Objective: This study was undertaken to determine whether there is a significant association between aortic arch calcification (AAC) on digital chest radiography (DCXR) and cerebrovascular disease (CVD) by computed tomography of the brain plain (BCT). It also aimed to determine if DCXR may be used to predict stroke.

Research Design: Retrospective Cross Sectional Chart Review Design

Methodology: All the 483 patients who underwent DCXR and BCTs at the Doctors Hospital, Inc. from January 2010 to December 2012 were included in the study. Demographic data and risk factors for atherosclerosis and CVD were obtained and analyzed. The DCXR were graded by three radiologists and its association with CVD on BCT using the Chi Square Test of Independence was done. Krusskall Wallis Test was employed. Cochrane Inter rater validity between the three readers was tested. Odds ratio, sensitivity and specificity of DCXR to diagnose CVD on BCT were then determined.

Results: Of the 483 patients included in the study, 52.8% were females with an average age of 65.86±14.46 years old. Patients of the older age group had a higher AAC grade (3) and had more infarcts on BCT. Although risk factors for AAC on DCXR and CVD on BCT were hypertension, dyslipidemia and renal disease, these were not statistically significant.

Cross sectional analysis of variables showed that patients with an AAC grade of 1 was highly associated with infarcts and an AAC grade of 2 was associated with hemorrhagic stroke (p=0.0200). A statistically significant inter rater agreement was noted among the three radiologists that read the DCXR.

Conclusion: The AAC grade (1) on DCXR is significantly associated with infarcts on BCT scan with a high specificity and strong positive predictive value. Larger studies may be necessary to determine the association of the other AAC grades (2 and 3) with the types of stroke.

