MDCalc

Embolic Stroke of Undetermined Source (ESUS) Criteria

Diagnoses embolic stroke of undetermined source.

Use in patients with ischemic stroke only, not hemorrhagic stroke.

All 4 must be present:

Lacunar = subcortical infarct ≤1.5 cm (≤2.0 cm on MRI diffusion images) in largest dimension, including on MRI diffusion-weighted images, and in distribution of small, penetrating cerebral arteries of cerebral hemispheres and pons
Major risk source = afib (permanent or paroxysmal), sustained atrial flutter, intracardiac thrombus, prosthetic cardiac valve, cardiac tumors (e.g. atrial myxoma), mitral stenosis, recent (<4 weeks) MI, left ventricular EF <30%, valvular vegetations, or infective endocarditis
E.g. arteritis, dissection, migraine/vasospasm, drug abuse

Diagnostic Result

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Advice
  • Strokes that meet ESUS criteria are thought to be due to sources of uncertain risk, including:
    • Minor-risk potential cardioembolic sources.
    • Occult paroxysmal atrial fibrillation.
    • Undiagnosed malignancy.
    • Arteriogenic emboli such as aortic arch atherosclerotic plaques or non-stenotic cerebral arteries.
    • Paradoxical embolism through an atrial septal defect.
Management
  • Depending on clinical suspicion, further evaluation may include any of the following:
    • Prolonged outpatient cardiac monitoring.
    • TEE.
    • Cardiac MRI.
    • Transcranial Doppler with monitoring for emboli.
    • Catheter angioplasty.
    • Workup for occult cancer.
    • Workup for non-embolic causes such as vasculitis.
  • Secondary prevention in all noncardioembolic ischemic strokes includes anti-platelet therapy, blood pressure control, anti-lipid therapy, and lifestyle modifications.
  • The benefit of anticoagulation therapy in ESUS without proven atrial tachyarrhythmia is unclear and the subject of ongoing clinical trials.
  • Certain patients aged ≤60 years with ESUS and patent foramen ovale (PFO) may benefit from percutaneous PFO closure in addition to antiplatelet therapy.
  • In patients with recurrent ESUS, switching antiplatelet agents or starting empiric anticoagulation therapy is reasonable.
Critical Actions

All ischemic strokes undergo the same acute therapy management regardless of etiology, including intravenous tPA or mechanical thrombectomy if indicated.

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