Letter by Wehrum and Harloff Regarding Article, “Complex Atheromatous Plaques in the Descending Aorta and the Risk of Stroke: A Systematic Review and Meta-Analysis”

Wehrum, Thomas; Harloff, Andreas

doi:10.1161/strokeaha.114.006211

Cited by 4 publications

(3 citation statements)

References 6 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Within the last years, there has been a controversy regarding the role of plaques in the DAo as a source of cerebral embolism [ 15 , 16 ]. However, ten patients of our study with otherwise cryptogenic brain infarction had an isolated plaque ≥4 mm in the proximal DAo which was potentially vulnerable in five cases (=50%).…”

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

Self Cite

View full text Add to dashboard Cite

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.

show abstract

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

Self Cite

View full text Add to dashboard Cite

show abstract

“…High‐risk atherosclerotic plaques (>4 mm thickness), typically assessed by transesophageal echocardiography, 2,3 in the ascending aortic or aortic arch have long been recognized as sources of ischemic stroke. More recently, retrograde embolization from plaques in the proximal descending aorta (DAo) has been considered a potential etiology for ischemic stroke 4‐6 . The asymmetry of ischemic patterns in patients with high‐risk atherosclerotic plaques in the DAo support this mechanism: the predominance of left‐sided lesions most likely originates from embolism via the left carotid or left vertebral arteries, closer to the DAo 6‐8 .…”

mentioning

confidence: 99%

Renin Angiotensin System Inhibitors Reduce Aortic Stiffness and Flow Reversal After a Cryptogenic Stroke

Soulat

Jarvis

Pathrose

et al. 2020

Magnetic Resonance Imaging

View full text Add to dashboard Cite

Background: Blood flow reversal is a possible mechanism for retrograde embolism in the setting of high-risk atherosclerotic plaques in the descending aorta (DAo). Evidence suggests that pulse wave velocity (PWV) is a determinant of blood flow reversal and can be reduced by the destiffening effect of renin-angiotensin system inhibitors (RASI). Purpose: To evaluate the impact of antihypertensive therapy on in vivo changes in PWV and flow reversal in patients with cryptogenic stroke. Study Type: Prospective. Population: Sixteen patients (69 AE 9 years; 10 males) included after cryptogenic stroke. Field Strength/Sequence: 3T. 4D flow sequence (temporal resolution = 19.6 msec) Assessment: Patients underwent aortic MRI at baseline and at 6-month follow-up. Patients received standard-of-care antihypertensive therapy that were classified as RASI vs. non-RASI medications (ie, destiffening vs. nondestiffening).We compared aortic PWV, flow reversal fraction (FRF), aortic measurements, cardiac function, and other aortic and cardiac measurements in the antihypertensive therapy groups. Statistical Tests: Two-tailed paired or unpaired Student's t-tests (normal distributions) or Wilcoxon tests (nonnormal distribution). Univariate correlations using Pearson correlation coefficients. Results: There was a significant decrease in PWV in the RASI (n = 10) group (9.4 AE 1.6 m/s vs. 8.3 AE 1.9 m/s; P < 0.05), as well as FRF (18.6% AE 4.1% vs. 16.3% AE 4.0%; P < 0.05) between baseline and the 6-month MRI studies. There were no changes in PWV or FRF in the non-RASI (n = 6) group (P = 0.146 and P = 0.32). A decrease in FRF was significantly correlated with a decrease in PWV (r = 0.53; P < 0.05). Data Conclusion: The findings of our study suggest that RASI therapy after cryptogenic stroke resulted in a decrease of blood flow reversal and aortic stiffness. Evidence Level: 1 Technical Efficacy Stage: 4

