Aortogenic Embolism Research Articles

Left Distal Transradial Approach for the Treatment of a Sacral Extradural Arteriovenous Fistula: A Technical Note and Literature Review

Sacral extradural arteriovenous fistula (SEAVF) is relatively rare, and its etiology is unknown. They are mostly fed by the lateral sacral artery (LSA). For endovascular treatment, both the stability of the guiding catheter and accessibility of the microcatheter to the fistula, distal to the LSA are required for sufficient embolization of the fistulous point. Cannulation of these vessels requires either crossover at the aortic bifurcation or retrograde cannulation using the transfemoral approach. However, atherosclerotic femoral and tortuous aortoiliac vessels can make the procedure technically difficult. Although the right transradial approach (TRA) can reduce this difficulty by straightening the access route, a potential risk remains for cerebral embolism because it passes the aortic arch. Herein, we present a case of successful embolization of a SEAVF using a left distal TRA. We report a case of a 47-year-old man with SEAVF treated with embolization using a left distal TRA. Lumbar spinal angiography showed a SEAVF with an intradural vein through the epidural venous plexus fed by the left LSA. A 6-French guiding sheath was cannulated into the internal iliac artery via the descending aorta using the left distal TRA. A microcatheter could be advanced into the extradural venous plexus over the fistula point from the intermediate catheter placed at the LSA. Embolization with coils and n-butyl cyanoacrylate was successfully performed. The SEAVF completely disappeared on neuroimaging, and the patient gradually recovered. Left distal TRA could be a useful, safe, and less invasive option for the embolization of SEAVF, especially for patients with high-risk factors for aortogenic embolism or puncture site complications.

Aortogenic emboli might play an important role in the development of delayed leukoencephalopathy after mechanical thrombectomy

AbstractA 76‐year‐old man developed delayed leukoencephalopathy 3 weeks after successful mechanical thrombectomy for middle cerebral artery occlusion. Pathological evaluation of the removed thrombus showed cholesterol clefts and fibrin with inflammatory cell infiltration, which were compatible with aortogenic embolism. Delayed leukoencephalopathy following recanalization in ischemic stroke has only been rarely reported, and the etiology in all the previously reported cases was cardioembolism, which is distinct from our case. Through this case, we considered that disruption of the blood–brain barrier caused by thrombus composed of cholesterol crystals and fibrin could be a trigger for delayed leukoencephalopathy. This case should provide better understanding of delayed leukoencephalopathy after acute ischemic stroke.

Teaching Video NeuroImage: ECG-Gated 4-D CT Angiography Can Detect Aortic Plaque Mobility in Cryptogenic Stroke.

An 80-year-old man developed an acute ischemic stroke and right posterior cerebral artery (PCA) occlusion (figure, A and B). Cardiac and carotid artery ultrasound examinations and 24-hour ECG monitoring did not identify any embolic sources. ECG-gated 4-D CT angiography (CTA) showed a noncalcified plaque with a superimposed mobile component on the ascending aorta (figure, C, and video 1). Virtual angioscopy using the datasets from ECG-gated 4-D CTA showed seaweed-like mobile component in the 3-D view (figure, D, and video 1). This was diagnosed as aortogenic embolism. The antithrombotic therapy was changed from clopidogrel to warfarin with an international normalized ratio of 2.0–3.0, and low-density lipoprotein cholesterol levels were controlled to less than 70 mg/dL by rosuvastatin.

Abstract P702: How Many Cryptogenic Stroke Patients Should Be Candidates for Patent Foramen Ovale Closure?

Background and Purpose: Recent several studies demonstrated that percutaneous patent foramen ovale (PFO) closure reduced the risk of stroke recurrence for patients with cryptogenic stroke (CS) and PFO. Our aim of this retrospective study is to survey the frequency of CS, which can be an indication of PFO closure. Methods: Subjects were consecutive stroke patients with symptomatic ischemic lesion detected by magnetic resonance imaging. Of them, CS were extracted according to exclusion of small-vessel collusion, large-artery atherosclerosis, cardioembolism, definite case of aortogenic embolism, and distinctive causeof ischemic stroke such as arterial dissection, hypercoagulable state and so on. After that, we selected patients in accordance with clinical guideline of PFO closure recommended by the Japanese Stroke Association (Figure). We analyzed the prevalence of CS with right-to-left shunt (RLS) as a good and recommended candidates for PFO closure. Results: Among 1,374 ischemic stroke patients from October 2012 to September 2019 , CS were 240 patients (83 females, mean age of 66 years, 17% of subjects). Of them, 100 patients (42%) had RLS (PFO; 65, atrial septal defect; 1, pulmonary arteriovenous fistula; 1, positive on transcranial Doppler (not performed in TEE) including 21 cases of definite of paradoxical embolism. In 65 patients of CS with PFO, 30 patients younger than 60 years (13% of CS) were good candidates for PFO closure. Moreover, 22 of 1,374 (1.6%) patients who were recommended candidates had one or more high risk factors of PFO, for example large shunt, atrial septal aneurysm, and the presence of shunt at rest (Figure). Conclusions: In our preliminary survey, 2% of acute ischemic stroke should be PFO closure candidates.

