Forcing open doors using images: ruptured aortic arch atheroma visualized by TEE in a stroke patient

Aortic arch atheroma is a major source of cerebral embolism and transesophageal echocardiography (TEE) is the gold standard for the detection of aortic atheroma and for morphological analysis of the plaques. Computed tomography angiography (CT angiography) of the aorta is helpful, but lacks sensitivity (1). Here we report an illustration with images that reminds the practitioners that we are, the role of TEE in the detection and the characterization of aortic atheroma in ischemic stroke of undetermined cause. A 66-year-old man with a history of tobacco use and recently stopped alcohol abuse was admitted for the assessment of a new onset of right lateral homonymous hemi-anopsia. Brain magnetic resonance imaging showed a left occipital ischemic stroke. A full evaluation failed to find a cause to this stroke. Transthoracic echocardiography was normal and CT angiography of the aortic arch was not contributory at the first reading. A transesophageal echocardiography (TEE) was then requested. The conventional imaging using a multiplane TEE probe showed protruding and ulcerated complex aortic arch atheroma (Fig. 1a). The ‘Biplane prepare’ modality, a new echocardiographic technique which allows simultaneous viewing of two different planes (Fig. 1b). After a slight modification of the section plane (Fig. 1c,d), this imaging modality showed a ruptured atherosclerotic plaque cap, not visualized by the conventional multiplane mode. Color Doppler imaging showed in the ‘Biplane prepare’ view, a circulating flow (arrow, Fig. 1d), allowing the authentication of plaque rupture. Correspondence: Nadia Benyounes*, Cardiology Unit, Fondation Adolphe de Rothschild, Paris 75019, France. Email: nbenyounes@fo-rothschild.fr