CTA Plaque-RADS Predicts Ipsilateral Recurrence in Embolic Stroke

Embolic stroke of undetermined source (ESUS) remains a diagnostic and therapeutic challenge, representing a subset of ischemic strokes where the source of embolism is not identified despite standard diagnostic protocols. Secondary prevention remains controversial, as a 2024 meta-analysis of 13,970 patients found that direct oral anticoagulants did not significantly reduce recurrent stroke risk compared to aspirin (RR 0.95; 95% CI 0.83, 1.08; p = 0.45) [1]. This lack of overall benefit likely reflects the etiological heterogeneity of the condition, which includes diverse sources such as occult atrial fibrillation and paradoxical embolism through a patent foramen ovale (a persistent opening between the atria that may facilitate the passage of venous thrombi into the systemic circulation) [2, 3]. Recent data indicate that nonstenotic carotid plaques (atherosclerotic lesions that do not meet traditional criteria for high-grade narrowing) with high-risk features are present in 31% of cases ipsilateral to the stroke (95% CI 27, 36%) and may be a primary driver of recurrence [4]. Furthermore, specific high-risk characteristics like ulcerated plaques have been associated with an eightfold increase in the risk of recurrent events (OR 8.2; 95% CI 1.02, 66.07; p = 0.048), highlighting the need for advanced imaging to identify these vulnerable lesions and tailor clinical management [5].