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Acute Thromboembolic Ischemic Stroke From Complex Aortic Arch Plaque.

Liaquat Ali1, Abeer Safan2, Sadat Kamran2

  • 1Neurology, Hamad General Hospital, Doha, QAT.

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|September 20, 2021
PubMed
Summary

Complex aortic arch plaques exceeding 4 mm thick increase stroke risk. Intravenous thrombolysis and mechanical thrombectomy show promise for treating associated thrombi in acute ischemic stroke cases.

Keywords:
atherosclerosislow molecular weight heparin (lmwh)mechanical thrombectomy (mt)tissue plasminogen activator (tpa)transesophageal echocardiography (tee)

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Area of Science:

  • Cardiovascular Medicine
  • Neurology
  • Vascular Surgery

Background:

  • Atherosclerosis, particularly involving the aorta, is a significant cause of systemic embolization.
  • Mobile and complex aortic plaques thicker than 4 mm elevate the risk of embolic events, commonly manifesting as stroke or transient ischemic attack.
  • Standard treatments include antiplatelets and statins, with anticoagulation reserved for thrombotic components.

Observation:

  • Two cases of acute ischemic stroke with large, mobile aortic arch thrombi and complex plaques were reported.
  • One patient experienced complete thrombus resolution after treatment with intravenous tissue plasminogen activator (TPA) followed by low molecular weight heparin (LMWH).
  • Transesophageal echocardiogram (TEE) is the preferred imaging modality for thoracic aortic plaques.

Findings:

  • Aortic plaques >4 mm thick are independent predictors of recurrent ischemic stroke.
  • Intravenous thrombolysis and mechanical thrombectomy (MT) data for aortic arch thrombus in acute ischemic stroke are limited.
  • Complex aortic arch plaques are recognized as an independent risk factor for recurrent stroke.

Implications:

  • Intravenous alteplase and MT via trans-brachial access may be considered for select patients with aortic arch thrombus, after excluding dissection and aneurysm.
  • Further multicenter, randomized controlled trials are necessary to establish the safety and efficacy of IV TPA and MT in these cases.
  • These findings highlight the importance of recognizing aortic arch plaques as a critical risk factor for embolic stroke.