A n 83-year-old man with a recent history of thyroid carcinoma presented with sudden pain and swelling of the left leg with bluish discoloration and livedo reticularis throughout. Two days before admission, swelling of the left lower extremity developed, and the diagnosis of partial left femoral vein thrombosis was confirmed by venous duplex ultrasonography and compression ultrasound. Anticoagulation with low-molecular-weight heparin and oral warfarin was initiated, and the patient was discharged home receiving maintenance anticoagulant therapy and wearing compression stockings.On arrival, the patient's arterial blood gas analysis and 12-lead ECG were normal. His blood pressure was 127/ 78 mm Hg, pulse rate was 84 bpm, and respiratory rate was 16 breaths per minute. His international normalized ratio was 1.2 (normal range, 0.8 -1.2) and D-dimer level was 2530 g/L (normal range, Ͻ190 g/L). On physical examination, the left leg was markedly swollen, violaceous, painful, tender, and slightly warm up to the inguinal regions (Figure 1). Compression ultrasound was performed again, and an occlusive thrombus was visualized from the left common iliac vein to the calf veins (Figure 2). A diagnosis of phlegmasia cerulea dolens was made, and to prevent potential irreversible venous gangrene and subsequent limb loss, the patient underwent catheter-directed thrombolysis combined with thrombectomy and showed subsequent symptomatic improvement. Seven days later, during oral anticoagulation therapy, the limb discoloration was entirely resolved (Figure 3), and recanalization of the limb vessels was apparent on power Doppler (Figure 4).Phlegmasia cerulea dolens is a rare syndrome caused by diffuse venous thrombosis that is characterized by sudden

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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 ultrasonography 3 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. DisclosuresNone. References