Aortic Arch Plaques

Learning objectives

Introduction

• Risk factor and mechanism for stroke and peripheral embolism
• Due to aortic arch atheroma
• Potential cause of cryptogenic embolic stroke

Aetiology

• Approximately 45% of individuals aged ≥ 45 years harbor atherosclerotic plaque in their aorta
• Large, ulcerated, noncalcified, or mobile atheromas, occur in 8% of the population,
• These have been particularly linked with stroke.
• Potential cause of cryptogenic embolic stroke

Clinical

• Systemic embolic including stroke
• Sudden onset affecting anterior and posterior circulation
• May cause systemic embolisation

Risk Factors from Plaque Morphology

investigations

• FBC, U&E, ESR and CRP may be elevated.
• Transoesophageal echocardiography can identify plaque
• CT Angiography of the Aorta Is Superior to Transoesophageal Echocardiography

Examples of aortic plaque detection by ECG-triggered CTA in sagittal oblique maximum-intensity projection of the aorta

Differential

• Atrial fibrillation
• Cardioembolic Stroke

Management

• There have been several trials trying to look at this. The ARCH trial randomised patients with TIA or minor stroke who had significant aortic plaques to either warfarin or the combination of aspirin and clopidogrel. This trial was stopped because it turned out that the trial would never reach the power for a definite result. The outcome was that there was a small benefit in favour of aspirin plus clopidogrel vs warfarin, which was not statistically significant. Unfortunately, we still don't know what the best treatment is for patients who have aortic plaques with TIA or minor stroke. A more recent [link] trial looked at aspirin 75 to 150 mg/d plus clopidogrel 75 mg/d over warfarin therapy and found no conclusive evidence as the study despite enrolling over 300 patients was underpowered. The current balance would then be towards DAPT unless there are indications for warfarin.
• Manage atherosclerotic risk factors - statins, diet, smoking, BP reduction, lipids, exercise
• Currently, there is uncertainty as to what this should be, but either combination antiplatelet therapy (aspirin plus clopidogrel) or anticoagulation with warfarin (target INR 2.0-3.0) are commonly used. Statin to lower cholesterol and good BP control.

References

• Aortic Arch Plaques and Risk of Recurrent Stroke and Death

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