Approximately 1 in 4 patients with an embolic event is found to have variable grades of aortic atheromatosis in transesophageal echocardiography (TEE). Atherosclerotic lesions of the thoracic aorta, especially complex plaques with superimposed thrombi and thickness >4 mm, are thought to be a risk factor for both cerebral and peripheral embolization. Moreover, aortic plaques situated in the descending thoracic aorta are often overlooked and may be neglected as a potential mechanism of cerebral embolism through retrograde aortic flow. Interestingly, 3-dimensional and 4-dimensional MRI data via image fusion demonstrated that emboli from complex plaques in the descending aorta reached the left subclavian artery and common carotid artery in 67% and 25% of evaluated cases. In addition, retrograde embolism from the descending aorta was postulated as the only probable cause of retinal or cerebral infarction in 24% of patients with cryptogenic stroke. The aim of the present systematic review and meta-analysis was to evaluate the potential association of atheromatosis in the descending aorta with cerebral ischemic events using data from prospective observational studies. We also estimated the prevalence of complex atheromatous plaques in the descending aorta in patients with unclassified ischemic stroke, cryptogenic infarction, and unselected individuals undergoing TEE examination for various indications.