Imaging Biomarkers and Prevalence of Complex Aortic Plaque in Cryptogenic Stroke: A Systematic Review

• Type of Material: Article
• Authors: Yu Sakai, University of Pennsylvania; Quy Cao, University of Pennsylvania; Jeremy Rubin, University of Pennsylvania; Jens Witsch, University of Pennsylvania; Dan Isaac Georges Cohen-Addad, Emory University; Katyucia de Macedo Rodrigues, Greensboro Radiology; Maria Begoña Coco-Martin, University of Valladolid; Pouyan Pasya, University of Pennsylvania; Jesús Juega, Vall d'Hebron University; Zhaoyang Fan, University of Southern California; Scott E. Kasner, University of Pennsylvania; Brett L. Cucchiara, University of Pennsylvania; Jae W. Song, University of Pennsylvania
• Language: English
• Date: 2023-11-28
• Publisher: Wiley
• Publication Version: Final Published Version
• Copyright Statement: © 2023 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): https://doi.org/10.1161/JAHA.123.031797
• Title of Journal or Parent Work: Journal of the American Heart Association
• Volume: 12
• Issue: 23
• Start Page: e031797
• Grant/Funding Information: The work is supported by the National Heart, Lung, and Blood Institute (R01 HL147355, Z.F.), American Heart Association Career Development Awards (938082 to J.W.S.; 23CDA1053561 to J.W.), Vice Provost for University Research Foundation (J.W.S.), and Institute of Translational Medicine and Therapeutics (J.W.S.).
• Keywords: aorta; stroke; biomarker; imaging; atherosclerosis
• Research Categories: Health Sciences, Public Health; Health Sciences, General

Abstract

Background Complex aortic plaque (CAP) is a potential embolic source in patients with cryptogenic stroke (CS). We review CAP imaging criteria for transesophageal echocardiogram (TEE), computed tomography angiography (CTA), and magnetic resonance imaging and calculate CAP prevalence in patients with acute CS. Methods and Results PubMed and EMBASE databases were searched up to December 2022 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guideline. Two independent reviewers extracted data on study design, imaging techniques, CAP criteria, and prevalence. The Cochrane Collaboration tool and Guideline for Reporting Reliability and Agreement Studies were used to assess risk of bias and reporting completeness, respectively. From 2293 studies, 45 were reviewed for CAP imaging biomarker criteria in patients with acute CS (N=37 TEE; N=9 CTA; N=6 magnetic resonance imaging). Most studies (74%) used ≥4 mm plaque thickness as the imaging criterion for CAP although ≥1 mm (N=1, CTA), ≥5 mm (N=5, TEE), and ≥6 mm (N=2, CTA) were also reported. Additional features included mobility, ulceration, thrombus, protrusions, and assessment of plaque composition. From 23 prospective studies, CAP was detected in 960 of 2778 patients with CS (0.32 [95% CI, 0.24–0.41], I 2=94%). By modality, prevalence estimates were 0.29 (95% CI, 0.20–0.40; I 2=95%) for TEE; 0.23 (95% CI, 0.15–0.34; I 2=87%) for CTA and 0.22 (95% CI, 0.06–0.54; I 2=92%) for magnetic resonance imaging. Conclusions TEE was commonly used to assess CAP in patients with CS. The most common CAP imaging biomarker was ≥4 mm plaque thickness. CAP was observed in one‐third of patients with acute CS. However, high study heterogeneity suggests a need for reproducible imaging methods.