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Ulcerated plaques in the aortic arch contribute to symptomatic multiple brain infarction
  1. Sohei Yoshimura,
  2. Kazunori Toyoda,
  3. Takahiro Kuwashiro,
  4. Masatoshi Koga,
  5. Ryoichi Otsubo,
  6. Kuni Konaka,
  7. Masaki Naganuma,
  8. Hideki Matsuoka,
  9. Hiroaki Naritomi,
  10. Kazuo Minematsu
  1. Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
  1. Correspondence to Dr Kazunori Toyoda, Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan; toyoda{at}


Background The configuration of aortic plaque appears to be as important as its thickness when it acts as an embolic source to the brain. The frequency and clinical predictors of ulcerated plaque at the aortic arch identified using transoesophageal echocardiography (TOE) in patients with stroke were determined, and the association between the ulcer and recent ischaemic stroke, particularly multiple brain infarcts, which appear to indicate embolic stroke, was examined.

Methods Aortic and cardiac embolic sources were evaluated using TOE in 360 patients with fresh ischaemic stroke proven by diffusion-weighted MRI, including 210 patients with a single infarct and 150 with multiple infarcts, as well as in 101 non-stroke control patients. An ulcer was defined as a crater on the plaque ≥2.0 mm in depth and width.

Results An ulcerated plaque was identified in 10.6% of patients with stroke versus 2.0% of non-stroke patients, showing a 5.11-fold higher frequency in patients with stroke (95% CI 1.51 to 31.96) after adjustment for age and sex. After multivariate adjustment for clinical and ultrasonographic features, multiple-infarct patients had a 7.61-fold higher risk (95% CI 1.99 to 50.43) of having an ulcer than control patients and a 3.32-fold higher risk (95% CI 1.61 to 7.18) of having an ulcer than single-infarct patients. Diabetes mellitus and drinking habit were independently related to the presence of ulcerated plaque in patients with stroke.

Conclusions Ulcerated plaque in the aortic arch was associated with the development of ischaemic stroke, especially multiple brain infarcts, probably involving, at least in part, an embolic mechanism.

  • Aacute stroke
  • embolism
  • atheromatous plaque
  • thoracic aorta
  • transoesophageal echocardiography
  • ultrasound

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  • Funding This study was supported in part by a Grant-in-Aid (H20-Junkanki-Ippan-019) from the Ministry of Health, Labour and Welfare of Japan, and a Grant-in-Aid for Scientific Research (C, #20591039) from the Japan Society for the Promotion of Science.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the local ethics committee. in National Cerebral and Cardiovascular Center

  • Provenance and peer review Not commissioned; externally peer reviewed.