Recurrent Stroke Incidence and Etiology in Patients with Embolic Stroke of Undetermined Source and Other Stroke Subtypes

J Atheroscler Thromb. 2022 Mar 1;29(3):393-402. doi: 10.5551/jat.61895. Epub 2021 Feb 18.


Aims: This study aimed at clarifying the incidence of recurrent stroke and its etiology in patients with embolic stroke of undetermined source (ESUS) and other stroke subtypes in both the acute and chronic periods.

Methods: A total of 645 patients who were admitted with acute ischemic stroke (IS) between March 2015 and August 2019 were enrolled. Among them, 511 patients with ESUS, cardioembolism (CE), large artery atherosclerosis (LAA), or small vessel disease (SVD) were analyzed in this study. After discharge, 391 patients who visited the outpatient clinic were followed up until August 2020. The outcome was stroke recurrence.

Results: In the acute admission, recurrence rates were 7.6%, 8.1%, 18.8%, and 2.2% in patients with ESUS, CE, LAA, and SVD, respectively, and there were significant differences between the groups. The subtype of recurrence was almost identical to that of the index stroke. In the outpatient clinic, the annual recurrence rates were 4.4%, 4.3%, 6.0%, and 2.9% in ESUS, CE, LAA, and SVD, respectively, and no difference was observed. Subtypes of recurrence in outpatients with ESUS included ESUS, intracerebral hemorrhage (ICH), and SVD. Patients with ESUS and SVD had a higher risk of ICH during follow-up.

Conclusions: Although the risk of recurrence was comparable between patients with ESUS and CE and intermediate between patients with LAA and SVD, in the acute admission unit, the risk in outpatients was similar among all subtypes. ESUS was the most recurrent stroke subtype in outpatients with ESUS. The risk of hemorrhagic stroke was significant in patients with SVD and ESUS.

Keywords: Atrial fibrillation; ESUS; Stroke etiology; Stroke recurrence; Stroke subtype.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Brain / diagnostic imaging*
  • Embolic Stroke / epidemiology
  • Female
  • Follow-Up Studies
  • Humans
  • Incidence
  • Japan / epidemiology
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Prospective Studies
  • Risk Factors
  • Stroke / diagnosis
  • Stroke / epidemiology*