Tabla I. Criterios de ictus criptogénico no lacunar de mecanismo embólico. |
Ictus no lacunar (infarto subcortical < 1,5 cm en tomografía computarizada o < 2 cm en resonancia magnética) |
Ausencia de ateroesclerosis > 50% intra o extracraneal sintomática |
Ausencia de causa de cardioembolismo mayor (fibrilación auricular permanente o paroxística, flutter atrial, trombo intracardíaco, prótesis valvular, mixoma auricular, otro tumor cardíaco, estenosis mitral, infarto agudo de miocardio < 4 semanas, fracción de eyección del ventrículo < 30%, vegetación valvular o endocarditis infecciosa) |
Ausencia de causa inhabitual de ictus (disección, arteritis, migraña, vasoespasmo, drogas) |
Figura. Selección de los artículos según las recomendaciones PRISMA para revisiones sistemáticas.
Tabla II. Epidemiología y características clínicas en pacientes con ictus criptogénico no lacunar de mecanismo embólico (ESUS) e ictus criptogénico. |
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Estudio y año |
Población incluida |
n total |
IC |
ESUS |
ESUS |
Edad con |
ESUS inicial en |
|
De la Riva et al [11] |
Retrospectivo 2012-2014 |
Registro nacional. España |
1.349 |
193 (14,3%) |
58,5% |
113 (8,3%) |
65 años |
5 |
Arauz et al [9] |
Retrospectivo 2003-2015 |
Registro nacional. México |
1.673 |
216 (12,9%) |
69,0% |
149 (8,9%) |
44 años |
7 |
Ueno et al [15] |
Retrospectivo 2008-2014 |
Registro nacional. Japón |
1.158 |
177 (15,3%) |
64 años |
3 |
||
Ntaios et al [12] |
Retrospectivo 1998-2011 |
Hospital de Atenas |
2.731 |
641 (23,5%) |
42,9% |
275 (10,1%) |
68 años |
5 |
Ntaios et al [17] |
Registro de 11 centros (Latinoamérica y Europa) |
1.095 |
68 años |
5 |
||||
Putaala et al [16] |
Retrospectivo de |
Hospital de Helsinki |
540 |
176 (32,6%) |
72,2% |
127 (8,5%) |
66 años |
4 |
Ryoo et al [14] |
Retrospectivo 2008-2014 |
Registro de Corea |
3.981 |
598 (15,0%) |
53,7% |
321 (8,1%) |
66 años |
3 |
Ladeira et al [10] |
Retrospectivo 2010-2014 |
Hospital de Lisboa |
100 |
51 (51,0%) |
82,4% |
42 (42,0%) |
45 años |
4 |
Perera et al [13] |
Retrospectivo 2013-2014 |
Registro de 19 centros (Europa, América del Norte, Latino-américa, este asiático y Pacífico) |
2.144 |
351 (16,3%) |
62 años |
4 |
||
Katsanos et al [8] |
Prospectivo 2014 |
Hospital de Memphis y Atenas |
1.134 |
186 (16,4%) |
36,6% |
68 (6,0%) |
44 años |
5 |
IC: ictus criptogénico; NIHSS: National Institutes of Health Stroke Scale. |
Tabla III. Causas de cardiembolismo en ESUS y pronóstico. |
|||||
Fibrilación auricular |
Cardioembolismo menor |
Monitorización |
Recurrencia (anual) |
Mortalidad |
|
De la Riva et al [11] |
10,61% (50% a los 3 meses) |
No evaluado |
24 horas |
8,4% |
12,4% |
Arauz et al [9] |
No evaluado |
No evaluado |
24 horas |
5,4% |
0% |
Ueno et al [15] |
No evaluado |
65% (58% foramen oval permeable, 27% aneurisma del septo auricular) |
24 horas |
5% |
No evaluado |
Ntaios et al [12] |
29,1% (62,5% a los 4 meses) |
No evaluado |
24 horas |
11,3% |
No evaluado |
Ntaios et al [17] |
No evaluado |
No evaluado |
No evaluado |
14,5% |
13,5% |
Putaala et al [16] |
No evaluado |
No evaluado |
48 horas |
7% |
2,2% |
Ryoo et al [14] |
39,9% |
47,7% foramen oval permeable |
> 72 horas |
No evaluado |
No evaluado |
Ladeira et al [10] |
No evaluado |
50% (16,67% foramen oval permeable) |
No evaluado |
No evaluado |
No evaluado |
Perera et al [13] |
28% |
25% foramen oval permeable, 7% estenosis aórtica |
24 horas |
No evaluado |
0,6% |
Katsanos et al [8] |
No evaluado |
52% (27,8% foramen oval permeable, 13,1% aneurisma del septo auricular) |
24 horas |
No evaluado |
No evaluado |
A systematic review of the characteristics and prognosis of subjects who suffer an embolic stroke of undetermined source Introduction. The concept of embolic stroke of undetermined source (ESUS) has recently appeared to better characterise patients with cryptogenic stroke. Patients and methods. A systematic review of studies published since 2014 was performed to evaluate the epidemiology, clinical features and prognosis of patients with ESUS and their proportion among patients with cryptogenic stroke. Results. Ten studies were identified with a total of 14,810 patients. The frequency of ESUS varied between 6% and 42%. We observed a high percentage of patients with cryptogenic stroke who met ESUS criteria (37-82%). The mean age of these patients was 65-68 years. The mean severity of the stroke, as measured using the National Institutes of Health Stroke Scale, was found to be 3-7 points. A high degree of variability was seen in the proportion of atrial fibrillation (detected during follow-up) related to the electrocardiogram monitoring technique. In five studies, some minor source of cardioembolism was observed in one out of every two patients, the most frequent being the persistence of patent foramen ovale. The risk of recurrence was 5-14.5%. Conclusion. The application of the new ESUS criteria provides a better definition of patients with cryptogenic stroke. Applying the concept of ESUS requires not only adequate electrocardiogram monitoring, but also routine complementary examinations to rule out the presence of minor sources of cardioembolism and other sources of embolism other than atrial fibrillation. Key words. Atrial fibrillation. Cryptogenic. Embolism. ESUS. Foramen ovale. Recurrence. |