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Atherosclerosis. 2019 May;284:181-186. doi: 10.1016/j.atherosclerosis.2019.03.009. Epub 2019 Mar 20.

Large aortic arch plaques correlate with CHADS2 and CHA2DS2-VASc scores in cryptogenic stroke.

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Department of Neurology, Juntendo University Faculty of Medicine, Tokyo, Japan. Electronic address:
Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki, Japan.
Department of Neurology, Iwate Prefectural Central Hospital, Iwate, Japan.
Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan.
Department of Neurology, St. Marianna University School of Medicine, Kanagawa, Japan.
Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan.
Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan.
Department of Neurology, Dokkyo Medical University, Tochigi, Japan.
Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan.
Department of Neurology, Juntendo University Faculty of Medicine, Tokyo, Japan.



Current trends have suggested covert atrial fibrillation as a mechanism of cryptogenic stroke. However, etiological heterogeneity regarding the underlying embolic sources remains a critical issue in cryptogenic stroke.


CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for Embolic Stroke of Undetermined Source/Cryptogenic Stroke) is a multicenter observational registry of cryptogenic stroke patients admitted to participating hospitals, who underwent transesophageal echocardiography between April 2014 and December 2016. We obtained baseline characteristics, radiological and laboratory data, and echocardiographic findings, especially for embolic sources demonstrated on transesophageal echocardiography, and conducted comparisons according to CHADS2 and CHA2DS2-VASc scores (0-1 vs. ≥2, respectively). This study was registered at


The study comprised 677 patients (age, 68.7 ± 12.8 years; 455 males; median National Institutes of Health Stroke Scale score, 2) with cryptogenic stroke. On multiple logistic regression analysis, large aortic arch plaque ≥4 mm (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.51-3.36; p < 0.001), with ulcerative or mobile components (OR, 2.37; 95%CI, 1.38-4.06; p = 0.002), was associated with CHADS2 score ≥2. Large aortic arch plaque ≥4 mm (OR, 3.88; 95%CI, 2.07-7.27; p < 0.001) and ulcerative or mobile components (OR, 3.25; 95%CI, 1.44-7.34; p = 0.005) were linked to CHA2DS2-VASc score ≥2.


The CHALLENGE ESUS/CS registry is a large TEE registry, and clarifies potential embolic etiologies of cryptogenic stroke using TEE. Large aortic arch plaques were associated with high CHADS2 and CHA2DS2-VASc scores, and represented important embolic sources in cryptogenic stroke.


Aortic arch plaque; Cryptogenic stroke; Stroke; Transesophageal echocardiography

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