnetic resonance imaging(MRI), brain CT angiography(CTA) and / or MR angiography(MRA), cervix vascular ultrasound, transcranial Doppler ultrasound(TCD), 12-lead ECG, 24 h Holter and echocardiography; exclude criteria:(1) patients with hemorrhagic cerebrovascular disease were excluded;(2) patients with brain tumors or cerebral infectious diseases were excluded;(3) patients whose diagonse were not premiere acute ischemic stroke were excluded;(4) patients with other serious diseases, such as liver or kidney dysfunction, thyroiddysfunction or severe anemia were excluded;(5) patients failed to complete the necessary ESUS diagnostic examinations were excluded. 3. diagnostic criteria of ESUS : According to the ESUS diagnostic criteria proposed by the Cryptogenic stroke/ESUS International Working Group [1]:(1) The head CT and / or MRI detection head excluded lacunar infarction; Lacunar stroke was defined as a subcortical brain infarct ≤1.5 cm in largest dimension in the distribution of the small, penetrating cerebral arteries;(2) The head CT and / or MRI detection head excluded extracranial or intracranial atherosclerosis causing ≥50% luminal stenosis in arteries supplying the area of ischemia;(3) Without high risk of unintentional sources of embolism, including atrial fibrillation, intraventricular thrombosis, cardiac tumors, rheumatic heart disease, myocarditis 4 weeks, left ventricular ejection fraction <30% of heart failure, valvular vegetations or infection myocarditis; 4) For 18 to 45 year-old patients and patients with other system characteristics need to exclude other rare causes, such as migraine-associated vasculitis, arterial dissection and reversible cerebral vasoconstriction syndrome. 4. Filter ESUS case among the included cases applying the diagnostic criteria for ESUS. 5. Patients do not meet the diagnostic criteria of ESUS were divided into 5 gropes with the TOAST etiology classification[2]: large artery atherosclerosis(LAA),cardioembolism(CE), small vessel occlusion(SVO),other etiology(ODE) and cryptogenic stroke(CS). 6. Grouping: patients meet the ESUS diagnosis were as ESUS group, other stroke subtypes were as the control group. 7. Statistical Methods: general conditions, risk factors and treatment of each group were recorded respectively and for statistical analysis; 1) Using SPSS20.0 statistical software for data analysis, P <0.05 was considered statistically significant, the confidence interval parameters were estimated using95% confidence intervals. 2) Descriptive statistics: the measurement data with normal distribution by using the mean standard deviation(S) said, do not meet the normal distribution using the median and interquartile range(M, Q) represents. Count data expressed in frequency and rate. 3) Univariate analysis: measurement data normally distributed t-test or t ’test(when missing variance), does not meet the normal distribution of variables by rank sum test, count data using Pearson X2 test, X2 test continuity correction or Fisher’s exact test.Results 1. In this study, 1,296 cases of acute ischemic stroke were detected, in which 200 cases were included for completing the necessary examines for diagnosing ESUS during hospitalization; 2. For these 200 cases, age ranging from 20 to 90 years old, mean age was 65.59 ± 12.47 years; males accounted for 68.5%(137/200 patients); 3. As to stroke subtype classification of these 200 patients, using both ESUS and TOAST classification: ESUS accounted for 46.5%(93/200 cases), large artery atherosclerosis accounted for 26%(52/200 cases), cardiogenic embolism accounted for 25%(50/200 patients), lacunar infarction accounted for 2.5%(5/200 patients), and cryptogenic stroke was 0 cases; 4. Baseline data were compared between the two groups: Compared with the control group, proportion of men was slightly higher in ESUS group(ESUS vs control group 76.3% vs 61.7% p = 0.03). Stroke risk factors between the two groups for age, hypertension, hyperlipidemia, diabetes, family history of stroke, history of smoking, drinking and other difference was not statistically significant(Table 1); 5. Treatment: In ESUS group, 90.3%(84/93 patients) receive single antiplatelet therapy during hospitalization and after discharge; 4.3%(4/93 patients) receive aspirin and clopidogrel dual antiplatelet therapy; 5.4%(5/93 cases) receive no antithrombotic treatment due to post-infarction bleeding, and none use of warfarinor novel oral anticoagulants anticoagulation. 6. Prognosis: Patients enrolled in this study with good prognoses, and there were no deaths; difference of modified Barthel index at discharge between the two groups was not statistically significant(ESUS vs control group 83.76 ± 23.24 vs 78.16 ± 27.15, p = 0.09). Conclusion Ischemic stroke patients meeting criteria for ESUS are not uncommon. Clinicians should complete the clinical examination of ESUS diagnosis to increase its diagnosis rate. The propose of ESUS diagnostic criteria greatly reduced the proportion of clinical diagnosis of cryptogenic stroke. The commen therapy for ESUS patients is antiplatelet at this stage due to lack of awareness.