Aortic Atherosclerosis Determines Increased Retrograde Blood Flow as a Potential Mechanism of Retrograde Embolic Stroke

Wehrum, Thomas; Guenther, Felix; Vach, Werner; Gladstone, Beryl Primrose; Wendel, Sarah K.; Fuchs, Alexander; Wu, Kehzong; Maurer, Christoph J.; Harloff, Andreas

doi:10.1159/000455053

Cited by 12 publications

(12 citation statements)

References 25 publications

(55 reference statements)

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“…This is especially important for plaques located distal to the outlets of the brain supplying arteries in the proximal descending aorta. However, aortic flow reversal varies between individuals [ 26 ] and even large plaques in the descending aorta are found in many patients without stroke. Accordingly, 4D flow CMR is necessary to discriminate if a plaque that is located in the proximal DAo may be the source of a cerebral embolism.…”

Section: Discussionmentioning

confidence: 99%

“…Using these three complementary CMR contrasts, we believe that even hyperintense plaque components in T1 weighted CMR were reliably discriminated from the bright blood signal. Multi-contrast plaque imaging protocols in the carotid arteries usually also comprise a time-of-flight (TOF) sequence which is used to detect fresh intra-plaque hemorrhage [ 26 ]. However, TOF imaging cannot be used in the aorta because of the large field of view and the resulting expenditure of measurement time.…”

Section: Discussionmentioning

confidence: 99%

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Aortic atheroma as a source of stroke – assessment of embolization risk using 3D CMR in stroke patients and controls

Wehrum

Dragonu

Strecker

et al. 2016

Journal of Cardiovascular Magnetic Resonance

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BackgroundIt was our purpose to identify vulnerable plaques in the thoracic aorta using 3D multi-contrast CMR and estimate the risk of cerebral embolization using 4D flow CMR in cryptogenic stroke patients and controls.MethodsOne hundred patients (40 with cryptogenic stroke, 60 ophthalmologic controls matched for age, sex and presence of hypertension) underwent a novel 3D multi-contrast (T1w, T2w, PDw) CMR protocol at 3 Tesla for plaque detection and characterization within the thoracic aorta, which was combined with 4D flow CMR for mapping potential embolization pathways. Plaque morphology was assessed in consensus reading by two investigators and classified according to the modified American-Heart-Association (AHA) classification of atherosclerotic plaques.ResultsIn the thoracic aorta, plaques <4 mm thickness were found in a similar number of stroke patients and controls [23 (57.5%) versus 33 (55.0%); p = 0.81]. However, plaques ≥4 mm were more frequent in stroke patients [22 (55.0%) versus 10 (16.7%); p < 0.001]. Of those patients with plaques ≥4 mm, seven (17.5%) stroke patients and two (3.3%) controls (p < 0.001) had potentially vulnerable AHA type VI plaques. Six stroke patients with vulnerable AHA type VI plaques ≥4 mm had potential embolization pathways connecting the plaque, located in the aortic arch (n = 3) and proximal descending aorta (n = 3), with the individual territory of stroke, which made them the most likely source of stroke in those patients.ConclusionsOur findings underline the significance of ≥4 mm thick and vulnerable plaques in the aortic arch and descending aorta as a relevant etiology of stroke.Clinical trial registrationUnique identifier: DRKS00006234; date of registration: 11/06/2014Electronic supplementary materialThe online version of this article (doi:10.1186/s12968-017-0379-x) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Aortic atheroma as a source of stroke – assessment of embolization risk using 3D CMR in stroke patients and controls

Wehrum

Dragonu

Strecker

et al. 2016

Journal of Cardiovascular Magnetic Resonance

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“…(31, 32) Generally, atherosclerosis in the DAo is a marker of atherosclerotic burden and ongoing systemic processes that cause brain injury, such as microvascular damage from increased vascular pulsatility pressure,(5) as opposed to a direct source of cerebral embolism. (32, 33) In the Rotterdam Scan Study, abdominal aortic atherosclerosis at mid-life, measured on radiographs, was associated with the presence of periventricular white matter lesions in late-life, but not with subcortical white matter lesions.…”