Abstract WP175: Similarities and Differences in Atherothrombosis, Aortogenic Embolism, and Branch Atheromatous Disease

Introduction: Branch atheromatous disease (BAD) and aortogenic embolism (Ao) are categorized as “unclassified” in accordance with “The Trial of Org 10172 in Acute Stroke Treatment (TOAST)” classification; however, their pathophysiology is similar to that of atherothrombosis (AT). We compared these categories of ischemic cerebrovascular disease (iCVD). Methods: A consecutive series of 1,079 patients with iCVD 7 days within onset were included. According to TOAST classification, 180 (16.7%), 159 (14.7%), 251 (23.3%), and 489 (45.3%) patients were classified as AT, lacunar, cardiogenic embolism, and unclassified, respectively. Of the unclassified, 145 and 82 patients were re-classified as Ao and BAD, respectively. Results: Mean age was 75.3, 75.7, and 73.0 years in AT, Ao, and BAD, respectively. Male predominance was most apparent in AT (62.6%), followed by BAD (54.7%) and Ao (54.6%). Prevalence of hypertension, diabetes mellitus, and dyslipidemia was 80.7%, 39.4%, and 53.6% in AT, 83.8%, 30.5%, and 53.9% in Ao, and 74.7%, 33.3%, and 57.3% in BAD, respectively. Hemodialysis was more common in Ao (6.7%) than in BAD (2.7%) and AT (0.7%). Median (IQR) of National Institutes of Health Stroke Scale score on admission and at discharge was 3 (1-6) and 1 (1-3) in AT, 2 (0-4) and 0 (0-2) in Ao, and 5 (3-6) and 2 (1-5) in BAD, respectively. Neurological deterioration was more frequent in BAD (30.7%) than in AT (16.1%) and Ao (2.6%). Median (IQR) of modified Rankin scale (mRS) prior to iCVD and at discharge was 0 (1-2) and 2 (0-4) in AT, 0 (0-1) and 1 (0-2.25) in Ao, and 0 (0-1) and 2 (1-4) in BAD, respectively. The percentage of patients with mRS 2 or better prior to onset and at discharge was 83.2% and 63.9% in AT, 88.3% and 75.3% in Ao, and 89.3% and 58.7% in BAD, respectively. Recurrence of iCVD at 3 months after onset was more frequent in AT (12.9%) than in Ao (9.7%) and BAD (5.3%). Conclusions: Ao and BAD have many similarities with AT, but there are some differences. In Ao, symptoms were often mild and rarely worsened, but with recurrence of up to 10%. There were many dialysis patients in Ao. Worsening was observed in more than 30% of patients, and outcomes were often poor, but recurrences were few in BAD patients.

Abstract TP85: The Characteristics of Diffusion Weighted Image Patterns in Different Potential Embolic Source

