TY - JOUR
T1 - Embolic strokes of undetermined source
T2 - The case for a new clinical construct
AU - Hart, Robert G.
AU - Diener, Hans Christoph
AU - Coutts, Shelagh B.
AU - Easton, J. Donald
AU - Granger, Christopher B.
AU - O'Donnell, Martin J.
AU - Sacco, Ralph L.
AU - Connolly, Stuart J.
N1 - Funding Information:
RGH obtained funding for a meeting of the International Working Group from Bayer, Bristol-Myers Squibb, and Boerhinger-Ingelheim, and research support from Bayer and Boerhinger-Ingelheim. He has no ownership interest and does not own stocks of any pharmaceutical company. H-CD received honoraria for participation in clinical trials, contribution to advisory boards, or oral presentations from Abbott, Allergan, AstraZeneca, Bayer Vital, Bristol-Myers Squibb, Boehringer Ingelheim, CoAxia, Corimmun, Covidien, Daichii-Sankyo, D-Pharm, EV3, Fresenius, GlaxoSmithKline, Janssen Cilag, Johnson & Johnson, Knoll, Lilly, MSD, Medtronic, MindFrame, Neurobiological Technologies, Novartis, Novo-Nordisk, Paion, Parke-Davis, Pfizer, Sanofi-Aventis, Schering-Plough, Servier, Solvay, Thrombogenics, WebMD Global, Wyeth, and Yamanouchi. Financial support for research projects was provided by AstraZeneca, GlaxoSmithKline, Boehringer Ingelheim, Lundbeck, Novartis, Janssen-Cilag, Sanofi-Aventis, Syngis, and Talecris. The Department of Neurology at the University Duisburg-Essen received research grants from the German Research Council, German Ministry of Education and Research, European Union, US National Institutes of Health, Bertelsmann Foundation, and Heinz-Nixdorf Foundation. H-CD has no ownership interest and does not own stocks of any pharmaceutical company. SBC has served on an advisory board for Pfizer and Bristol-Myers Squibb. She has no ownership interest and does not own stocks of any pharmaceutical company. JDE has received consulting compensation and research support from AstraZeneca for the SOCRATES trial, and Sanofi provides drug and placebo for the POINT trial, for which JDE is coprincipal investigator, which is funded by the US National Institutes of Health. MJO'D has received honoraria from Boerhinger Ingelheim, Bristol-Myers Squibb, and Pfizer for lecture presentations. RLS receives consulting income for participation in two academically run and pharmaceutically sponsored Data Safety and Monitoring Boards for clinical trials of antiplatelet agents in stroke and cardiovascular disease treatment (AstraZeneca). SJC declares that he has no competing interests.
PY - 2014/4
Y1 - 2014/4
N2 - Cryptogenic (of unknown cause) ischaemic strokes are now thought to comprise about 25% of all ischaemic strokes. Advances in imaging techniques and improved understanding of stroke pathophysiology have prompted a reassessment of cryptogenic stroke. There is persuasive evidence that most cryptogenic strokes are thromboembolic. The thrombus is thought to originate from any of several well established potential embolic sources, including minor-risk or covert cardiac sources, veins via paradoxical embolism, and non-occlusive atherosclerotic plaques in the aortic arch, cervical, or cerebral arteries. Accordingly, we propose that embolic strokes of undetermined source are a therapeutically relevant entity, which are defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources, with a clear indication for anticoagulation. Because emboli consist mainly of thrombus, anticoagulants are likely to reduce recurrent brain ischaemia more effectively than are antiplatelet drugs. Randomised trials testing direct-acting oral anticoagulants for secondary prevention of embolic strokes of undetermined source are warranted.
AB - Cryptogenic (of unknown cause) ischaemic strokes are now thought to comprise about 25% of all ischaemic strokes. Advances in imaging techniques and improved understanding of stroke pathophysiology have prompted a reassessment of cryptogenic stroke. There is persuasive evidence that most cryptogenic strokes are thromboembolic. The thrombus is thought to originate from any of several well established potential embolic sources, including minor-risk or covert cardiac sources, veins via paradoxical embolism, and non-occlusive atherosclerotic plaques in the aortic arch, cervical, or cerebral arteries. Accordingly, we propose that embolic strokes of undetermined source are a therapeutically relevant entity, which are defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources, with a clear indication for anticoagulation. Because emboli consist mainly of thrombus, anticoagulants are likely to reduce recurrent brain ischaemia more effectively than are antiplatelet drugs. Randomised trials testing direct-acting oral anticoagulants for secondary prevention of embolic strokes of undetermined source are warranted.
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U2 - 10.1016/S1474-4422(13)70310-7
DO - 10.1016/S1474-4422(13)70310-7
M3 - Comment/debate
C2 - 24646875
AN - SCOPUS:84896079786
VL - 13
SP - 429
EP - 438
JO - The Lancet Neurology
JF - The Lancet Neurology
SN - 1474-4422
IS - 4
ER -