10.4081/btvb.2023.79
Mobile atheromatous plaques affecting large arteries are a major risk factor for embolic strokes. We report a case of extensive embolic cerebral infarction secondary to a vulnerable internal carotid artery plaque. A 67-year-old female was admitted with sudden left-sided weakness. A computed tomography brain scan revealed early ischemic changes in the right middle cerebral territory. The ultrasound Doppler showed soft mobile plaque with thrombus in the right internal carotid artery causing 90% stenosis. Magnetic resonance imaging brain scan performed later showed extensive right cerebral infarction. A computed tomography angiogram revealed ulcerated non-occlusive soft tissue plaque in the right internal carotid artery. She was also diagnosed with bladder cancer during this admission and was managed medically due to her performance status. Unstable vulnerable plaques can be symptomatic even in the absence of significant carotid stenosis. Hence, early identification of the plaque vulnerability, using new imaging modalities, and its medical stabilization can help to reduce the risk of cerebrovascular insults. The etiopathogenesis of inflammation within unstable vulnerable plaques and its concordance with inflammatory markers is still unclear. It is feasible in our case the malignantprocess could also be contributing to the inflammation within the blood vessels promoting vulnerability of the plaques.
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Narayanamoorthi Saravanan
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Bleeding, Thrombosis and Vascular Biology
acute ischemic stroke
Importance of assessment of carotid plaques in the managementof acute ischemic stroke: floating intracarotid plaque
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Case Reports
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2023-07-31
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Bleed Thromb Vascul Biol
Narayanamoorthi Saravanan
2023/09/06
10.4081/btvb.2023.79
Department of Stroke Medicine, Fairfield General Hospital
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acute ischemic stroke
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Lovett JK, Rothwell PM. Site of carotid plaque ulceration in relation to direction of blood flow: an angiographic and pathological study. Cerebrovasc Dis 2003;16:369-75
Importance of assessment of carotid plaques in the managementof acute ischemic stroke: floating intracarotid plaque
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                                                                                                                      CASE REPORT

Importance of assessment of carotid plaques in the management
of acute ischemic stroke: floating intracarotid plaque
Marwa Eltemamy, Robert Namushi, Narayanamoorthi Saravanan

Department of Stroke Medicine, Fairfield General Hospital, UK



ABSTRACT
     Mobile atheromatous plaques affecting large arteries are a major risk factor for embolic strokes. We report a case of extensive
embolic cerebral infarction secondary to a vulnerable internal carotid artery plaque. A 67-year-old female was admitted with sudden
left-sided weakness. A computed tomography brain scan revealed early ischemic changes in the right middle cerebral territory. The ul-
trasound Doppler showed soft mobile plaque with thrombus in the right internal carotid artery causing 90% stenosis. Magnetic resonance
imaging brain scan performed later showed extensive right cerebral infarction. A computed tomography angiogram revealed ulcerated
non-occlusive soft tissue plaque in the right internal carotid artery. She was also diagnosed with bladder cancer during this admission
and was managed medically due to her performance status. Unstable vulnerable plaques can be symptomatic even in the absence of
                                                                          significant carotid stenosis. Hence, early identification of the




                                                                                               ly
                                                                          plaque vulnerability, using new imaging modalities, and its med-




                                                                                       on
                                                                          ical stabilization can help to reduce the risk of cerebrovascular
                                                                          insults. The etiopathogenesis of inflammation within unstable
   Correspondence: Marwa Ahmed Eltemamy, 19 Sharrington Drive,            vulnerable plaques and its concordance with inflammatory
   Manchester M23 9PE, UK.




