Dr. Silver of the University of Massachusetts Medical School has no relevant financial relationships to disclose.)
Dr. Levine of the SUNY Health Science Center at Brooklyn has received honorariums from Genentech for service on a scientific advisory committee and a research grant from Genentech as a principal investigator.)
This article includes discussion of aortic atherosclerosis and stroke, aortic atheroma, aortic debris, complex plaque, and protruding atherosclerotic plaque. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.
Aortic atheroma is an important risk factor for ischemic stroke. In particular, large and complex aortic arch atheroma has been associated with an increased risk of ischemic stroke. The optimal treatment of patients with aortic arch atheroma is still uncertain and is the subject of ongoing clinical trials.
• Aortic arch atherosclerosis is a known cause of ischemic stroke.
• Plaques measuring 4 mm or greater carry the highest risk of stroke.
• Stroke often tends to be left hemispheric due to the location of plaque within the aorta.
• There is no proven treatment for aortic arch atherosclerosis specifically; however, usual treatments for ischemic stroke such as antithrombotic therapy, statin therapy, and lifestyle changes are recommended.
Historical note and terminology
Stroke is the fourth leading cause of death in the United States. Of the 795,000 strokes occurring annually in the United States, 87% are ischemic stroke and 13% are hemorrhagic stroke (Go et al 2014).
Atherosclerosis is a diffuse systemic vascular disorder affecting large and medium-sized arteries, causing patchy intimal plaques known as atheromas.
Aortic atheromatous plaques garnered attention as a possible cause of stroke in the early 1990s. In 1990, transesophageal echocardiographic examination of 3 patients with cryptogenic stroke to identify potential cardiac sources demonstrated the presence of "large, protrusive plaques. . . with mobile projections that moved freely with the blood flow" (Tunick and Kronzon 1990). This was followed by a larger study in 1991 which demonstrated a higher incidence of embolism when aortic plaques had mobile elements (Karalis et al 1991). The association of aortic atheroma and stroke was first described by Amarenco and colleagues in a landmark autopsy study of 500 patients with cerebrovascular and other neurologic diseases. The prevalence of ulcerated plaques was 16.9% in patients with cerebrovascular diseases compared to 5.1% among patients with other neurologic diseases. Ulcerated plaques were present in 61% of cryptogenic cerebral infarcts compared to 22% with a known cause (Amarenco et al 1992b). Plaques that were at least 4 mm in thickness were found to be an independent risk factor for ischemic stroke (Amarenco et al 1994; Mitusch et al 1994; Mitusch et al 1997).
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