Skip to main content
Erschienen in:

02.09.2020 | original article

Outcome after intravenous thrombolysis in embolic stroke of undetermined source compared to cardioembolic stroke

verfasst von: Zeljko Zivanovic, Zorana Ostojic, Sonja Rajic, Dmitar Vlahovic, Milija Mijajlovic, Mirjana Jovicevic

Erschienen in: Wiener klinische Wochenschrift | Ausgabe 17-18/2020

Einloggen, um Zugang zu erhalten

Summary

Background

It is assumed that most cases of embolic stroke of undetermined source (ESUS) are of cardioembolic origin. The data about outcome after the treatment with intravenous thrombolysis (IVT) for this type of acute ischemic stroke (AIS) are limited. We aimed to compare clinical characteristics and outcomes after IVT for AIS between patients with ESUS and cardioembolic stroke (CS).

Methods

This study was a single center retrospective analysis of stroke patients treated with IVT. The Trial of ORG 10172 in Acute Stroke Treatment criteria were used to establish stroke etiology subtype at 3 months, while ESUS was considered a subset of stroke of undetermined etiology, defined according to 2014 international criteria. Functional outcome was assessed at 3 months and defined as excellent (modified Rankin scale 0–1) and favorable (modified Rankin scale 0–2).

Results

Total of 394 patients were treated with IVT; 113 had a cardioembolism, 88 had undetermined stroke subtype, of which 62 met the ESUS criteria. Patients with ESUS were on average younger (63.7 years versus 69.7 years, p = 0.001), had a lower National Institutes of Health Stroke Scale (NIHSS) score on admission (12 versus 15, p = 0.002) and lower prevalence of antiplatelets use (27.4% versus 42.5%, p = 0.04) compared with CS patients. Favorable outcome was more likely in ESUS patients, at discharge (48.4% versus 24.0%, p = 0.002) and after 3 months (71.0% versus 37.2%, p < 0.001). Hemorrhagic transformation was less frequent (17.7% versus 33.6%, p = 0.03) in ESUS patients. Independent predictors of 3‑month favorable outcome were ESUS, the absence of leukoaraiosis on computed tomography (CT) and absence of diabetes as a risk factor.

