The three leading causes of stroke are:
1)Carotid artery atherosclerosis
2)Atrial fibrillation
3)Severe aortic plaques in the aortic arch


The risk of stroke in 1 year for patients with severe plaque in the aortic arch on transesophageal echocardiography (TEE )is high: 10% to 12%. This risk was found in 3 independent studies. The risk of all vascular events is even higher, with stroke or peripheral emboli seen in 33% in 1 year in a prospective study.
Aortic plaque is an expression of generalized atherosclerosis. As such, it is most often seen in the elderly (the average age of those with 4-mm plaque on TEE is 70 years).It also is more common in patients with hypertension and hypercholesterolemia and in those who smoke.Plaque in the aorta is associated not only with these traditional atherosclerotic risk factors but also with elevated levels of homocysteine, markers of a thrombotic diatheses (prothrombin and activated protein C resistance),and inflammatory markers such as elevated white blood cell count and C-reactive protein. It also is found to a greater degree in patients with left ventricular hypertrophy.Aortic enlargement can also signal the presence of aortic plaque that increases stroke risk.

It is not surprising that patients with significant carotid atherosclerosis also have a higher prevalence of aortic arch atherosclerosis than do those without carotid disease and therefore have >1 potential source of embolization to the brain.One retrospective study found aortic arch plaques in significantly more stroke and transient ischemic attack patients with carotid stenosis (38%) than in those without carotid stenosis(17%). That study also found that mobile thrombi superimposed on the aortic arch plaques were exclusively found in patients whose carotid stenosis was >80%. Thus, patients with the highest-risk carotid lesions also had the highest-risk aortic plaques.
 Therefore, when one sees a patient with stroke and severe carotid stenosis, it is important to always consider the possibility that the embolic event may have originated in the aortic arch. When the stroke or transient ischemic attack is contralateral to the carotid stenosis or is associated with peripheral emboli, the aorta should always be evaluated. This evaluation should also take place in patients who have neurological events after recovery from a technically successful carotid operation.
Rest at site.       http://circ.ahajournals.org/cgi/content/full/114/1/63

Fortunately we can shrink plaque in the aorta.Dr .Davis wrote"The New Paradigm for Stroke Prevention".The article can be found in his report"What your doctor probably didn't tell you about stroke, aneurysms and depression."The report is is the TYP Member Library in the Free Guides & Handbooks (Members only) section.