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Intracranial Atherosclerotic Plaque as Potential Cause of Embolic Stroke
Quick Takes
- Embolic stroke of undetermined source (ESUS) accounts for up to one third of all ischemic strokes.
- Artery-to-artery embolism from intracranial vessel plaque has not historically been considered a major cause of ESUS.
- The results of this study suggest a possible etiologic role for intracranial plaque in ESUS, though the results of this study are unlikely to change patient management in the near future.
Study Questions:
Is intracranial vessel plaque a potential cause of embolic stroke of undetermined source (ESUS)?
Methods:
Consecutive stroke patients admitted with acute anterior circulation ischemic stroke were retrospectively enrolled in the study. Patients were included in the analysis if they had ESUS or a small vessel disease (SVD) (i.e., non-embolic) stroke etiology. High-resolution magnetic resonance imaging (MRI) was used to identify intracranial vessel plaque and to evaluate plaque characteristics. Specific plaque characteristics evaluated were remodeling index (outward expansion or shrinkage of the vessel wall), plaque burden, discontinuity of plaque surface, thick fibrous cap, intraplaque hemorrhage, and any or both of discontinuity of plaque surface and intraplaque hemorrhage. The investigators hypothesized that intracranial plaque would have a higher prevalence and would have more high-risk features on the ipsilateral side of infarct compared with the contralateral side of infarct in patients with ESUS.
Results:
A total of 243 ESUS patients and 160 SVD (non-embolic) stroke patients were included in the analysis. The prevalence of intracranial plaque ipsilateral to the infarct was higher compared with that contralateral to the infarct in ESUS patients (63.8% vs. 42.8%; odds ratio, 5.25; 95% confidence interval, 2.83-9.73). The prevalence of any intracranial plaque was significantly more common in patients with ESUS (68.7%) compared to those with SVD (40.0%) (p < 0.001). In the ESUS group, larger plaque burden, higher remodeling index, higher prevalence of positive remodeling, higher prevalence of discontinuity of plaque surface, and higher prevalence of complicated plaque were observed with ipsilateral versus contralateral plaque. No plaque features were associated with ipsilateral stroke in the SVD group.
Conclusions:
In patients with ESUS but not patients with non-embolic stroke (SVD), ipsilateral intracranial plaque was more common than contralateral intracranial plaque. In patients with ESUS, ipsilateral plaque was more likely to have high-risk plaque characteristics compared to contralateral plaque. The authors concluded that high-risk intracranial plaque likely represents a significant embolic source in ESUS.
Perspective:
ESUS has historically been attributed to occult atrial fibrillation, atrial cardiopathy, patent foramen ovale, aortic arch atherosclerosis, and non-stenotic large vessel (e.g., internal carotid) atherosclerosis. This was the first large study to investigate a potential etiologic role for intracranial vessel plaque in ESUS. At present, the identification of intracranial plaque and plaque characteristics by high-resolution MRI is not readily available to most practitioners. At this time, the typical therapy for patients with stroke from intracranial vessel disease includes cholesterol-lowering agents, blood pressure control, and an antiplatelet medication. Because the radiographic techniques in this study are not widespread and patients cannot at present be easily identified as having ESUS related to intracranial atherosclerotic plaque, this typical therapy is unlikely to change in the near future.
Clinical Topics: Noninvasive Imaging, Prevention, Vascular Medicine, Magnetic Resonance Imaging, Nuclear Imaging
Keywords: Atherosclerosis, Brain Ischemia, Carotid Artery Diseases, Diagnostic Imaging, Hemorrhage, Infarction, Intracranial Arteriosclerosis, Magnetic Resonance Imaging, Plaque, Atherosclerotic, Radiography, Risk, Stroke, Secondary Prevention, Vascular Diseases
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