Conclusion

Patients with ESUS had better outcome after IVT than patients with CS, which can be attributed to younger age and milder strokes in these patients.
Literatur
1.
Zurück zum Zitat Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of org 10172 in acute stroke treatment. Stroke. 1993;24:35–41.PubMed Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of org 10172 in acute stroke treatment. Stroke. 1993;24:35–41.PubMed
2.
Zurück zum Zitat Grau AJ, Weimar C, Buggle F, Heinrich A, Goertler M, Neumaier S, et al. Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German stroke data bank. Stroke. 2001;32:2559–66.PubMed Grau AJ, Weimar C, Buggle F, Heinrich A, Goertler M, Neumaier S, et al. Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German stroke data bank. Stroke. 2001;32:2559–66.PubMed
3.
Zurück zum Zitat Hart RG, Diener HC, Coutts SB, Easton JD, Granger CB, O’Donnell MJ, et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol. 2014;13(4):429–38.PubMed Hart RG, Diener HC, Coutts SB, Easton JD, Granger CB, O’Donnell MJ, et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol. 2014;13(4):429–38.PubMed
4.
Zurück zum Zitat Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014;370(26:2478–86. Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014;370(26:2478–86.
5.
Zurück zum Zitat Gladstone DJ, Spring M, Dorian P, Panzov V, Thorpe KE, Hall J, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med. 2014;370(26):2467–77.PubMed Gladstone DJ, Spring M, Dorian P, Panzov V, Thorpe KE, Hall J, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med. 2014;370(26):2467–77.PubMed
6.
Zurück zum Zitat Ntaios G, Papavasileiou V, Milionis H, Makaritsis K, Manios E, Spengos K, et al. Embolic strokes of undetermined source in the Athens stroke registry: a descriptive analysis. Stroke. 2015;46(1):176–81.PubMed Ntaios G, Papavasileiou V, Milionis H, Makaritsis K, Manios E, Spengos K, et al. Embolic strokes of undetermined source in the Athens stroke registry: a descriptive analysis. Stroke. 2015;46(1):176–81.PubMed
7.
Zurück zum Zitat Ntaios G, Papavasileiou V, Milionis H, Makaritsis K, Vemmou A, Koroboki E, et al. Embolic strokes of undetermined source in the Athens stroke registry: an outcome analysis. Stroke. 2015;46(8):2087–93.PubMed Ntaios G, Papavasileiou V, Milionis H, Makaritsis K, Vemmou A, Koroboki E, et al. Embolic strokes of undetermined source in the Athens stroke registry: an outcome analysis. Stroke. 2015;46(8):2087–93.PubMed
8.
Zurück zum Zitat Boeckh-Behrens T, Kleine JF, Zimmer C, Neff F, Scheipl F, Pelisek J, et al. Thrombus histology suggests cardioembolic cause in cryptogenic stroke. Stroke. 2016;47(7):1864–71.PubMed Boeckh-Behrens T, Kleine JF, Zimmer C, Neff F, Scheipl F, Pelisek J, et al. Thrombus histology suggests cardioembolic cause in cryptogenic stroke. Stroke. 2016;47(7):1864–71.PubMed
9.
Zurück zum Zitat Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of aquantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. Lancet. 2000;355(9216):1670–4.PubMed Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of aquantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. Lancet. 2000;355(9216):1670–4.PubMed
10.
Zurück zum Zitat Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet. 1991;337:1521–6.PubMed Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet. 1991;337:1521–6.PubMed
11.
Zurück zum Zitat Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Lancet. 1998;352:1245–51.PubMed Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Lancet. 1998;352:1245–51.PubMed
12.
Zurück zum Zitat Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160–236.PubMed Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160–236.PubMed
13.
Zurück zum Zitat Arauz A, Morelos E, Colin J, Roldan J, Barbaroza MA. Comparison of functional outcome and stroke recurrence in patients with embolic stroke of undeterminated source (ESUS) vs. cardioembolic stroke patients. PLoS ONE. 2016;11(11):e166091.PubMedPubMedCentral Arauz A, Morelos E, Colin J, Roldan J, Barbaroza MA. Comparison of functional outcome and stroke recurrence in patients with embolic stroke of undeterminated source (ESUS) vs. cardioembolic stroke patients. PLoS ONE. 2016;11(11):e166091.PubMedPubMedCentral
14.
Zurück zum Zitat Hart RG, Catanese L, Perera KS, Ntaios G, Connolly SJ. Embolic stroke of undetermined source: a systematic review and clinical update. Stroke. 2017;48(4):867–72.PubMed Hart RG, Catanese L, Perera KS, Ntaios G, Connolly SJ. Embolic stroke of undetermined source: a systematic review and clinical update. Stroke. 2017;48(4):867–72.PubMed
15.
Zurück zum Zitat Hart RG. Cardiogenic embolism to the brain. Lancet. 1992;339(8793):589–94.PubMed Hart RG. Cardiogenic embolism to the brain. Lancet. 1992;339(8793):589–94.PubMed
16.
Zurück zum Zitat Perera KS, Swaminathan B, Veltkamp R, Arauz A, Ameriso S, Marti-Fabregas J, et al. Frequency and features of embolic stroke of undeterminated source in young adults. Eur Stroke J. 2018;3(2):110–6.PubMedPubMedCentral Perera KS, Swaminathan B, Veltkamp R, Arauz A, Ameriso S, Marti-Fabregas J, et al. Frequency and features of embolic stroke of undeterminated source in young adults. Eur Stroke J. 2018;3(2):110–6.PubMedPubMedCentral
17.
Zurück zum Zitat Fan Y, Liao X, Pan Y, Dong K, Wang Y, Wang Y. Intravenous thrombolysis is safe and effective for the cryptogenic stroke in China: data from the thrombolysis implementation and monitor of acute ischemic stroke in China (TIMS-China). J Stroke Cerebrovasc Dis. 2019;28(1):220–6.PubMed Fan Y, Liao X, Pan Y, Dong K, Wang Y, Wang Y. Intravenous thrombolysis is safe and effective for the cryptogenic stroke in China: data from the thrombolysis implementation and monitor of acute ischemic stroke in China (TIMS-China). J Stroke Cerebrovasc Dis. 2019;28(1):220–6.PubMed
18.
Zurück zum Zitat Chang JJ, Chiem T, Alderazi YJ, Chapple K, Restrepo L. Clinical outcomes after intravenous fibrinolysis in cryptogenic strokes with or without patent foramen ovale. J Stroke Cerebrovasc Dis. 2013;22(8):e492–e9.PubMed Chang JJ, Chiem T, Alderazi YJ, Chapple K, Restrepo L. Clinical outcomes after intravenous fibrinolysis in cryptogenic strokes with or without patent foramen ovale. J Stroke Cerebrovasc Dis. 2013;22(8):e492–e9.PubMed
19.
Zurück zum Zitat Hart RG, Sharma M, Mundl H, Kasner SE, Bangdiwala SI, Berkowitz SD, et al. Rivaroxaban for stroke prevention after embolic stroke of undetermined source. N Engl J Med. 2018;378(23):2191–201.PubMed Hart RG, Sharma M, Mundl H, Kasner SE, Bangdiwala SI, Berkowitz SD, et al. Rivaroxaban for stroke prevention after embolic stroke of undetermined source. N Engl J Med. 2018;378(23):2191–201.PubMed
20.
Zurück zum Zitat Diener HC, Sacco RL, Easton JD, Granger CB, Bernstein RA, Uchiyama S, et al. Dabigatran for prevention of stroke after embolic stroke of undetermined source. N Engl J Med. 2019;380(20):1906–17.PubMed Diener HC, Sacco RL, Easton JD, Granger CB, Bernstein RA, Uchiyama S, et al. Dabigatran for prevention of stroke after embolic stroke of undetermined source. N Engl J Med. 2019;380(20):1906–17.PubMed
Metadaten
Titel
Outcome after intravenous thrombolysis in embolic stroke of undetermined source compared to cardioembolic stroke
verfasst von
Zeljko Zivanovic
Zorana Ostojic
Sonja Rajic
Dmitar Vlahovic
Milija Mijajlovic
Mirjana Jovicevic
Publikationsdatum
02.09.2020
Verlag
Springer Vienna
Erschienen in
Wiener klinische Wochenschrift / Ausgabe 17-18/2020
Print ISSN: 0043-5325
Elektronische ISSN: 1613-7671
DOI
https://doi.org/10.1007/s00508-020-01727-5

Weitere Artikel der Ausgabe 17-18/2020

Wiener klinische Wochenschrift 17-18/2020 Zur Ausgabe

MUW researcher of the month

MUW researcher of the month

mitteilungen der gesellschaft der ärzte in wien

Veranstaltungstipps