Embolic Stroke of Undetermined Source and Carotid Intraplaque Hemorrhage on MRI : A Systemic Review and Meta-Analysis.

Mark, Ian T; Nasr, Deena M; Huston, John; de Maria, Lucio; de Sanctis, Paolo; Lehman, Vance T; Rabinstein, Alejandro A; Saba, Luca; Brinjikji, Waleed

BACKGROUND Embolic stroke of undetermined source (ESUS) has traditionally discounted the significance of internal carotid artery stenosis of <50%; however, recent studies have examined the role of carotid artery intraplaque hemorrhage (IPH) as an etiology in nonstenotic carotid arteries. We performed a systemic review of the literature to determine the prevalence of carotid artery IPH on magnetic resonance imaging (MRI) of the vessel wall in patients with ESUS. METHODS We used PubMed, Epub ahead of print, Ovid MEDLINE in-process and other non-indexed citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane central register of controlled trials, Ovid Cochrane database of systematic reviews and Scopus. Our study consisted of all case series with >10 patients with IPH and ESUS published through October 2018. Additionally, we included 123 patients from an institutional database from 2015-2019. Random effects meta-analysis was used for pooling across studies. Meta-analysis results were expressed as odds ratio (OR) with respective 95% confidence intervals (CI). RESULTS A total of 7 studies with 354 patients were included. The mean age was 67.5 years old. The overall prevalence estimate for prevalence of IPH ipsilateral to the ischemic lesion was 25.8% (95% CI 13.1-38.5). The odds of having IPH on the ipsilateral side versus the contralateral side was 6.92 (95% CI 3.04-15.79). CONCLUSION Patients with ESUS have IPH in the carotid artery ipsilateral to the ischemic stroke in 25.8% of cases. Carotid artery vessel wall MRI should be considered as part of the standard work-up in patients with ESUS.