Keywords: aortic arc calcification, cerebrovascular disease, stroke,

1. Libby, P: The Pathogenesis, Prevention and Treatment of Atherosclerosis,Harrisons’ 18th Edition,2011,p1983.
2. PasternakRC, Criqui,MH, Benjamin EJ, Fowkes GR, Eisselbacher EM, McCullough PA, Wolf, PA, Zheng ZJ. Atherosclerotic Vascular Disease Conference Writing Group I: Epidemeology. AHA Conference Proceedings. Circulation 2004;109:2605-2612.
3. Hunt JR. The role of the Carotid Arteries in the Causation of Vascular Lesions of the Brain, with Remarks on Certain Special Features of the symptomatology. American Journal of Medical Sciences. May 1914;147(5): 704-712.
4. Estol CJ. Dr. C. Miller fisher and the History of Carotid Artery Disease.Stroke. 1996;27:559-566.
5. Fisher MC. Occlusion of the Internal Carotid Artery. Arch Neurol Psych. 1951;65:346-377.
6. O’Leary DH, Polak JF, Kronmal RA, Savage PJ, Borhani NO, Kithner SJ, Tracy R,Gardin JM, Price TR, Furberg CD. Thickening of the Carotid Wall. A Marker for Atherosclerosis in the Elderly? Cardiovascular Health Study Collaborative Research Group. Stroke; 1996;27(2) 224-231.
7. Wang TJ, Nam BJ, Wilson PW, Wolf PA, Levy D, Polak JF, D’Agostino RB, O’ Donell CJ. The Association of C-Reactive protein with Carotid Atherosclerosis in Men and Women: the Framingham Heart Study. Arterioscler Thromb Vasc Biol 2002 Oct 1;22(10):1662-7.
8. Howard G, Manalio TA, Burke GL, Wolfson SK, O’Leary DH. Does the Assoication of Risk Factors and Atherosclerosis Change with Age? An analysis of the combined ARIC and CHS cohorts. The Aterosclerosis risk in communities (ARIC) and Cardiovacular Health Study (CHS) Investigators. Stroke;1997 Sep;28(9):1693-701.
9. Howard G, Sharrett AR, Heiss G, Evans GW, Chambless LE, Riley WA, Burke GL. Carotid Artery Intimal- Medial Thickness Distribution in General Populations as Evaluated by B mode Ultrasound. ARIC Investigators. Stroke. 1993 Sep;24(9):1297-304.
10. O’Leary DH, Polak JF, Kronmal RA, Manalio TA, Burke GI, Wolfson SK Jr. Carotid Artery Intima and Media Thickness as a Risk Factor for Myocardial Infarction and Stroke in Older Adults. Cardiovascular health Study Collaborative Research Group. N Engl J Med. 1999 Jan 7; 340(1): 14-22.
11. Hodis HN, Mack WJ, LaBree L, Selzer RH, Liu Cr, Liu CH, Azen SP. The Role of Carotid ARTerial Intima-Media Thickness in Prediciting Clinical Coronary Events. Ann Intern Med 1998 Feb 15; 128(4) :262-9.
12. Hodis HN, Mack WJ, LaBree RH, Liu CR, Liu CH, Alaupovic P, kwong-Fu H, Azen SP. Reduction in the Carotid Arterial Wall Thickness using Lovastatin and Dietary Therapy: A randomized Controlled Clinical Trial. Ann Intern Med. 1996 Mar 15;124(6): 548-56.
13. North American Symptomatic Carotid Endarterectomy Collaborators. Beneficial Effect of Carotid Endarterectomy in Symptomatic Patients with Highg grade Carotid Stenosis. N Eng J Med. 1991 Aug 15;325 (7):445-53.
14. Tunick PA, Kronzon I. Protruding Atherosclerotic Plaque in the Aortic Arch of Patients with Systemic Embolization: A New Finding Seen by Transesophageal Echocardiography. Am Heart J. 1990 sep;120(3):658-60.
15. Zavala JA, Amarrenco P, Davis SM, Jones EF, Young D, Macleod MR, Horky LL, Donnan GA. Aortic Arch Atheroma. Int J Stroke. 2006 May; 1(2): 74-80.
16. Amarenco P, Cohen A, Tzourio C, Vertrand B, Hommel M, Besson G, chauvel C, Touboul PJ, Bousser MG. N engl J Med 1994;331:1474-79.
17. Tunick PA,Kronzon I. Atheromas of the Thoracic Aorta: Clinical and Therapeutic Update. Journal of the American College of Cardiology.2000 Mar 1;35(3): 545-54.
18. Kronzon I, Tunick PA. Atheromatous Disease of the Thoracic aorta: Pathological and Clinical Implications. Ann Intern Med.1997 Apr 15; 126 (8): 629-37.
