More to Atherosclerosis Than Stenosis
Symptomatic Carotid Artery With Intraplaque Hemorrhage
A 66-year-old man presented with left facial weakness on awakening. He had cerebrovascular risk factors, including HIV, hypertension, and hyperlipidemia. When the facial weakness did not resolve after a few days, he presented to a local hospital. A brain magnetic resonance imaging scan, including an axial diffusion-weighted imaging sequence, demonstrated an ischemic stroke in the face representation area of the right precentral gyrus. Transthoracic echocardiography, carotid ultrasound, and cardiac telemetry were unrevealing. He was prescribed dual antiplatelet therapy and a statin. He was referred to a vascular neurologist at our tertiary care center. After seeing the vascular neurologist, a noncontrast magnetic resonance angiogram (MRA) of the head and neck was obtained: 3-dimensional (3D) time-of-flight (TOF) imaging demonstrated ≤50% stenosis of the carotid bulbs bilaterally (40%–50% bilaterally by NASCET criteria [North American Symptomatic Carotid Endarterectomy Trial]). On these T1-weighted images and on a fat-suppressed axial T1 sequence, there were focal, crescentic, subintimal hyperintense signals at the bifurcations bilaterally (Figure 1). The findings were highly suggestive of intraplaque hemorrhage. However, given the modest degree of stenosis and an incomplete etiologic investigation, the right carotid artery was not yet considered definitively symptomatic. He then underwent 30 days of extended cardiac rhythm monitoring to investigate occult arrhythmias as a potential source of the presumed embolic stroke. The facial weakness completely resolved.