Abstract
Aortic atheroma is a known cause of ischemic stroke. However, it is unclear whether ischemic stroke is caused by emboli from aortic atheroma or by accompanying atherosclerosis. In this study, we evaluated lesion patterns of patients with complex aortic plaque (CAP) to assume the underlying pathophysiology. Acute ischemic stroke patients who underwent transesophageal echocardiography were included. CAP was defined as a plaque in the proximal aorta ≥ 4 mm thick or with a mobile component. The diffusion-weighted imaging lesion patterns of patients with CAP were compared to those with large arterial atherosclerosis (LAA) or cardioembolism (CE). A total of 64 CAP patients, 127 LAA patients, and 80 CE patients were included. Small cortical pattern was more common in the CAP group (45.3%) than in the LAA (7.9%, p < 0.001) or the CE group (23.8%, p = 0.018). A large cortical pattern was more common in the CE group than in the CAP group (p < 0.001), whereas subcortical only pattern tended to be more common in the CAP group than in the CE group (p = 0.057). In multinominal analysis, the CAP group was more likely to have a small cortical lesion than the LAA group [odds ratio (OR) 14.63; 95% confidence interval (CI) 4.67–45.85] or the CE (OR 3.69, 95% CI 1.19–11.39) group. In conclusion, patients with CAP frequently had small cortical lesions or subcortical single lesion. These findings imply that ischemic stroke in aortic atheroma patients is associated with either small emboli or small artery disease.
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Meissner I, Khandheria BK, Sheps SG, Schwartz GL, Wiebers DO, Whisnant JP, Covalt JL, Petterson TM, Christianson TJ, Agmon Y (2004) Atherosclerosis of the aorta: risk factor, risk marker, or innocent bystander? A prospective population-based transesophageal echocardiography study. J Am Coll Cardiol 44:1018–1024
Zavala JA, Amarrenco P, Davis SM, Jones EF, Young D, Macleod MR, Horky LL, Donnan GA (2006) Aortic arch atheroma. Int J Stroke 1:74–80
Kang DW, Chalela JA, Ezzeddine MA, Warach S (2003) Association of ischemic lesion patterns on early diffusion-weighted imaging with TOAST stroke subtypes. Arch Neurol 60:1730–1734
Wessels T, Wessels C, Ellsiepen A, Reuter I, Trittmacher S, Stolz E, Jauss M (2006) Contribution of diffusion-weighted imaging in determination of stroke etiology. AJNR Am J Neuroradiol 27(1):35–39
Roh JK, Kang DW, Lee SH, Yoon BW, Chang KH (2000) Significance of acute multiple brain infarction on diffusion-weighted imaging. Stroke 31:688–694
Kim SJ, Ryoo S, Hwang J, Noh HJ, Park JH, Choe YH, Bang OY (2012) Characterization of the infarct pattern caused by vulnerable aortic arch atheroma: DWI and multidetector row CT study. Cerebrovasc Dis 33:549–557
Ueno Y, Kimura K, Iguchi Y, Shibazaki K, Inoue T, Hattori N, Urabe T (2007) Mobile aortic plaques are a cause of multiple brain infarcts seen on diffusion-weighted imaging. Stroke J Cerebr Circ 38:2470–2476
Ha YS, Han SW, Cho KC, Nam HS, Kim JY, Paik JS, Park JH (2006) Analysis of ischemic stroke patterns using the diffusion-weighted imaging in patients with complicated aortic plaques. J Korean Neurol Assoc 24(2):106–111
Lee BI, Nam HS, Heo JH, Kim DI (2001) Yonsei Stroke Registry. Analysis of 1000 patients with acute cerebral infarctions. Cerebrovasc Dis 12:145–151
Nam HS, Kim HC, Kim YD, Lee HS, Kim J, Lee DH, Heo JH (2012) Long-term mortality in patients with stroke of undetermined etiology. Stroke 43:2948–2956
Nam HS, Han SW, Lee JY, Ahn SH, Ha JW, Rim SJ, Lee BI, Heo JH (2006) Association of aortic plaque with intracranial atherosclerosis in patients with stroke. Neurology 67:1184–1188