Section: Discussionmentioning

confidence: 99%

Association of descending thoracic aortic plaque with brain atrophy and white matter hyperintensities: The Framingham Heart Study

et al. 2017

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Background and aims Aortic atherosclerosis is an aggregate marker of vascular risk factor exposure and has been associated with intracranial atherosclerosis and stroke. We hypothesized that atherosclerosis of the descending aorta (DAo) could be a risk marker for brain aging and injury. Methods We evaluated 1527 participants (mean age 59.9 years, 53.5% women) in the Framingham Offspring cohort who underwent both aortic and brain MRI. Participants were free of clinical stroke, dementia, or other neurological illness at the time of axial MRI of the thoracic and abdominal DAo and subsequent brain MRI. We related the prevalence and burden of aortic plaque to total cerebral brain volume (TCBV) and white matter hyperintensity volume (WMHV). An additional analysis compared incidence of stroke or TIA in participants with and without DAo plaques. Results Presence of thoracic DAo plaque (8%) was associated with decreased TCBV in sex-pooled analysis (−0.77, SE 0.25, p=0.002, equivalent to 4.5 years of aging) and with increased WMHV only in men (0.26, SE 0.12, p=0.032, equivalent to 6.5 years aging). We observed similar associations of DAo plaque burden with TCBV and WMHV. There were 43 strokes and 11 TIAs in prospective follow-up (median 7 years). Presence of DAo plaque was not associated with subsequent stroke or TIA. Conclusions In this cross-sectional community-based study, we found DAo plaque is associated with accelerated brain aging. These data underscore the potential implications of incidentally identified subclinical aortic atherosclerosis and question whether targeted intervention in these high risk individuals can modulate cognitive decline.

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“…Transesophageal echocardiography (TEE) can provide concrete information about the aortic arch. Aortic complicated lesions (ACLs), usually diagnosed on TEE, are key parameters for evaluating aortic embolic sources in cases of embolic stroke [2,[6][7][8][9]. In addition, ACLs have been suggested as independent predictors of recurrence [10] and poor prognosis [11] among ischemic stroke patients.…”

Section: Introductionmentioning

confidence: 99%

Associations of High Intensities on Magnetization-Prepared Rapid Acquisition with Gradient Echo with Aortic Complicated Lesions in Ischemic Stroke Patients

et al. 2019

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Background: Aortic complicated lesions (ACLs) are key parameters for evaluating aortic embolic sources in embolic stroke, and are usually diagnosed using transesophageal echocardiography (TEE). However, alternative methods for diagnosing ACLs have not been well established. We investigated associations between high-intensity areas on T1-weighted imaging (T1WI) with magnetization-prepared rapid acquisition with gradient echo (MPRAGE) and ACLs on TEE among ischemic stroke patients. Methods: Participants comprised 135 patients (mean age, 71 years; 35 women) with ischemic stroke or transient ischemic attack who underwent TEE for evaluation of embolic sources and plaque imaging using MPRAGE for evaluation of aortic or carotid plaques. Aortic plaque with signal intensity ≥200% of sternocleidomastoid intensity on MPRAGE was categorized as “high intensity”. ACLs on TEE were defined by focal increases in intima-media thickness (IMT) ≥4.0 mm or the presence of ulcerated or mobile plaques. Results: Fifty-six patients (42%) showed high-intensity areas on MPRAGE at the aortic arch. Aortic maximum IMT was significantly higher in patients with high intensities than in those without (p < 0.001). Incidences of ACLs (66 vs. 20%, p < 0.001) or ulcerated or mobile plaques (30 vs. 6%, p < 0.001) were significantly higher in patients with high intensities than in patients without. Multivariable logistic regression analysis showed that high intensities on MPRAGE were independently associated with the presence of ACLs (OR 5.72; 95% CI 2.38–13.70) and ulcerated or mobile plaques (OR 4.18; 95% CI 1.29–13.50). Conclusions: High intensities on T1WI with MPRAGE in the aortic arch were significantly associated with the presence of ACLs. An evaluation of the aortic arch using MPRAGE may be useful for predicting ACLs.

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Aortic Atherosclerosis Determines Increased Retrograde Blood Flow as a Potential Mechanism of Retrograde Embolic Stroke

Cited by 12 publications

References 25 publications

Aortic atheroma as a source of stroke – assessment of embolization risk using 3D CMR in stroke patients and controls

Aortic atheroma as a source of stroke – assessment of embolization risk using 3D CMR in stroke patients and controls

Association of descending thoracic aortic plaque with brain atrophy and white matter hyperintensities: The Framingham Heart Study

Associations of High Intensities on Magnetization-Prepared Rapid Acquisition with Gradient Echo with Aortic Complicated Lesions in Ischemic Stroke Patients

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