Aortic Atherosclerosis Determines Increased Retrograde Blood Flow as a Potential Mechanism of Retrograde Embolic Stroke
Authors: Wehrum Thomas , Guenther Felix , Vach Werner , Gladstone Beryl Primrose , Wendel Sarah , Fuchs Alexander , Wu Kehzong , Maurer Christoph Johannes , Harloff Andreas 
Published: January 2017

<b><i>Background:</i></b> Retrograde brain embolization from complex plaques of the proximal descending aorta (DAo) has been identified as a new potential mechanism of stroke. Our purpose was to identify predictors of increased retrograde aortic blood flow indicating an elevated risk of brain embolization from the DAo. <b><i>Methods:</i></b> A total of 485 patients with acute ischemic stroke were prospectively included and underwent transesophageal echocardiography. Blood flow velocities in the proximal DAo were studied using 2D pulse-wave Doppler ultrasound. Velocity-time integrals (VTI) were calculated for antegrade and retrograde velocity directions. The ratio (VTI<sub>retrograde</sub>/VTI<sub>antegrade</sub>) was used to estimate retrograde flow extent. Associations between patient demographics, cardiovascular risk factors, echocardiographic parameters, and VTI<sub>ratio</sub> were analyzed using multivariate linear regression. <b><i>Results:</i></b> Retrograde blood flow in the DAo occurred in all patients. Velocity profiles in the proximal DAo were as follows (mean ± SD): VTI<sub>antegrade</sub> = 21.1 ± 6.5, VTI<sub>retrograde</sub> = 11.0 ± 3.6, and VTI<sub>ratio</sub> = 0.54 ± 0.16. Diameter (<i>r</i> = 0.25, <i>p < </i>0.001), presence of complex plaques (<i>r</i> = 0.12, <i>p</i> = 0.007), and reduced strain of the DAo (<i>r</i> = -0.23, <i>p < </i>0.001) had significant partial effects in a predictor model based on predefined variables, which predicted 26% (adjusted <i>R</i><sup>2</sup> = 0.26) of the variance in VTI<sub>ratio</sub>. A unit increase in the DAo diameter was associated with a 2% increase in VTI<sub>ratio</sub> (95% CI 1-2.8%, <i>p < </i>0.001). Presence of complex plaques increased VTI<sub>ratio</sub> by 7% (95% CI 2-13%, <i>p</i> = 0.007) and an increase in strain by 0.1 indicated a decrease in VTI<sub>ratio</sub> by about 11% (95% CI 6.2-15.5%, <i>p</i> < 0.001). Complex atheroma was found in the proximal DAo of 79 subjects, of which 40 (50.6%) had a VTI<sub>ratio</sub> above average (VTI<sub>ratio</sub> ≥0.54) compared to 87 of 261 (33.3%) patients without any complex plaques (<i>p < </i>0.001). Twenty-five of 79 (31.7%) patients with complex DAo plaques had a VTI<sub>ratio</sub> ≥0.60, which indicates a high likelihood of retrograde pathline length of ≥3 cm and thus increased risk of retrograde cerebral embolization. Stroke etiology of those 25 patients was determined in 13 and cryptogenic in 12 cases. <b><i>Conclusions:</i></b> Retrograde blood flow in the DAo was found in all stroke patients. However, it increased further in patients with concomitant complex plaques, low strain, and/or large aortic diameter, that is, in those with atherosclerosis of the DAo. Accordingly, such patients may be predisposed to retrograde embolization in case of occurrence of a complex plaque in proximity to a brain-supplying artery.