title: Do stroke patients with normal carotid arteries require TEE for exclusion of relevant aortic plaques?
abstract: OBJECTIVE
  This study investigated (a) the hypothesis that stroke patients with aortic atheroma would show comparable atherosclerotic changes in the carotid arteries, which are easily accessible for ultrasound evaluation and (b) the possibility of carotid duplex sonography as a replacement for transoesophageal echocardiography (TEE) for the exclusion or prediction of relevant aortic plaques.
  
  
  METHODS
  In 301 consecutive patients (mean age 62 years) with acute cerebral ischaemia, two dimensional ultrasound measurements were taken of common carotid artery intima media thickness (IMT) and maximal plaque area (PA) and the local degree of internal carotid artery (ICA) stenosis were determined. Maximal aortic wall thickness (AWT) was assessed by TEE.
  
  
  RESULTS
  An IMT < or =0.9 mm yielded a negative predictive value (NPV) of 95.8% for exclusion of aortic atheromas > or =4 mm and an NPV of 100% for the exclusion of aortic thrombi. However, positive predictive value of IMT >0.9 mm was low (29.6%), increasing only slightly in the presence of carotid plaques (33%). Incidence of aortic thrombi was significantly higher with > or =50% compared with <50% ICA stenosis (11.3% v 3.9%, respectively). IMT and PA correlated moderately with AWT (r = 0.47, r = 0.53, respectively; p<0.001). Systolic blood pressure, coronary heart disease and peripheral artery disease, increased IMT, and ICA stenosis > or =50% were independently related to AWT > or =4 mm.
  
  
  CONCLUSIONS
  A high NPV of normal carotid ultrasound does not support routine TEE for the exclusion of complex aortic plaques as a high risk source of cerebral embolism. However, in patients with carotid atherosclerosis, particularly in those with ICA stenosis > or =50%, TEE should be performed to exclude an additional high risk source for stroke.
authors.affiliation: Department of Neurology and Clinical Neurophysiology, Albert-Ludwigs-Universität, Breisacher Strasse 64, D-79106 Freiburg, Germany. harloff@nz.ukl.uni-freiburg.de
authors.forename: A
authors.initials: A
authors.lastname: Harloff
authors.forename: M
authors.initials: M
authors.lastname: Handke
authors.forename: A
authors.initials: A
authors.lastname: Geibel
authors.forename: E
authors.initials: E
authors.lastname: Oehm
authors.forename: B
authors.initials: B
authors.lastname: Guschlbauer
authors.forename: M
authors.initials: M
authors.lastname: Olschewski
authors.forename: A
authors.initials: A
authors.lastname: Hetzel
mesh_terms: D000368:Aged; D001018:Aortic Diseases / Q000150:complications*; D050197:Atherosclerosis / Q000150:complications*; D002545:Brain Ischemia; D002339:Carotid Arteries / Q000000981:diagnostic imaging* / Q000473:pathology*; D016893:Carotid Stenosis / Q000000981:diagnostic imaging; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012307:Risk Factors; D020521:Stroke / Q000209:etiology*; D017539:Tunica Intima / Q000000981:diagnostic imaging / Q000473:pathology