McMaster University and Population Health Research Institute, Hamilton, ON, Canada.
University Duisburg-Essen, Essen, Germany.
Lancet Neurol. 2014 Apr;13(4):429-38. doi: 10.1016/S1474-4422(13)70310-7.
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.
目前认为，不明原因（隐源性）缺血性脑卒中约占所有缺血性脑卒中的 25%。成像技术的进步和对脑卒中病理生理学的深入理解促使人们重新评估隐源性脑卒中。有充分证据表明，大多数隐源性脑卒中是血栓栓塞性的。血栓被认为起源于几个已确立的潜在栓塞源，包括低危或隐匿性心源性来源、通过反常栓塞的静脉，以及主动脉弓、颈部或脑动脉中的非闭塞性粥样硬化斑块。因此，我们提出，不明来源的栓塞性脑卒中是一种具有治疗相关性的实体，其定义为无近端动脉狭窄或心源性栓塞源的腔隙外脑梗死，有明确抗凝指征。由于栓塞主要由血栓组成，抗凝剂可能比抗血小板药物更有效地减少复发性脑缺血。有必要进行随机试验，以测试直接作用的口服抗凝剂在预防不明来源的栓塞性脑卒中的二级预防中的作用。
