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(Stroke. 2009;40:e319.)
© 2009 American Heart Association, Inc.

Case Report

Showered Calcific Emboli to the Brain, the ‘Salted Pretzel’ Sign, Originating From the Ipsilateral Internal Carotid Artery Causing Acute Cerebral Infarction

Brett A. Christian, MD; Daniel J. Kirzeder, MD; Jim Boyd, MD; Jeffery Laing, MD Judson R. Gash, MD

From the University of Tennessee Medical Center, Knoxville, Tenn.

Correspondence to Brett A. Christian, MD, University of Tennessee Medical Center, 1924 Alcoa Highway, Knoxville, TN 37920. E-mail b_rett{at}yahoo.com

Background and Purpose— Unenhanced head CT has become the first line imaging study in the evaluation of suspected acute cerebral ischemia. It is important to identify subtle findings of acute ischemia on this exam to direct appropriate patient management.

Summary of Case— We report the first case of multiple pial surface distal internal carotid artery territory calcified emboli causing multifocal cerebral infarctions, likely from a carotid bifurcation source.

Conclusions— Visualization of multiple pial surface calcifications on unenhanced head CT, the ‘salted pretzel sign’, should raise suspicion for acute infarction from showered calcific emboli.

Key Words: acute care • brain infarction • cerebrovascular accident • CT • MRI • radiology • stroke in evolution