19. Tunick PA, Perez JL, Kronzon I. Protruding Atheromas in the Thoracic Aorta and Systemic Embolization. Ann Intern Med. 1991 Sep 15; 115(6): 423-7.
20. Yoshimura s, Toyoda K, Kuwashiro T, Koga M, Otsubo R, Konaka K, Naganum M, Matwuoka H, Naritomi H, Minematsu K. Ulcerated Plaques in the aortic Arch contribute to Wymptomatic Mltiple Brain Infarction. J Neurol Neurosurg Psychiatry. 2010 Dec ;81(12):1306-11.
21. Tunick PA, Krinsky GA, Lee VS, Kronzon I. Diagnostic Imaging of the Thoracic Aortic Atherosclerosis. American Journal of Roentenology. 2000Apr;174(4):1119-25.
22. Matsumura Y, Osaki Y, Fukui T., Yabe T, Yamasaki M, Hamashige, Doi Y. Protruding Atheroslcerotic Aortic Plaques and Dyslipidemia: Correlation to Subtypes of Ishemic Stroke. Eur J Echocardiography.2002;3:8-12.
23. The French Study of Aortic Plaques in Stroke Group. Atherosclerotic Disease of the Aortic Arch as a Risk Factor for Recurrent Ischemic Stroke.N Engl J Med 1996;334:1216-21.
24. Meissner I, Whisnant JP, Khandheria BK, Spittell PC, O’Fallon WM, Pascoe RD, Enriquez-Sarano M, Sewart JB, covalt JL, Sicks JD, Wiebers DO. Prevanlence of Potential Risk Factors for Stroke Assessed by Transesophageal Echocardiography and Carotid Ultrasonography: the SPARC Study. Stroke Prevention: Assessment of Risk in a Community.Mayo Clinic Pro. 1999 Sep; 74(9):862-9.
25. Deif R, El-Sayed M, Allah FA, Baligh E, El Fayomy NM, Ezzat L, Gamal H. Atherosclerotic Aortic Arch Plaques in Acute Ischemic Stroke. J Vasc Interv Neurol. 2011 Jan;4(1):5-9.
26. Di Tullio MR, Russo C. Homma S. Aortic Arch Plaques and Risk of Recurrent Death. Circulation. 2009 May 5; 119 (17):2376-2382.
27. Capmany RP, Ibanez MO, Pesquer XJ. Complex Atheromatosis of the Aortic Arch in Cerebral Infarction. Curr Cardiol Rev. 2010 Aug;6(3):184-193.
28. Sen S. Aortic Arch Plaque in Stroke. Jan 2009.11(1):28- 35.
29. O’Donnell, Elosua R. Cardiovascular risk Factors. Insights rom Framingham Heart Study. Rev Esp Cardiol. 2008;61(3):299-10.
30. Petrea RE, Beiser AS, Kelly-Hayes M. Kase CS, Wolf PA. Gender Differences in Stroke Incidence and Poststrke Disability in the Framingham Heart Study. Stroke. 2009 Apr;40(4):1032-7.
31. Litovchik I, Krakover R, Blatt A and Vered Z. Coronary and Aortic Calcification: Is the Relationship Important?. Isr Med Assoc J.2007 Apr; 9(4):328-30.
32. London GM, Marchais SJ, Guerin AP, Metivir F. Arteriosclerosis. Vascular Calcifications and Cardiovascular Disease in Uremia. Curr Opin nephrol Hypertens 2005;14:525-31.
33. Kronzon I, Tunick PA. Contemporary Reviews in Cardiovascular Medicine:Aortic Atherosclerosis and Stroke. Circulation 2006;114:63-75.
34. Fazzio GP. Redberg RF, winslow T,Schiller NB. Transesopahageal Echocardiographyica l ly Detected Atherosclerotic Aortic Plaque is a Marker for Coronary Artery Disease. J AM Coll Cardiol. 1993Jan; 21(1)144- 50.
35. Briley DP, Lababidi Z, Bowdler AJ, Krishanamurthy M, Cansino SP, Touchon RC. Aortic Atherosclerosis and Stroke. J Stroke Cerebrovasc Dis. 1997 Jan;6(3):125-9.
36. Eisen A, Tenenbaum A, Koren-Morag N, Tanne D, Shemsesh J, Imazio M, Fisman EZ, Motro M, Schwammenthal E, Adler Y. Calcification of the Thoracic Aorta as Detected by Spiral Computed Tomography Among Stable angina Pectoris Patients Association With Cardiovascualr Events and Death. Circulation.2008;118:1328-34.
37. Itane Y, Watanabe s, Matsuda Y. Relationship Between aortic Calcification and Stroke in a Mass Screeing Program Usi g a Mobile Helical computed Tomography Unit. Circ J. 2006 Jun;70(6):733-6.
38. Iribaren C,Sidney S, Stemfeld B, Browner WS. Calcification of the Aortic Arch: Risk Factors and Association with Coronary Heart Disease, Stroke, and Peripheral Vascualr Disease. JAMA.200 Jun 7;283(21):2810-5.
