Secondary Stroke Prevention in Cryptogenic Stroke and Embolic Stroke of Undetermined Source (ESUS)

  • Hans-Christoph DienerEmail author
  • Richard Bernstein
  • Robert Hart
Stroke (H Diener, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Stroke


Purpose of the Review

The purpose of the study was to review the literature on cryptogenic stroke and embolic stroke of undetermined stroke (ESUS). Cryptogenic stroke according to TOAST criteria is a stroke which is not due to cardiogenic embolism, small vessel disease with lacunes or large vessel disease of brain supplying arteries. In the context of secondary stroke prevention studies, cryptogenic stroke is not operationally defined.

Recent Findings

The new concept of “embolic stroke of undetermined source” (ESUS) provides an operational definition. ESUS is diagnosed as a non-lacunar stroke on cerebral imaging and exclusion of large vessel atherosclerosis by CTA, MRA or ultrasound. Cardiogenic embolism is made less likely by ECG monitoring and echocardiography. At present, aspirin is used for secondary stroke prevention in patients with cryptogenic stroke.


Based on the construct that ESUS might be caused by undetected atrial fibrillation or other embolic mechanisms, ongoing randomised secondary stroke prevention trials are comparing non-vitamin K oral anticoagulants (NOACs) with aspirin.


Cryptogenic stroke Embolic stroke of undetermined source (ESUS) Secondary stroke prevention Antiplatelet therapy Non-vitamin K oral anticoagulants 



The editors would like to thank Dr. John Brust for taking the time to review this manuscript.

Compliance with Ethical Standards

Conflict of Interest

Hans-Christoph Diener received honoraria for participation in clinical trials, contribution to advisory boards or oral presentations from: Abbott, Achelios, Allergan, AstraZeneca, Bayer Vital, BMS, Boehringer Ingelheim, CoAxia, Corimmun, Covidien, Daiichi-Sankyo, D-Pharm, Fresenius, GlaxoSmithKline, Janssen-Cilag, Johnson & Johnson, Knoll, Lilly, MSD, Medtronic, MindFrame, Neurobiological Technologies, Novartis, Novo-Nordisk, Paion, Parke-Davis, Pfizer, Sanofi-Aventis, Schering-Plough, Servier, Solvay, St. Jude, Syngis, Talecris, Thrombogenics, WebMD Global, Wyeth and Yamanouchi. Financial support for research projects was provided by AstraZeneca, GSK, Boehringer Ingelheim, Lundbeck, Novartis, Janssen-Cilag, Sanofi-Aventis, Syngis and Talecris. The Department of Neurology at the University Duisburg-Essen received research grants from the German Research Council (DFG), German Ministry of Education and Research (BMBF), European Union, NIH, Bertelsmann Foundation and Heinz-Nixdorf Foundation. Hans-Christoph Diener has no ownership interest and does not own stocks of any pharmaceutical company.

Within the past year, Hans-Christoph Diener served as editor of Aktuelle Neurologie, Arzneimitteltherapie, Kopfschmerznews, Stroke News, as co-editor of Cephalalgia and on the editorial board of Lancet Neurology, Stroke, European Neurology and Cerebrovascular Disorders. Hans-Christoph Diener chairs the Treatment Guidelines Committee of the German Society of Neurology and contributed to the EHRA and ESC guidelines for the treatment of AF.

Richard Bernstein has been compensated for speaking, consulting and research by Medtronic and Boehringer Ingelheim.

Robert Hart reports grants and personal fees from Bayer AG.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Hans-Christoph Diener
    • 1
    Email author
  • Richard Bernstein
    • 2
  • Robert Hart
    • 3
  1. 1.Department of NeurologyUniversity Hospital Essen and Medical Faculty of the University Duisburg-EssenEssenGermany
  2. 2.Davee Department of NeurologyNorthwestern University Feinberg School of MedicineChicagoUSA
  3. 3.McMaster University/Population Health Research InstituteHamiltonCanada

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