Introduction: Few studies have focused on the characteristics of diffusion weighted image (DWI) pattern in different embolic stroke. Hypothesis: Studying the DWI pattern in patients with embolic stroke of determined source may help presume the cause of ESUS. Methods: From a prospective registry of 1,764 consecutive patients with acute ischemic strokes , we selected 422 patients with embolic stroke of determined source comprising of 4 groups as follows. 1: continuous atrial fibrillation (cAf) (n=232), 2: paroxysmal Af (pAf) (n=99), 3: paradoxical embolism associated with the foramen ovale (PXE) (n=48) and 4: aortogenic embolism associated with aortic atheroma (≥4mm, ulcer or mobile) (AoE) (n=56). The DWI patterns were classified as follows. First, cortical infarcts were classified according to the affected area of middle cerebral artery (MCA) segments such as M1: the horizontal segment, M2: after the bifurcation segments within the Sylvian fissure and M4: terminal cortical branch. Among patients with M1, pure striatocapsular infarction (SCI) was identified. Moreover, patients with the M2 and the M4 were divided into 2 groups including parietal ascending branches and temporal descending branches. Second, cortical and subcortical small multiple infarcts (<20mm) (sMI) were identified. Finally, infarcts in the anterior cerebral artery (AC) and the posterior circulation (PC) were identified. Results: The distribution of the DWI patterns in the 4 groups (cAf: pAf: PXE: AoE, %) are as follows: M1 (n=100) (76.0: 17.0: 7.0: 0), M2 (n=118) (59.3: 30.5: 7.6: 2.5), M4 (n=50) (50.0: 26.0: 18.0: 6.0), SCI (n=20) (2.1: 4.0: 14.5: 0), sMI (n=49) (18.3: 16.3: 18.3: 46.9), AC (n=13) (46.1: 46.1: 0: 7.6), and PC (n=92) (50.0: 20.6: 15.2: 14.1). Among 162 patients with M2 and M4 infarction, there were 57 involvements of descending branches (35.1%), comprising of 38 patients (41.7%) in cAf, 17 (34.6) in pAf, 1 (6.2) in PXE and 1(7.4) in AoE. Conclusions: Infarct sized was large in the Af groups. The involvement of inferior division of the MCA was exclusively found in the Af groups. The SCI was most prevalent in the PX. Multiple small scattered pattern was characteristically found in the AoE. The different DWI patterns relatively well associated with different embolic source.

Abstract T MP97: Efficacy of Poststroke Intensive Rosuvastatin Treatment for Aortogenic Embolic Stroke: Episteme Trial

Background: Large atheromatous aortic plaques (AAPs) are associated with stroke recurrence. Rosuvastatin is a potent lipid-lowering agent and repress atherosclerosis. Whether rosuvastatin has anti-atherogenic effect for AAPs in stroke patients has been unclear. We performed repeated transesophageal echocardiography (TEE) examinations and analyzed the changes of AAPs after rosuvastatin treatment in stroke patients. Methods: This trial is prospective randomized open label study. Inclusion patients were acute ischemic stroke with hypercholesterolemia and AAPs ≥4 mm in thickness on TEE. The patients are randomly assigned to either a group treated with 5 mg/day rosuvastatin or a control group. Primary endpoint is the changes in volume and composition of AAPs after 6 months using TEE. Biochemical findings are analyzed. By using repeated TEE and binary image analysis, we compared the dynamic changes in plaque composition of AAPs before and after therapy in the two groups. Results: 102 patients were undergoing TEE, and 23 had AAPs greater than 4 mm in thickness. Of them, 16 patients (age, 68±9 years; 16 male) with acute ischemic stroke were undergoing repeated TEE and enrolled to the study. The rosuvastatin-treated and control groups had 9 and 7 patients, and 16 and 16 AAPs ≥4mm, respectively. In the rosuvastatin-treated group, the changes in low-density lipoprotein-cholesterol (LDL-C), non-high-density lipoprotein-cholesterol (non-HDL-C), and LDL-C/HDL-C ratio from baseline to end of follow-up were -42.7±10.2%, -38.5±11.1%, and -41.9±8.9%, respectively, which reached significant differences compared to the control (P<0.05). In repeated TEE, there was no significant difference in changes of plaque size among two groups. Rosuvastatin significantly increased high-echoic plaques area from baseline to end of follow-up, whereas the control group showed decrease in high-echoic plaques area (58.2±63.7 vs –14.3±31.5, P<0.001). Conclusions: Rosuvastatin improved lipid profiles, and exerted robust morphological change of AAPs from lipid-rich to fibrous content. The EPISTEME trial provided an evidence for a therapeutic strategy for aortogenic brain embolism.

Rationale and Design of the EPISTEME Trial: Efficacy of Post-Stroke Intensive Rosuvastatin Treatment for Aortogenic Embolic Stroke

Large atheromatous aortic plaques (AAPs) are associated with stroke recurrence. Rosuvastatin is a potent lipid-lowering agent and suppresses carotid and coronary artery atherosclerosis. It is unclear whether rosuvastatin has anti-atherogenic effects against AAPs in stroke patients. We designed a clinical trial in stroke patients to analyze changes in AAPs after rosuvastatin treatment using repeated transesophageal echocardiography (TEE). This trial is a prospective randomized open label study. Inclusion criteria were patients were ischemic stroke with hypercholesterolemia and AAPs ≥ 4 mm in thickness. The patients are randomly assigned to either a group treated with 5 mg/day rosuvastatin or a control group. Primary endpoint is the changes in volume and composition of AAPs after 6 months using transesophageal echocardiography (TEE). Biochemical findings are analyzed. By using repeated TEE and binary image analysis, we will be able to compare the dynamic changes in plaque composition of AAPs before and after therapy in the two groups. The EPISTEME trial will provide information on the changes in plaque volume and composition achieved by improvement of lipid profiles with rosuvastatin therapy in stroke patients with aortic atherosclerosis. The results of the study may provide evidence for a therapeutic strategy for aortogenic brain embolism. This study is registered with UMIN-CTR (UMIN000010548).

