Welcome to Stroke Education.CO.UK

Learning objectives

  • Risks factors for those at risk of artery to artery stroke
  • Identify those at risk of artery to artery stroke
  • Appropriate management of risks

    Causes of Artery to Artery stroke

    The main source of embolism in total is from the valves and chambers of the left side of the heart due to inherent structural defects and underlying atrial fibrillation. Cardioembolic stroke is dealt with in this location. The other main cause is embolism from lesions within the arteries to occlude more distal smaller calibre arteries with thrombus.

    The main cause of this is embolism comes from aortic or subclavian or internal carotid atheroma. Another important cause is thrombus forming over areas of arterial dissection. Aortic atheroma is detectable by TOE is significantly more common in stroke patients than health controls. Atheromatous plaques may be a source of embolic material through rupture and thrombus formation.

    Clinical

    The presentation may be sudden with an acute carotid or intracranial vessel occlusion and corresponding TIA or stroke neurology. A carotid bruit may be heard if there is carotid disease. Patient may have coexisting coronary artery disease, be a smoker or have hyperlipidaemia or hypertension.

    CauseAbout
    Carotid Atherosclerotic disease Usually rupture of an unstable atherosclerotic plaque leads to overlying platelets activation and clot formation which embolises
    Aortic Atherosclerotic diseaseUsually rupture of an unstable atherosclerotic plaque which releases debris into the carotids/vertebrals
    Subclavian Atherosclerotic diseaseUsually rupture of an unstable atherosclerotic plaque which releases debris into the vertebrals
    Carotid Artery Dissection Usually rupture of the intima with overlying platelets activation and clot formation which embolises
    Vertebral Artery Dissection Usually rupture of the intima with overlying platelets activation and clot formation which embolises
    Intracranial Artery Atherosclerotic Commoner in Afro-carribeans. Can be plaque rupture and embolisation

    Artery to artery emboli

    Management: If there is > 50% carotid stenosis which is symptomatic and the likely source of emboli then carotid endarterectomy (or stenting) should be considered. Antiplatelets are started and in some cases dual antiplatelets are sometimes considered. Smoking cessation is key. Aggressive lipid lowering, blood pressure control and management of vascular risk factors is advocated. Finally, most embolism is thrombotic but other rare sources of emboli are air, fat, cholesterol, bacteria, tumour cells, and particulate matter from injected drugs should be considered in rare cases. Carotid plaque


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