show abstract

“…2 Drs Wehrum and Harloff 1 indicate that in the pivotal French study, the crude odds ratio (OR) for stroke was ≈4× greater for plaques ≥4 mm located in the distal arch/proximal DAo (crude OR, 5.5; 95% confidence interval, 2.8-10.6) compared with those located in the distal straight segment of the DAo (crude OR, 1.5; 95% confidence interval, 0.5-4.8). 5 However, we note that in the same study the likelihood of cerebral ischemia was considerably higher for plaques ≥4 mm located in the ascending aorta or proximal arch (crude OR, 13.8; 95% confidence interval, 5.2-36.1) in comparison with plaques located in the distal arch/proximal DAo.…”

mentioning

confidence: 99%

Response to Letter Regarding Article, “Complex Atheromatous Plaques in the Descending Aorta and the Risk of Stroke: A Systematic Review and Meta-Analysis”

Katsanos

Tsivgoulis

2014

Stroke

View full text Add to dashboard Cite

First of all, we thank Drs Wehrum and Harloff 1 for their timely comments and constructive criticism about our meta-analysis. 2 We acknowledge that the 2 studies from the research group of Harloff et al 3,4 were not included in our meta-analysis because of the restriction of our inclusion criteria in prospective cohort studies that reported the prevalence of complex atheromatous plaques in the descending aorta (DAo) using the widely available and the (still considered) gold standard investigation of transesophageal echocardiography.2 The aforementioned studies 3,4 used sophisticated MRI protocols to detect plaques and further analyze blood flow in the DAo, reporting considerably higher complex athoromatous rates in the DAo (43.6% and 52.4%, respectively) 3,4 compared with the studies presented in the meta-analysis that used protocols more close to everyday clinical practice.2 The results of these pioneering studies were, however, mentioned in the introduction (reference 6) and in the discussion section of our article (reference 29), whereas a previous study published from the same group-which reported data on the prevalence of complex DAo plaques in transesophageal echocardiographic examination-was used in the quantitative synthesis (reference 15).2 Drs Wehrum and Harloff 1 indicate that in the pivotal French study, the crude odds ratio (OR) for stroke was ≈4× greater for plaques ≥4 mm located in the distal arch/proximal DAo (crude OR, 5.5; 95% confidence interval, 2.8-10.6) compared with those located in the distal straight segment of the DAo (crude OR, 1.5; 95% confidence interval, 0.5-4.8).5 However, we note that in the same study the likelihood of cerebral ischemia was considerably higher for plaques ≥4 mm located in the ascending aorta or proximal arch (crude OR, 13.8; 95% confidence interval, 5.2-36.1) in comparison with plaques located in the distal arch/proximal DAo. In addition, the authors have provided adjusted OR according to the cause of stroke only for the ascending aorta or proximal arch plaques.5 Consequently, it is uncertain whether the unadjusted association between plaques located in the distal arch/proximal DAo and ischemic stroke would retain its statistical significance after adjustment for potential confounders. Nevertheless, we agree with the comment raised by Drs Wehrum and Harloff 1 that the exact location of complex plaques in the DAo could be a potential moderator in the risk of cerebral embolism, but the available literature data are still insufficient to assess this assumption in a subgroup or a meta-regression analysis. Furthermore, we note that also in the study by Kim et al 6 no precise definition of different aortic segments is provided. Consequently, this study that has been cited by Drs Wehrum and Harloff 1 as a potential argument supporting their theory that atheromatous plaques in the DAo may cause cerebral ischemia via retrograde embolization suffers from the same methodological limitation as our meta-analysis.Our article is a systematic review and meta-analysis of prospect...

show abstract

Letter by Wehrum and Harloff Regarding Article, “Complex Atheromatous Plaques in the Descending Aorta and the Risk of Stroke: A Systematic Review and Meta-Analysis”

Cited by 4 publications

References 6 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

Renin Angiotensin System Inhibitors Reduce Aortic Stiffness and Flow Reversal After a Cryptogenic Stroke

Response to Letter Regarding Article, “Complex Atheromatous Plaques in the Descending Aorta and the Risk of Stroke: A Systematic Review and Meta-Analysis”

Contact Info

Product

Resources

About