                                                                                 e
                                                                          markers is still unclear. It is feasible in our case the malignant
   E-mail: marwaeltemamy@yahoo.com
                                                                          process could also be contributing to the inflammation within
   Citation: Eltemamy M, Namushi R, Saravanan N. Importance of
  assessment of carotid plaques in the management of acute ischemic
                                                                            us
                                                                          the blood vessels promoting vulnerability of the plaques.

  stroke: floating intracarotid plaque. Bleeding, Thrombosis, and
                                                                            al
  Vascular Biology 2023;2:79.
                                                                             Introduction
                                                         ci

  Key words: carotid arterial disease, vulnerable plaque, floating
                                                                                 Large artery atherosclerosis is one of the five etiologies of
                                                       er


  plaque, acute ischemic stroke.
                                                                             acute ischemic stroke according to the Trial of Org 10172 in
  Contributions: the authors contributed equally.                            Acute Stroke Treatment.1 It accounts for 20-30% of ischemic
                                                      m




                                                                             stroke cases.
  Conflict of interest: the authors declared no potential conflict of
                                          om




                                                                                 Atherosclerosis is a dynamic inflammatory and immune
  interest.                                                                  process that involves arterial walls. Atherosclerotic plaque is the
                                                                             main pathology induced by atherosclerosis.2 Most plaques are
  Funding: none.
                                                                             silent and asymptomatic.
                                    -c




  Informed consent: written informed consent was obtained from the               Floating plaque is a form of unstable or vulnerable plaque.
                           on




  patient for the publication of this case report and any accompany-         When present, it is associated with cerebrovascular incidents
  ing images.                                                                like transient ischemic attack or ischemic stroke. However, it is
                                                                             uncommon in clinical practice.
                     N




  Conference presentation: This case was presented as a poster at the            We present a case of floating vulnerable plaque in the right
  8th MENA Stroke Congress, 21-23 October 2022 Abu Dhabi, UAE.               internal carotid artery in a woman who presented with left hemi-
                                                                             paresis to our stroke unit.
  Received: 10 April 2023.
  Accepted: 8 August 2023.

  Publisher’s note: all claims expressed in this article are solely those    Case Report
  of the authors and do not necessarily represent those of their affili-
  ated organizations, or those of the publisher, the editors and the re-         A 67-year-old woman was admitted to our stroke unit with
  viewers. Any product that may be evaluated in this article or claim        significant left-sided weakness and left facial palsy. She didn’t
  that may be made by its manufacturer is not guaranteed or endorsed         have a significant medical history, but she was a heavy smoker
  by the publisher.                                                          (40 pack-years) and drank an excess of alcohol. Her first com-
                                                                             puted tomography (CT) brain showed an acute cortical infarct
  ©
   Copyright: the Author(s), 2023                                            in the right frontal lobe. A carotid duplex (Figure 1) was done,
  Licensee PAGEPress, Italy
                                                                             and it revealed a right internal carotid artery (ICA) mixed
  Bleeding, Thrombosis and Vascular Biology 2023; 2:79
  doi:10.4081/btvb.2023.79                                                   plaques and thrombus causing 80-89% stenosis. The case was
                                                                             discussed by the vascular surgeons and the MDT decision was
  This work is licensed under a Creative Commons Attribution-                for medical management and not for surgical intervention in
  NonCommercial 4.0 International License (CC BY-NC 4.0).                    view of the patient’s high NIH Stroke Scale.
                                                                                 The patient was treated medically with high-dose aspirin


                                              Bleeding, Thrombosis and Vascular Biology 2023; 2:79
16                                                         M. Eltemamy et al.




and high dose statin. After two days, her weakness got worse,              Histologically, the vulnerable plaque has a large lipid core
and she developed new dysphagia, so a magnetic resonance im-           and a thin fibrous cap. The high lipid content decreases the load-
aging (MRI) of the brain was requested (Figure 2). There was           bearing capability of the plaque and increases the stress in the
extensive acute infarction in the right hemisphere in the MRI          overlying fibrous cap.6 Under certain extrinsic factors, like high
scan: frontal, temporal, and occipital lobes. A computed tomog-        blood pressure and vasospasm, the plaque can easily rupture.7
raphy angiogram (CTA) showed a soft tissue ulcerated plaque            Other features of plaque vulnerability are neovascularization and
at the right ICA bulb with stenosis of less than 30% (Figure 3).
Her laboratory investigations came with iron deficiency anemia
and high C-Reactive Protein (CRP). As she gave a history of re-
cent significant weight loss, a CT thorax, abdomen, and pelvis
was done. A urinary bladder mass was found, and it was con-
firmed malignant on cystoscopy examination. She received pal-
liative treatment for her tumor because of her significant
stroke-related disability. She had a percutaneous endoscopic gas-
trostomy tube inserted for feeding and was discharged to a 24-
hour care home.




