Aortic arch atheroma

Aortic arch atheroma is now increasingly diagnosed by transesophageal echocardiography in patients with TIAs or ischemic stroke, but so far there are no surgical, or indeed medical, treatment options over and above controlling vascular risk factors and antiplatelet drugs. One trial of medical treatment has been started, the Aortic Arch Related Cerebral Hazard (ARCH) trial (MacLeod et al. 2004). 

Homocysteine—still under study, but hyperhomocysteinemia may be related to increased stroke risk Asymptomatic carotid stenosis Subclinical disease—aortic arch atheromas Multiple Risk Factors—Stroke Is Increased by the Presence of Multiple Risk Factors Framingham profile... 

A transesophageal echocardiogram is a more sensitive test for left atrial thrombus. It is also effective in examining the aortic arch for atheroma, another potential source of emboli. 

Pathological, angiographic and ultrasonic studies show that the most common extracranial sites for atheroma are the aortic arch, the proximal subclavian arteries, the carotid... 

Approximately 90% of atherothromboembolic strokes in whites are caused by atheroma in the extracranial vessels, whereas intracranial disease appears to be equally important in blacks and Hispanics (Sacco et al. 1995 Wityk et al. 1996). Atheromatous disease in the ascending aorta and the aortic arch is increasingly recognized as a source of cerebral emboli and an independent risk factor for ischemic stroke in vivo (Amarenco et al. 1994 Jones et al. 1995 Heinzlef et al. 1997 MacLeod et al. 2004). 

Macleod MR, Amarenco P, Davis SM et al. (2004). Atheroma of the aortic arch an important and poorly recognized factor in the aetiology of stroke. Lancet Neurology 3 408-414... 

Tenderness of the branches of the external carotid artery (occipital, facial, superficial temporal) points towards giant cell arteritis. Tenderness of the common carotid artery in the neck can occur in acute carotid occlusion but is more Ukely to be a sign of dissection, or arteritis. Absence of several neck and arm pulses in a young person occurs in Takayasu s arteritis (Ch. 6). Delayed or absent leg pulses suggest coarctation of the aorta or, much more commonly, peripheral vascular disease. Other causes of widespread disease of the aortic arch are atheroma, giant cell arteritis, syphihs, subintimal fibrosis, arterial dissection and trauma. 

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