Transesophageal echocardiography for aortic arch atheromas in patients with cryptogenic stroke/transient ischemic attack – An underutilized entity

Abstract

Introduction: Large aortic arch atheromas (≥4 mm) and complex and mobile aortic atheromas have been associated with ischemic brain stroke in various previous studies. Transesophageal echocardiography (TEE) is the imaging modality of choice, however, is an underutilized investigation in routine clinical practice. We sought out to find the prevalence and severity of aortic arch atheromas in patients with cryptogenic stroke/transient ischemic attack (TIA) at a tertiary care center. Patients and Methods: One hundred and eighty-eight consecutive stroke patients were screened for stroke risk factors. Sixty-one patients were found to have stroke without obvious cause (cryptogenic), 52 patients underwent TEE, four patients were further excluded after evidence of potential cardioembolic source in TEE, and finally, data of 48 patients with cryptogenic stroke were analyzed. Results: We found that one-third of the patients (n = 16, 33.3%) had aortic atheromas and half of them (n = 8, 16.4%) had atheromas ≥4 mm. Diabetes, dyslipidemia, and smoking status were individually associated with a higher prevalence of aortic plaques in our study (P = 0.03). The frequency of aortic plaques was significantly higher in patients with ischemic brain infarction than in TIA (P = 0.01). Large atheromas (≥4 mm) were significantly associated with more severe clinical illness as assessed by the National Institute of Health Stroke Scale, longer hospital stay, and death (P < 0.001). Conclusions: In the present observational study at a tertiary care center, we found that the relevant aortic atheromas in patients with cryptogenic stroke are fairly common and are associated with adverse clinical events. The diagnosis of aortic atheromas should be sought actively by TEE in patients with cryptogenic stroke or in patients with recurrent embolic events and multiple risk factors. Antiplatelet agents and statins are the mainstay of therapy. Anticoagulation is reasonable in selected high-risk patients. Future randomized trials of direct oral anticoagulants compared to antiplatelet therapy in patients with complex aortic atheromas are anticipated to guide the clinicians.

Keywords

• aortic arch atheromas
• cryptogenic stroke
• transesophageal echocardiography
• underutilized entity