Neurology® Podcast Embolic Stroke of Undetermined Source Treated With Antiplatelet Agents or Anticoagulation
Jul 21, 2025
Dr. James Ernest Siegler, a stroke and vascular neurologist, discusses the intricate challenges in treating embolic stroke of undetermined source (ESUS). He emphasizes the value of personalized treatment strategies, advocating for thorough evaluations to uncover hidden stroke mechanisms. The conversation highlights a critical study comparing antiplatelet agents and anticoagulants, suggesting that traditional approaches may need reevaluation. Comprehensive diagnostics and tailored management plans are essential to address the risks and benefits for diverse patient populations.
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ESUS Is Heterogeneous and Complex
- Embolic stroke of undetermined source (ESUS) is a heterogeneous group accounting for 20-30% of ischemic strokes with high recurrence risk.
- Treating all ESUS patients uniformly with aspirin is insufficient; individualized workups and treatments are needed.
No Clear Benefit of Anticoagulation
- In real-world practice, anticoagulation shows no benefit over antiplatelet therapy for preventing recurrent strokes in ESUS.
- About 90% of ESUS patients are treated with aspirin, 10% with anticoagulation, but outcomes are similar between treatments.
Thrombi Similar Yet Treatment Differs
- ESUS thrombi resemble atrial fibrillation thrombi histopathologically but anticoagulation hasn't shown superiority over antiplatelet therapy.
- Atrial fibrillation patients benefit from anticoagulation, but ESUS patients do not clearly share this benefit despite similar clot appearance.