Cho HJ, Choi HY, Kim YD, Nam HS, Han SW, Ha JW, Chung NS, Heo JH (2010) Transoesophageal echocardiography in patients with acute stroke with sinus rhythm and no cardiac disease history. J Neurol Neurosurg Psychiatry 81:412–415
Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24:35–41
van Everdingen KJ, van der Grond J, Kappelle LJ, Ramos LM, Mali WP (1998) Diffusion-weighted magnetic resonance imaging in acute stroke. Stroke 29:1783–1790
Roberts TP, Rowley HA (2003) Diffusion weighted magnetic resonance imaging in stroke. Eur J Radiol 45:185–194
Tatu L, Moulin T, Bogousslavsky J, Duvernoy H (1996) Arterial territories of human brain: brainstem and cerebellum. Neurology 47:1125–1135
Tatu L, Moulin T, Bogousslavsky J, Duvernoy H (1998) Arterial territories of the human brain: cerebral hemispheres. Neurology 50:1699–1708
Mangla R, Kolar B, Almast J, Ekholm SE (2011) Border zone infarcts: pathophysiologic and imaging characteristics. Radiographics 31:1201–1214
Yong SW, Bang OY, Lee PH, Li WY (2006) Internal and cortical border-zone infarction: clinical and diffusion-weighted imaging features. Stroke 37:841–846
Timsit SG, Sacco RL, Mohr JP, Foulkes MA, Tatemichi TK, Wolf PA, Price TR, Hier DB (1993) Brain infarction severity differs according to cardiac or arterial embolic source. Neurology 43:728–733
Friedman M, Van den Bovenkamp GJ (1966) The pathogenesis of a coronary thrombus. Am J Pathol 48:19–44
Minnerup J, Kleinschnitz C (2011) Visualization of clot composition in ischemic stroke: do we get what we see? Stroke 42:1193–1194
Ogata J, Yutani C, Otsubo R, Yamanishi H, Naritomi H, Yamaguchi T, Minematsu K (2008) Heart and vessel pathology underlying brain infarction in 142 stroke patients. Ann Neurol 63:770–781
Ezzeddine MA, Primavera JM, Rosand J, Hedley-Whyte ET, Rordorf G (2000) Clinical characteristics of pathologically proved cholesterol emboli to the brain. Neurology 54:1681–1683
Lee DK, Kim JS, Kwon SU, Yoo SH, Kang DW (2005) Lesion patterns and stroke mechanism in atherosclerotic middle cerebral artery disease: early diffusion-weighted imaging study. Stroke 36:2583–2588
Min WK, Park KK, Kim YS, Park HC, Kim JY, Park SP, Suh CK (2000) Atherothrombotic middle cerebral artery territory infarction: topographic diversity with common occurrence of concomitant small cortical and subcortical infarcts. Stroke 31:2055–2061
Masuda J, Yutani C, Ogata J, Kuriyama Y, Yamaguchi T (1994) Atheromatous embolism in the brain: a clinicopathologic analysis of 15 autopsy cases. Neurology 44:1231–1237
Song TJ, Kim YD, Yoo J, Kim J, Chang HJ, Hong GR, Shim CY, Song D, Heo JH, Nam HS (2016) Association between aortic atheroma and cerebral small vessel disease in patients with ischemic Stroke. J Stroke 18:312–320
Chuang ML, Gona P, Oyama-Manabe N, Manders ES, Salton CJ, Hoffmann U, Manning WJ, O’Donnell CJ (2014) Risk factor differences in calcified and noncalcified aortic plaque: the Framingham Heart Study. Arterioscler Thromb Vasc Biol 34:1580–1586
Khan U, Porteous L, Hassan A, Markus HS (2007) Risk factor profile of cerebral small vessel disease and its subtypes. J Neurol Neurosurg Psychiatry 78:702–706
O’Rourke MF, Safar ME (2005) Relationship between aortic stiffening and microvascular disease in brain and kidney: cause and logic of therapy. Hypertension 46:200–204
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This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HC15C1056).
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Kim, S.W., Kim, Y.D., Chang, HJ. et al. Different infarction patterns in patients with aortic atheroma compared to those with cardioembolism or large artery atherosclerosis. J Neurol 265, 151–158 (2018). https://doi.org/10.1007/s00415-017-8685-7
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DOI: https://doi.org/10.1007/s00415-017-8685-7