Symptomatic Ulcerative Carotid Plaque
A 65-year-old man with a history of smoking, hypertension, and diabetes mellitus presented because of sudden-onset left hemiparesis. On admission, neurological examination disclosed a mild left-sided weakness, a normal consciousness level, and a right carotid bruit. The blood pressure, ECG, echocardiogram, and laboratory studies were all unremarkable. He was taking daily aspirin, enalapril, and metformin. Magnetic resonance imaging of the brain revealed a right small cerebral infarct.
Intracranial stenotic lesion was not detected by magnetic resonance angiography. Carotid ultrasonography showed a large heterogeneous plaque with ulceration (arrow) and stenosis of 70% at the bifurcation of the right common carotid artery (Figure 1). The symptoms and signs improved gradually during a period of 4 days.
Six weeks after the stroke, the patient underwent elective right carotid endarterectomy, and the arteriotomy was closed with a Dacron patch (Figure 2).
No neurological deficits or cranial nerve palsy were noted postoperatively. The patient was discharged, and 11 months after the operation no new neurological events have occurred.
Plaque rupture may play an important role in acute cerebral events,1 just as it has been shown to play a role in acute coronary syndromes.2 Recent technological advances in ultrasonography3 could provide a noninvasive diagnostic modality of atherosclerotic lesion characterization by clearly visualizing flow conditions and large neck vessel morphology that isn’t currently possible in coronary arteries without invasive procedures.4 Further studies are needed, however, to clarify if the early recognition of carotid plaque rupture should lead to early nonconservative therapeutic strategies.