大動脈原性脳塞栓症・奇異性脳塞栓症(卵円孔開存・深部静脈血栓症)(1.脳神経外科医が知っておきたい全身合併症,<特集>全身脈管病としての脳卒中)

大動脈原性脳塞栓症・奇異性脳塞栓症(卵円孔開存・深部静脈血栓症)(1.脳神経外科医が知っておきたい全身合併症,<特集>全身脈管病としての脳卒中)

Relation Between Mitral Annular Calcium and Complex Aortic Atheroma in Patients With Cerebral Ischemia Referred for Transesophageal Echocardiography

Mitral annular calcium (MAC) has been shown to be an independent predictor of stroke, but the basis for this association remains incompletely defined. This study was conducted to investigate the extent to which aortogenic embolism may mediate the MAC-stroke relation. In a cross-sectional study of patients referred for transesophageal echocardiography for the evaluation of cerebral ischemia, the relation between MAC and proximal and distal complex aortic atheroma (CAA) was assessed. In 419 patients composing the study cohort, MAC was associated with atherosclerosis risk factors, previous cardiovascular disease, atrial fibrillation, ipsilateral large-artery stenosis, left-sided cardiac abnormalities, and aortic valve calcium. MAC was associated with CAA of the proximal and distal thoracic aorta in unadjusted analyses, and these associations became stronger with increasing MAC severity. After adjustment for clinical and echocardiographic covariates, MAC exhibited a significant association with proximal and distal CAA in the entire cohort. In patients without alternative potential mechanisms for cerebral ischemia, however, the relation with proximal CAA became more pronounced (adjusted odds ratio 2.74, 95% confidence interval 1.22 to 6.16), but that for distal CAA changed little and became nonsignificant (adjusted odds ratio 1.97, 95% confidence interval 0.87 to 4.45). In conclusion, MAC was significantly associated with proximal and distal CAA independent of clinical and echocardiographic covariates in this cohort with cerebral ischemia, but in subjects without identifiable alternative mechanisms, the magnitude of the relation increased only for proximal CAA. These findings support the role of proximal CAA as a direct mediator of the increased stroke risk associated with MAC.

Aortogenic embolism is a possible mechanism of cryptogenic stroke

Aortogenic embolism is a possible mechanism of cryptogenic stroke

Aortic atherosclerotic plaques as a source of systemic embolism

Objectives. Our study was designed to determine the significance of aortogenic embolism in an unselected autopsy collective.Background. Although embolism arising from atherosclerotic plaques in the aorta has been acknowledged, the role of aortic atheromatosis among other well known sources of embolism remains to be further clarified.Methods. We examined the proximal part of the arterial system with regard to the presence of atherosclerotic lesions as well as cardiac changes in 120 consecutive necropsy studies. Pathologic evidence of embolic events was recorded. Clinical and neuropathologic data were also surveyed in all patients.Results. Among atherosclerotic lesions, fibrous plaques (p < 0.05) and calcified (p < 0.0001) and ulcerated lesions (p < 0.0001) as well as thrombi (p < 0.005) were observed significantly more frequently in the aortic arch and in the descending aorta than in the ascending aorta, whereas fatty streaks were distributed uniformly. In 40 (33%) of the 120 patients, we found pathologic evidence of arterial embolization. Multiple logistic regression analysis revealed a significant correlation between embolism and complicated atherosclerotic plaques in the aortic arch (odds ratio [OR] 5.8, 95% confidence interval [Cl] 1.1 to 31.7, p < 0.05), severe ipsilateral carotid artery disease (OR 3.1, 95% CI 3.1 to 45.3, p < 0.001) and atrial fibrillation (OR 3.5, 95% CI 1.1 to 9.9, p < 0.05).Conclusions. Complicated atherosclerotic plaques in the aortic arch represent an independent risk factor for systemic embolism similar to atrial fibrillation and severe atherosclerosis of the carotid arteries.