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A tool to identify patients with embolic stroke of undetermined source at high recurrence risk.

Journal article
Authors George Ntaios
Georgios Georgiopoulos
Kalliopi Perlepe
Gaia Sirimarco
Davide Strambo
Ashraf Eskandari
Stefania Nannoni
Anastasia Vemmou
Eleni Koroboki
Efstathios Manios
Ana Rodríguez-Campello
Elisa Cuadrado-Godia
Jaume Roquer
Valentina Arnao
Valeria Caso
Maurizio Paciaroni
Exuperio Diez-Tejedor
Blanca Fuentes
Jorge Rodríguez Pardo
Sara Sánchez-Velasco
Antonio Arauz
Sebastian F Ameriso
Lucía Pertierra
Maia Gómez-Schneider
Maximiliano A Hawkes
Miguel A Barboza
Beatriz Chavarria Cano
Ana Maria Iglesias Mohedano
Andrés García Pastor
Antonio Gil-Núñez
Jukka Putaala
Turgut Tatlisumak
Efstathia Karagkiozi
Vasileios Papavasileiou
Konstantinos Makaritsis
Fabio Bandini
Konstantinos Vemmos
Patrik Michel
Published in Neurology
Volume 93
Issue 23
Pages e2094-e2104
ISSN 1526-632X
Publication year 2019
Published at Institute of Neuroscience and Physiology, Department of Clinical Neuroscience
Pages e2094-e2104
Language en
Subject categories Neurology


A tool to stratify the risk of stroke recurrence in patients with embolic stroke of undetermined source (ESUS) could be useful in research and clinical practice. We aimed to determine whether a score can be developed and externally validated for the identification of patients with ESUS at high risk for stroke recurrence.We pooled the data of all consecutive patients with ESUS from 11 prospective stroke registries. We performed multivariable Cox regression analysis to identify predictors of stroke recurrence. Based on the coefficient of each covariate of the fitted multivariable model, we generated an integer-based point scoring system. We validated the score externally assessing its discrimination and calibration.In 3 registries (884 patients) that were used as the derivation cohort, age, leukoaraiosis, and multiterritorial infarct were identified as independent predictors of stroke recurrence and were included in the final score, which assigns 1 point per every decade after 35 years of age, 2 points for leukoaraiosis, and 3 points for multiterritorial infarcts (acute or old nonlacunar). The rate of stroke recurrence was 2.1 per 100 patient-years (95% confidence interval [CI] 1.44-3.06) in patients with a score of 0-4 (low risk), 3.74 (95% CI 2.77-5.04) in patients with a score of 5-6 (intermediate risk), and 8.23 (95% CI 5.99-11.3) in patients with a score of 7-12 (high risk). Compared to low-risk patients, the risk of stroke recurrence was significantly higher in intermediate-risk (hazard ratio [HR] 1.78, 95% CI 1.1-2.88) and high-risk patients (HR 4.67, 95% CI 2.83-7.7). The score was well-calibrated in both derivation and external validation cohorts (8 registries, 820 patients) (Hosmer-Lemeshow test χ2: 12.1 [p = 0.357] and χ2: 21.7 [p = 0.753], respectively). The area under the curve of the score was 0.63 (95% CI 0.58-0.68) and 0.60 (95% CI 0.54-0.66), respectively.The proposed score can assist in the identification of patients with ESUS at high risk for stroke recurrence.

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