                                                                                                 ly
Discussion




                                                                                          on
     Atherosclerosis is a systemic disease. The atherosclerotic
plaque is composed of a lipid core and a covering fibrous cap
(FC). There are continuous changes within the plaque itself dur-




                                                                                    e
ing the development of atherosclerosis.3 The plaque will be
symptomatic once the changes lead to significant vascular steno-
sis or occlusion. However, few plaques cause damage apart from
                                                                            us
the degree of stenosis. These are called vulnerable or unstable
                                                                      al
plaques.4
     A cascade of changes converts the stable plaque into a vul-
                                                          ci

nerable plaque. This starts with endothelial activation by numer-
                                                        er


ous factors that include infectious agents, nicotine,
homocysteine and oxidized low-density lipoprotein (LDL).5
                                                       m



Dysfunctional endothelium allows inflammatory cells and LDL            Figure 2. Magnetic resonance imaging of the brain shows ex-
                                                                       tensive right cerebral infarcts.
to pass into the subendothelial space and lipid core. Then LDL
                                             om




is oxidized by free radicals to form a reactive and cytotoxic com-
pound. This oxidized LDL stimulates inflammatory cells to pro-
duce proteases like matrix metalloproteinases (MMPs) and
                                       -c




cytokines. MMPs degrade the plaque cap exposing the underly-
ing thrombogenic core to luminal blood. Finally, a thrombus
                                on




forms at the site of rupture and this may lead to embolism de-
pending on local coagulation and fibrinolytic mechanisms.
                           N




Figure 1. Carotid Doppler shows intra-arterial mixed plaque and        Figure 3. The computed tomography angiogram shows an ul-
thrombosis.                                                            cerated plaque at the right internal carotid artery bulb.


                                        Bleeding, Thrombosis and Vascular Biology 2023; 2:79
        Importance of assessment of carotid plaques in the management of acute ischemic stroke: floating intracarotid plaque           17



intraplaque haemorrhage.8 There are controversies regarding the
effect of arterial calcification on plaque nature. Some studies       Conclusions
suggest that calcification gives the plaque more stability,9 while
                                                                          Unstable plaques can be symptomatic even in the absence
others consider it a sign of vulnerability, irrespective of the de-
                                                                      of significant carotid stenosis. Hence, early identification of the
gree of stenosis.10
                                                                      plaque vulnerability, using new imaging modalities, and its med-
     There is an asymmetrical distribution of the mechanical
                                                                      ical stabilization can help to reduce the risk of cerebrovascular
stress levels along the symptomatic carotid plaques according
                                                                      insults. The etiopathogenesis of inflammation within unstable
to Thrysøe et al.11 Around 50% of the mechanical stress was
                                                                      vulnerable plaques and its concordance with inflammatory
proximal (upstream side) while 25% was distal (downstream
                                                                      markers is still unclear. It is likely that in our case the malignant
side) to the point of maximal stenosis. This stress level has an
                                                                      process could also be contributing to the inflammation within
inverse correlation with the thickness of the fibrous cap (FC).
                                                                      the blood vessels promoting vulnerability of the plaques.
The upstream side of the stenosis is considered the oldest part
of the plaque. It is proved that it has more neovascularization
and hemorrhage with the thinnest FC.12 This could explain why
vulnerable carotid plaque mostly ruptures in this region.13 Dif-      References
ferent imaging modalities are in use now, to improve the identi-       1. Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classifica-
fication of rupture-prone plaques, like intravascular ultrasound,         tion of subtype of acute ischemic stroke. Definitions for use
intravascular ultrasound elastography, high-resolution MRI and




                                                                                         ly
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optical coherence tomography.                                             in Acute Stroke Treatment. Stroke 1993;24:35-41.




                                                                                 on
     It is proved that inflammation is the main feature of the ath-    2 The World Health Organization MONICA Project (moni-
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                        on




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                                        Bleeding, Thrombosis and Vascular Biology 2023; 2:79
