Depratment of Neurology, Tokyo Medical University Hospital.
Department of Neurology, University of Yamanashi Hospital.
J Atheroscler Thromb. 2024 Dec 1;31(12):1641-1651. doi: 10.5551/jat.RV22026. Epub 2024 Sep 27.
Cryptogenic stroke (CS) accounts for approximately one-fourth of acute ischemic strokes, with most cases derived from embolic etiologies. In 2014, embolic stroke of undetermined source (ESUS) was advocated and the efficacy of anticoagulant therapy was anticipated. However, 3 large-scale clinical trials failed to demonstrate the superiority of direct oral anticoagulants (DOACs) over aspirin, potentially due to the heterogeneous and diverse pathologies of ESUS, including paroxysmal atrial fibrillation (AF), arteriogenic sources such as nonstenotic carotid plaque and aortic complicated lesion (ACL), patent foramen oval (PFO), and nonbacterial thrombotic endocarditis (NBTE) related to active cancer.Transesophageal echocardiography (TEE) is one of the most effective imaging modalities for assessing embolic sources in ESUS and CS. The Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for Embolic Stroke of Undetermined Source/Cryptogenic Stroke (CHALLENGE ESUS/CS) registry is a multicenter registry that enrolled consecutive patients with CS who underwent TEE at 8 hospitals in Japan between April 2014 and December 2016. Their mean age was 68.7±12.8 years, and 455 patients (67.2%) were male. The median National Institutes of Health Stroke Scale (NIHSS) score was 2. Since 7 analyses have been conducted from each institution to date, novel and significant insights regarding embolic origins and pathophysiologies of ESUS and CS were elucidated from this multicenter registry. This review discusses the diagnosis and treatment of ESUS and CS, tracing their past and future directions. Meaningful insights from the CHALLENGE ESUS/CS registry are also referenced and analyzed.
不明来源的栓塞性卒中（ESUS）占急性缺血性卒中的四分之一左右，大多数病例来源于栓塞性病因。2014 年，提出了不明来源的栓塞性卒中（ESUS）的概念，并预期抗凝治疗的疗效。然而，3 项大型临床试验未能证明直接口服抗凝剂（DOAC）优于阿司匹林，这可能是由于 ESUS 的异质性和多样性病理学，包括阵发性心房颤动（AF）、非狭窄性颈动脉斑块和主动脉复杂病变（ACL）等动脉源、卵圆孔未闭（PFO）和与活动性癌症相关的非细菌性血栓性心内膜炎（NBTE）。经食管超声心动图（TEE）是评估 ESUS 和 CS 中栓塞源的最有效影像学方法之一。不明来源的栓塞性卒中/隐源性卒中经食管超声心动图解析栓子来源（CHALLENGE ESUS/CS）登记研究是一项多中心登记研究，该研究纳入了 2014 年 4 月至 2016 年 12 月期间在日本 8 家医院接受 TEE 的 CS 连续患者。他们的平均年龄为 68.7±12.8 岁，455 名患者（67.2%）为男性。中位 NIHSS 评分为 2 分。由于迄今为止每家机构已进行了 7 项分析，因此该多中心登记研究阐明了 ESUS 和 CS 栓塞起源和病理生理学的新的重要见解。这篇综述讨论了 ESUS 和 CS 的诊断和治疗，追溯了它们的过去和未来方向。还参考和分析了 CHALLENGE ESUS/CS 登记研究的有意义的见解。
