Cerebrovascular disease in adults with aortic coarctation

Background Adults with aortic coarctation (CoA) have an increased risk of premature morbidity and mortality despite successful repair or intervention 1. Once thought of as a discrete lesion, CoA is now considered to be a diffuse arteriopathy 2. Little is known about cerebral small vessel disease in this population which has been associated with stroke or cognitive impairment. Purpose The aim of this study was to explore the prevalence of microvascular and macrovascular cerebrovascular disease and the association between hypertension and microvascular disease in adults with CoA. Method In this retrospective observational study, we included adults (age≥18 years by December 2025) with repaired or unrepaired CoA who attended our clinic and underwent brain computed tomography (CT) or magnetic resonance imaging (MRI) between 2009 and 2025. We excluded patients with complex congenital heart disease or arteritis. Microvascular cerebrovascular disease included microbleeds, silent brain infarcts and microangiopathic changes and macrovascular disease included clinical or imaging diagnosed stroke and cerebral aneurysm. Blood pressure from 24-hour ambulatory blood pressure measurement (ABPM) was recorded when available. Stage 1 hypertension was defined as mean daytime systolic BP>130 mmHg or diastolic BP>80 mmHg, and stage 2 hypertension as mean daytime systolic BP>140 mmHg or diastolic BP>90 mmHg. The Fisher exact test was used to compare groups. Results In total, 171 patients with CoA were identified (median age at most recent brain imaging 33 years [interquartile range (IQR), 25-48]). Of these, 158 (92%) patients were repaired (surgically or with percutaneous stent implantation). Microvascular disease was identified in 35 patients (21%), and macrovascular disease in 16 patients (9%) (9 strokes and 7 cerebral aneurysms). Microvascular disease was more common in patients with clinical stroke compared with those without stroke (78% vs 17%, p<0.001). Among the cohort, 71 patients (42%) had ABPM results (median age at ABPM 26 years [IQR 20-38]), and mean daytime blood pressure was 135 (±14) / 75 (±12) mmHg. Forty-three patients (61%) met criteria of stage 1 hypertension and 25 patients (35%) for stage 2 hypertension. In the subset of patients with ABPM, microvascular disease was more frequent in patients with stage 1 hypertension compared to those with normal blood pressure (27% vs 4%, p=0.077) although not statistically significant. Microvascular disease was more common in patients with stage 2 hypertension compared to those with normal blood pressure (32% vs 4%, p=0.003). Conclusions Microvascular and macrovascular cerebrovascular disease are common in adults with CoA, and patients with clinical stroke had a higher proportion of microvascular disease on CT or MRI. Elevated blood pressure was associated with microvascular disease. Further study is required to explore the prognostic relevance of microvascular cerebral disease.