Embolischer Schlaganfall unbekannter Quelle (ESUS) – Diagnostik und aktuelle klinische Studien

ESUS (embolischer Schlaganfall unbekannter Quelle) ist ein potenziell bedeutsames neues Konstrukt des kryptogenen Schlaganfalls. Die pathophysiologische Hypothese nimmt Embolien durch fibrinreiche Thromben aus unterschiedlicher Quelle als ESUS-Ursache an. Demzufolge wird vermutet, dass eine sekundärprophylaktische Therapie mit oraler Antikoagulation effektiver ist als mit Thrombozytenaggregationshemmung. Klasse-I-Evidenz zur ESUS-Sekundärprophylaxe fehlt aktuell jedoch noch. 3 Phase-III-Studien (RE-SPECT ESUS, NAVIGATE ESUS, ATTICUS) klären derzeit diese für die neuro-kardio-vaskuläre Medizin grundlegend wichtige Frage. Mit ersten Daten ist 2018 zu rechnen.

ESUS (embolic stroke of undetermined source) is a potentially important construct of cryptogenic stroke. The pathophysiological hypothesis of ESUS implies that most emboli consist of fibrin-rich thrombi from a variety of sources. Accordingly, it is speculated that oral anticoagulation is the more effective secondary prevention compared to antiplatelet therapy. However, class-I evidence for secondary prevention of re-stroke in ESUS patients is currently missing. Three phase-III randomized clinical trials (RE-SPECT ESUS, NAVIGATE ESUS, ATTICUS) are currently testing this for the stroke field fundamentally important question. First data are to be expected in 2018.

Key words

ESUS (embolic stroke of undetermined source) - thrombi - anticoagulation - antiplatelet therapy

• Literatur

• 1 European Stroke Organisation Executive C , Committee ESOW. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25: 457-507
• 2 Furie KL, Kasner SE, Adams RJ et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke 2011; 42: 227-276
• 3 Hart RG, Diener HC, Coutts SB et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet neurology 2014; 13: 429-438
• 4 Wolf ME, Sauer T, Alonso A et al. Comparison of the new ASCO classification with the TOAST classification in a population with acute ischemic stroke. J Neurol 2012; 259: 1284-1289
• 5 Desai JA, Abuzinadah AR, Imoukhuede O et al. Etiologic classification of TIA and minor stroke by A-S-C-O and causative classification system as compared to TOAST reduces the proportion of patients categorized as cause undetermined. Cerebrovasc Dis 2014; 38: 121-126
• 6 Mohr JP, Thompson JL, Lazar RM et al. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 2001; 345: 1444-1451
• 7 Sacco RL, Diener HC, Yusuf S et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke. N Engl J Med 2008; 359: 1238-1251
• 8 Diener HC, Easton JD, Granger CB et al. Design of Randomized, double-blind Evaluation in secondary Stroke Prevention comparing the EfficaCy and safety of the oral Thrombin inhibitor dabigatran etexilate vs. acetylsalicylic acid in patients with Embolic Stroke of Undetermined Source (RE-SPECT ESUS). Int J Stroke 2015; 10: 1309-1312
• 9 Handke M, Harloff A, Olschewski M et al. Patent foramen ovale and cryptogenic stroke in older patients. N Engl J Med 2007; 357: 2262-2268
• 10 Homma S, Sacco RL, Di Tullio MR et al. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation 2002; 105: 2625-2631
• 11 Cotter PE, Martin PJ, Ring L et al. Incidence of atrial fibrillation detected by implantable loop recorders in unexplained stroke. Neurology 2013; 80: 1546-1550
• 12 Ritter MA, Kochhauser S, Duning T et al. Occult Atrial Fibrillation in Cryptogenic Stroke: Detection by 7-Day Electrocardiogram Versus Implantable Cardiac Monitors. Stroke 2013; 44: 1449-1452
• 13 Sanna T, Diener HC, Passman RS et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014; 370: 2478-2486
• 14 Poli S, Diedler J, Härtig F et al. Insertable cardiac monitors after cryptogenic stroke - a risk factor based approach to enhance the detection rate for paroxysmal atrial fibrillation. Eur J Neurol 2016; 23: 375-381
• 15 Thijs VN, Brachmann J, Morillo CA et al. Predictors for atrial fibrillation detection after cryptogenic stroke: Results from CRYSTAL AF. Neurology 2016; 86: 261-269
• 16 Connolly SJ, Eikelboom J, Joyner C et al. Apixaban in patients with atrial fibrillation. N Engl J Med 2011; 364: 806-817
• 17 Diener HC, Eikelboom J, Connolly SJ et al. Apixaban versus aspirin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a predefined subgroup analysis from AVERROES, a randomised trial. Lancet neurology 2012; 11: 225-231