Management of Patients with Embolic Stroke of Unknown Source: Interpreting the Evidence in the Light of Clinical Judgement

Purpose of Review To assess the validity of the belief that anticoagulation is not beneficial in patients with embolic stroke of unknown source (ESUS), and to asssess the benefits and safety of direct-acting oral anticoagulants (DOACs). Recent Findings The failure of randomized trials to show benefit of anticoagulation in ESUS is probably due to misclassification of large artery atherosclerosis (LAA) as ESUS, as defined by a stenosis >= 50%. There are important differences among DOACs. There are a number of problems with dabigatran, and rivaroxaban and edoxaban are not suitable for once-daily dosing. Recent evidence from real-world practice indicates that apixaban is more effective and safer than rivaroxaban. Plaque burden should be included in the definition of LAA. Patients in whom a cardioembolic source is strongly suspected should be anticoagulated; antiplatelet agents are not significantly safer than DOACs, and are not effective in cardioembolic stroke.

Automated summary

The purpose of this review is to evaluate the validity of anticoagulation therapy for embolic stroke of unknown source (ESUS) and to assess the benefits and safety of direct-acting oral anticoagulants (DOACs). Recent findings suggest that the lack of benefit from anticoagulation may be due to misclassification of large artery atherosclerosis as ESUS. DOACs have important differences, and apixaban may be more effective and safer than rivaroxaban. Plaque burden should be considered in the definition of ESUS, and anticoagulation is more effective than antiplatelet agents for cardioembolic stroke.