2025 American Academy of Neurology Abstract Website

Objective:

The efficacy and safety of direct oral anticoagulant therapy versus aspirin in patients with embolic stroke of undetermined source remained to be fully explored.

Background:

Embolic stroke of undetermined source (ESUS) accounts for 25% of ischemic stroke and it is associated with a stroke recurrence of approximately 4.5% per year.

Design/Methods:

PubMed, Scopus and Embase were searched for randomized controlled trials (RCTs) comparing DOAC to Aspirin in patients with ESUS with primary outcome of death from any cause.

Results:

We included 3 RCTs comparing DOAC to Aspirin in patients with embolic stroke of undetermined source (ESUS). The pooled results showed that death from any cause (OR = 1.09; 95% CI [0.84, 1.41]; I² = 0%; p = 0.522), cardiovascular death (OR = 1.10; 95% CI [0.62, 1.94]; I²= 15%; p = 0.749), hemorrhagic stroke (OR = 2.21; 95% CI [0.30, 16.07]; I² = 78%; p = 0.433), intracranial hemorrhage (OR = 1.87; 95% CI [0.48, 7.26]; I² = 84%; p = 0.364), disabling stroke (OR = 0.92; 95% CI [0.39, 2.16]; I² = 84%; p = 0.845), ischemic stroke (OR = 0.91; 95% CI [0.77, 1.09]; I² = 0%; p = 0.307), recurrent stroke (OR = 0.95; 95% CI [0.75, 1.22]; I²= 62%; p = 0.710), major bleeding (OR = 1.71; 95% CI [0.84, 3.50]; I² = 73%; p = 0.140), myocardial infarction (OR = 0.92; 95% CI [0.55, 1.55]; I² = 16%; p = 0.756) and systemic embolism (OR = 0.52; 95% CI [0.21, 1.25]; I²= 0%; p = 0.144) were not statistically different between the DOAC and Aspirin groups.

Conclusions:

In patients with ESUS, DOAC therapy did not show any significant difference with Aspirin for death from any cause, cardiovascular death, hemorrhagic stroke, intracranial hemorrhage, disabling stroke, ischemic stroke, recurrent stroke, major bleeding, MI and systemic embolism.