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Many strokes from a single non-stenosing plaque: from the last event a light to the first one?

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January 2025

Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Via Amendola 2, Reggio Emilia, 42122, Italy.

Introduction: Large artery atherosclerosis is a relevant cause of ischemic stroke. Beyond carotid artery stenosis ≥ 50%, causative in etiological classification of stroke, non-stenosing plaques are an increasingly reported cause of stroke with embolic pattern.

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Adequate secondary prevention in survivors of intracerebral hemorrhage (ICH) who also have atrial fibrillation (AF) is a long-standing clinical dilemma because these patients are at increased risk of recurrent ICH as well as of ischemic stroke. The efficacy and safety of oral anticoagulation, the standard preventive medication for ischemic stroke patients with AF, in ICH patients with AF are uncertain. PRESTIGE-AF is an international, phase 3b, multi-center, randomized, open, blinded end-point assessment (PROBE) clinical trial that compared the efficacy and safety of direct oral anticoagulants (DOACs) with no DOAC (either no antithrombotic treatment or any antiplatelet drug).

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Transcarotid artery revascularization (TCAR) is a novel method to treat severe stenosis of the carotid artery with minimal embolization. During TCAR, flow reversal system redirects blood from the internal, external, and common carotid arteries into the femoral vein through a filter system to prevent debris and microparticles from entering the cerebral circulation. Transcranial Doppler (TCD) monitoring allows real-time detection of blood flow in the cerebral arteries during the operation and informs the surgeon of flow changes or possible emboli.

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Aims: Atherogenic dyslipidemia (AD) is regarded as a residual risk of cardiovascular diseases characterized by low high-density lipoprotein cholesterol (HDL-C) and high triglyceride (TG) levels and related to the intracranial stenosis of atheromatous thrombotic brain infarction (ATBI). Further, atherosclerosis is possibly related to another stroke subtype, including cryptogenic stroke (CS). In particular, an aortic complicated lesion (ACL) is a notable embolic source of CS, since recurrence of aortogenic brain embolism is not rare.

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