Aortic Arch Atheroma

See related article, p 1248.Despite the common occurrence of aortic arch atherosclerosis in patients with stroke, evidence-based treatment for this disease has remained fundamentally uncharted territory. After Winter1 first described this phenomena in 1957 from autopsy cases, the association between aortic atheroma and stroke has been a topic of great interest. A strong association with cerebral ischemic events was established by a landmark postmortem study of 500 patients with neurological symptoms; aorta atherosclerotic disease was present in 28% of the patients who perished from a cerebrovascular insult compared with 5% in patients who died from another neurological process.2 Subsequent studies, including prospective cohorts evaluated with transesophageal echocardiography,3 established the presence of aortic arch atheroma (especially plaques >4 mm or mobile plaques) as a risk factor for cerebrovascular disease and a high risk factor for recurrent stroke.4Until now, however, retrospective studies and subgroup analysis of larger trials have provided the sole source of guidance for treating patients with severe aortic arch disease and cryptogenic stroke.5 In fact, the latest guidelines from the American College of Cardiology Foundation and the American Heart Association state that for significant aortic atherosclerosis (>4 mm) there is no definitive therapeutic regimen for this high-risk patient group because no randomized trial has been completed.6 These guidelines proceed to state that either oral anticoagulation or antiplatelet therapy is a reasonable option for antithrombotic therapy. In this issue of Stroke , Amarenco et al7 describe the first prospective randomized trial addressing …