Which is the Best Treatment in High Suspicion Embolic Stroke of Undetermined Etiology? A Case Report

Aims: Presence of aphasia or cortical stroke on neuroimaging suggests an embolic etiology of the stroke. However sometimes it is difficult to discover the source of the emboli doing the decision of the optimal treatment a challenge.
Presentation of Case: 75-year old female was admitted on February 2007 due to a sudden left hemiparesis. Cranial MRI showed two right parietal cortical ischemic lesions. Cardiological and neurovascular studies were normal. Despite the high suspicion of embolic etiology, the patient was discharged home with clopidogrel and low molecular weight heparin (LMWH). Transesophageal echocardiography was later made and showed a minor atherosclerosis of the aortic artery. Patent foramen ovale and atrial aneurism were discarded. LMWH was stopped. On April 2007, the patient was admitted due to global aphasia and right hemiparesis. Cranial CT showed a cortical subacute ischemic stroke in the left middle cerebral artery territory. A complete etiological study (including systemic study) was normal. Anticoagulation was initiated. The patient has remained stable since then (mRS 3: moderate disability).
Discussion: The American and European guidelines do not include the possibility of highly probable embolic stroke of undetermined cause. In these patients, anticoagulation treatment might increase the possibility of intracranial hemorrhages. On the other hand, antiplatelet treatment does not prevent the recurrence of embolic events with devastating consequences.
Conclusion: This case illustrates the controversy about antithrombotic treatment when the etiology remains unknown in highly suspicious embolic stroke. Even if the source of stroke remains unknown, an oral anticoagulation should be carefully considered in these patients.