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Background: Complex atheromatous aortic plaques (CAAP) are a source of embolism stroke but is not clear established the best secondary prevention treatment yet.Objective: we aimed to analyze recurrence of stroke in ESUS patients based on different prevention treatment strategies regarding characteristics of atheromatosis aortic plaques .Methods: From January 2012 to July 2017, CAAP screening in acute phase of stroke in ESUS patients was realized (we excluded main cardioembolic sources and intracranial or extracranial symptomatic stenosis >50%). We performed CTA from proximal to distal aortic arch. CAAP was defined as a plaque > 4 mm thickness or with irregular ulcerations > 2 mm depth. Baseline characteristics and neuroimaging patterns were recorded. In patients that was possible to perform a transesophageal echocardiography (TTE) in subacute phase we assessed the size of endoluminal plaques, presence of ulcerated plaques and mobile components or thrombus .Follow up with analysis of recurrence in this cohort was done.Results: 157 patients were screened. CAAP detection by CTA was 57% (88/157). CAAP was associated with older age (73± 9 vs. 66±14 years, p=0.005), hypertension (76.6% vs. 59.4%, p=0.027), diabetes (34.1% vs. 18.8%, p=0.037), and a trend towards stroke recurrence (19.5% vs. 9.4%, p=0.086). TEE was performed in 73 patients: recurrence of stroke (n=9) (12%) was associated with bigger endoluminal plaques (6.7±3.5 vs. 4.8±2.6 mm, p<0.001), ulcerated plaques (26.9% vs 4.3%, p=0.005), and with presence of thrombus or mobile components (26.3 % vs. 5.7 %, p=0.014). All patients with presence of mobile thrombus in TEE (n=19) received oral anticoagulation (OAC); in 16 patients ( 85%) , OAC was withdrawn after 3 months with control TEE that confirmed disappear of mobile parts and antiagregation was initiated with recurrence in 5/ 19 patients associated with active smoking (60.0% vs. 7.1%, p =0.013 ).Conclusions: Complex atheromatous aortic plaques are relevant stroke sources of embolism. Size, ulcerated plaques and mobile components were associated with stroke recurrence. A subgroup of patients may benefit of chronic oral anticoagulation in order to avoid stroke recurrence.