39. Xu L, Jiang CQ, Lam TH, Thomas GN, Zhang WS, Cheng KK. Aortic Arch Calcification and Vascular Disease: The Guangzhou Biobank Cohort Study. Cardiology2010;117:260-64.
40. Inoue T, Ogawa T, Ishida H, Ando Y, Nitta K. Aortic Arch Calcification Evaluated on Chest xray is a Strong Independent Preditor of Cardiovascualr Events in Chronic Hemodialysis Patients. Hear Vessels. 2012 Mar;27(2):135- 42.
41. Hashimot H, Iijima K, Hashimoto M, Son BK, Ota H, Ogawa S, Eto M, akishita M, Ouchi Y. Validity and Usefulness of Aortic Arch Calcification in Chest Xray. Journal of Atherosclerosis and Thrombosis 16(3);226-64.
42. Spagnolli LG, bonanno E, Sangiorgi G, mauriello A. role of Inflammation in Atherosclerosis. J nuc Med;2007:48(11):1800-15
43. Davies MJ, Richardson PD, Woolf N, Katz DR, Mann J. Risk of Thrombosis in Human Atherosclerotic Plaques: Role of Extracellualr Lipid, Macrophage and Smooth Muscle content. Br Heart J. 1993 May; 69(5):377-81.
44. Lundberg B. Chemical Composition and Physical State of Lipid Deposits in Atherosclerosis. Atherosclerosis 1985; Jul;56(1)93-110.
45. Falk E, Shah PK, Fuster V. Coronary Plaque Disruption. Circulation.1995;92:657-71.
46. Shimuda Y, Ueno Y, Tanaka Y, Okuzumi A, Miyamoto N, Yamashiro K, Tanaka R, Hattori N, Urabi T. Aging, Aortic Arch Calcification and Multiple Brain Infarcs are Associated with Aortogenic Brain embolism. Cerebrovasc Dis. 2013;35(3):282-90.
47. Fitzpatrick LA,Severson A, Edwards WD, Ingram RT. Diffuse Calcification in Human coronary Arteries. Associatio of Osteopontin with Atherosclerosis. J Clin Invest. 1994 Oct;94(4):1597-604.
48. Huang H, The Impact of Calcification on biochemical Stability of Atherosclerotic Plaques. Circulation.2001;103:1051-56.
49. Burke, AP, Kolodgie FD,Farb A, Wever D, Virmani R. Clinical Investigation and Reports Morphological Predictors of Remodeling in Coronary Atherosclerosis. Circulation.2002;105: 927-303.
50. Hayashi K, Mani V, Nemade A,Aguilar S, Postley J, Fuster V, Fayad Z. Varioations in Atheroclerosis and Remodeling patterns in Aorta and Carotids. Journal of Cardiovascular Magnetic Resonance.2010;12:10.
51. Anand S, Vallantyne CM, Chasman D, Cook NR, A’Agostino R, Kannel W, Levy D. Munroe P, O’donnell CJ, Ridker PM, Eckardstein AV, Wald N, Wilson P.Risk Factors for Atherosclerosis. XV Internation symposium on Atherosclerosis. 2009 June.1-32.
52. Sacco R, Benjamin E, Broderick J, dyken M, Easton D, Feingerg W, Goldstein L, Gorelick P, Howard G, Kittner S, Manolio T, Whisnant J, Wolr P. Risk Factors. Stroke. 1997:28:1507-17.
53. Brown RD, Whisnant JP, Sicks JD, O’Fallon WM, Wievers DO. Stroke Incidence, Prevalence, and survival: Secular Trends in Rochester , Mineesota, through 1089. Stroke. 1996 Mar;27(373-80.
54. Wolf PA, D’Agostino RB, O’Neal MA, Sytkowski P, Kase Cs, Belanger AJ, Kannel WB. Secular Trends in Stroke Incidence and Mortality. The Framingham Study. Stroke. 1992. Nov;23(11)1551-5
55. Coy CM. Maurer G, Goodman D. Siegel RJ, TransesophagealEchocardiographic Detection of Aortic Atheromatosis may provide Clues to occult Renal dysfunction in the Elderly. American Heart Journal.1992;123:1684-86.
56. Lee MJ, Shin HD, Kim SJ, Oh HJ, Yoo DE, Ko KI, Koo, HM, Kim CH, Doh FM, Park JT, Han SH. Proression of Aortic Arch Calcification Over 1 year is an Independent Predictor of Mortality in Incident Peritoneal dialysis Patients. Plus One 2012 Nov. DOI:10.1371/journal.pone.0048793.
57. Okuno S, Ishimura E, Kitatani K, Fujino Y,Kohno K, Maeno Y, Maekawa KYamakawa T, Imanishi Y,Inaba M, Nishizawa Y. The Presence of Abdominal Aortic Calcification is Significantly Associated with All Cause and Cardiovascular Mortality in Maintenance hemodialysis Patients. Am J Kidney Dis. 2007 Mar; 49(3):417-25.