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

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

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)307-313
Number of pages7
JournalClinical Neuroradiology
Issue number2
StatePublished - Jun 2021


  • Carotid artery
  • Case series
  • Ischemia
  • Magnetic resonance imaging
  • Stenosis

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Clinical Neurology


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