Serial High-Spatial-Resolution, Multisequence Magnetic Resonance Imaging Studies Identify Fibrous Cap Rupture and Penetrating Ulcer Into Carotid Atherosclerotic Plaque
A 67-year-old woman with a history of bilateral carotid artery stenosis and 4 episodes of myocardial infarction had left arm claudication for 1 month. Diffusion-weighted magnetic resonance imaging (MRI) did not identify acute cerebral infarction. Transcranial Doppler imaging did not reveal any emboli. She had been followed by a clinical research study, PRIMARI (Plaque Rupture In MAgnetic Resonance Imaging). A baseline high-spatial-resolution, multisequence MRI performed 10 months previously showed an atherosclerotic plaque with intraplaque hemorrhage in the right internal carotid artery (Figure 1A through 1D) and a calcified plaque in the left carotid artery. Both arteries had intact fibrous cap.1,2 A repeat MRI identified fibrous cap rupture and an ulcer penetrating into the plaque in the right internal carotid artery (Figure 1E through 1H). Contrast-enhanced 2-dimensional spoiled GRASS and carotid angiography confirmed the presence of the fibrous cap rupture and ulcer (Figure 2). There was no change in the left carotid artery between baseline and follow-up MR scans. Significant left subclavian artery stenosis identified on the carotid angiogram was considered to be the underlying cause of her left arm claudication. Although there was no cerebral embolization that originated from fibrous cap rupture and ulcer, serial-high-spatial resolution, multisequence carotid MRI identified the atherosclerotic plaque with intraplaque hemorrhage at baseline and fibrous cap rupture and ulcer during follow-up study. This case suggests that intraplaque hemorrhage may be a driving force for plaque progression and that silent plaque rupture can also occur in carotid atherosclerosis.3,4
This study was supported by National Institutes of Health grants R01-HL-61851 and R01-HL-073401.
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