Do stroke patients with normal carotid arteries require TEE for exclusion of relevant aortic plaques?

Abstract

Objectives: This study investigated (a) the hypothesis that stroke patients with aortic atheroma would show comparable atherosclerotic changes in the carotid arteries, which are easily accessible for ultrasound evaluation and (b) the possibility of carotid duplex sonography as a replacement for transoesophageal echocardiography (TEE) for the exclusion or prediction of relevant aortic plaques. Methods: In 301 consecutive patients (mean age 62 years) with acute cerebral ischaemia, two dimensional ultrasound measurements were taken of common carotid artery intima media thickness (IMT) and maximal plaque area (PA) and the local degree of internal carotid artery (ICA) stenosis were determined. Maximal aortic wall thickness (AWT) was assessed by TEE. Results: An IMT (0.9 mm yielded a negative predictive value (NPV) of 95.8% for exclusion of aortic atheromas >4 mm and an NPV of 100% for the exclusion of aortic thrombi. However, positive predictive value of IMT .0.9 mm was low (29.6%), increasing only slightly in the presence of carotid plaques (33%). Incidence of aortic thrombi was significantly higher with >50% compared with ,50% ICA stenosis (11.3% v 3.9%, respectively). IMT and PA correlated moderately with AWT (r = 0.47, r = 0.53, respectively; p,0.001). Systolic blood pressure, coronary heart disease and peripheral artery disease, increased IMT, and ICA stenosis >50% were independently related to AWT >4 mm. Conclusions: A high NPV of normal carotid ultrasound does not support routine TEE for the exclusion of complex aortic plaques as a high risk source of cerebral embolism. However, in patients with carotid atherosclerosis, particularly in those with ICA stenosis >50%, TEE should be performed to exclude an additional high risk source for stroke.

Combined Measurement of Carotid Stiffness and Intima-Media Thickness Improves Prediction of Complex Aortic Plaques in Patients With Ischemic Stroke

“…The predictive value of IMT found in this study is slightly lower than in our previous study, 6 which might have been attributable to the fact that we performed TEE only in those patients without clarified stroke etiology after routine diagnostic testing; ie, patients with Ն80% stenosis of the internal carotid artery or atrial fibrillation were not included. Therefore, a certain number of patients with progressive atherosclerosis of the carotid arteries and the aorta are not represented.…”

“…In a previous study, we demonstrated that a normal carotid IMT excluded aortic high-risk sources of cerebral embolism, such as thrombi or plaques Ն4 mm, thus making transesophageal echocardiography (TEE) dispensable for assessment of the aorta. 6 However, in concordance with others, 7 positive predictive values were low.…”

Carotid Artery Atherosclerotic Profile as a Predictor of the Aorta Atherosclerotic Profile in Patients with Cerebrovascular Events

“…This result is in accordance with the findings of Harloff et al [25] in which CIMT ≤0.9 mm had a 95.8% negative predictive value for aorta plaques >4 mm thick. The positive predictive value of CIMT >0.9 mm was only 29.6% but increased to 33% in the presence of plaque in the carotid artery.…”

Use of Carotid Intima-Media Thickness to Identify Patients With Ischemic Stroke and Transient Ischemic Attack With Low Yield of Cardiovascular Sources of Embolus on Transesophageal Echocardiography

“…Our findings are consistent with recent studies suggesting the use of CIMT testing for the exclusion of significant aortic atheroma. 8,9,17 In a prospective study, Harloff et al reported that use of CIMT testing achieved a negative predictive value of 92% for the detection of complex aortic atheroma. 9 Complex aortic plaques are particularly important to exclude because they are associated with a increased risk of recurrent stroke and may warrant therapy with statins or warfarin.…”