neurology

Embolic Stroke of Undetermined Source (ESUS) Criteria

Diagnostic criteria for ESUS -- a subset of cryptogenic stroke characterised by non-lacunar infarct with embolic pattern, used to guide anticoagulation trials and workup.

Non-lacunar ischaemic stroke on CT/MRI (cortical, subcortical > 1.5 cm, or cerebellar infarct)*

Absence of AF on ECG/prolonged monitoring (>= 24-hour cardiac monitoring)*

Absence of significant (>= 50%) stenosis of intra- or extracranial arteries supplying the ischaemic territory*

Absence of major-risk cardioembolic source (intracardiac thrombus, vegetations, mechanical valve, recent MI < 4 weeks, EF < 30%, dilated cardiomyopathy, AF/flutter)*

No other specific cause of stroke identified (vasculitis, dissection, migraine with aura, drug use, coagulopathy, etc.)*

Score interpretation

ESUS Criteria Met 5

All 5 ESUS criteria satisfied -- Embolic Stroke of Undetermined Source confirmed

→ ESUS management: Antiplatelet therapy (aspirin 75-100 mg OD preferred; dual antiplatelet aspirin + clopidogrel for 21 days then single antiplatelet per POINT/CHANCE trial data if TIA/minor stroke); extended cardiac monitoring (implantable loop recorder if index event < 30 days, detect paroxysmal AF -- CRYSTAL-AF: 30% AF detection at 3 years); echocardiogram if not done; hypercoagulable screen if < 60 years; patent foramen ovale (PFO) assessment (TOE/bubble echo) -- PFO closure if confirmed ESUS < 60 years (CLOSE, DEFENSE-PFO, REDUCE trials); anticoagulation NOT recommended as standard (NAVIGATE-ESUS and RE-SPECT-ESUS trials negative); MRI brain with DWI for pattern analysis; vascular risk factor control; follow-up MRI/MRA brain and neck in 3-6 months.

ESUS Criteria NOT Met 0–4

One or more ESUS criteria not fulfilled -- specific stroke aetiology may be identified

→ Classify stroke by TOAST or SSS criteria (large artery atherosclerosis, cardioembolism, small vessel occlusion, other determined, undetermined); if lacunar: small vessel disease management (BP < 130/80, statin, antiplatelet); if AF confirmed: anticoagulation (DOAC preferred -- apixaban, rivaroxaban, edoxaban, dabigatran); if significant stenosis: carotid endarterectomy if symptomatic >= 50-70% (NASCET/ECST criteria); if cardioembolic: treat underlying cause.

Interpretation bands for the ESUS Criteria. Apply clinical judgement and local guidance.

References

Hart RG et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol. 2014;13(4):429-438.
NAVIGATE ESUS Investigators. Rivaroxaban for Stroke Prevention after Embolic Stroke of Undetermined Source. N Engl J Med. 2018;378(23):2191-2201.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Pathways

Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.

Score interpretation

References

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