Mobile floating carotid plaque in a young woman

Abstract

A 32-year-old white woman presented with acute onset of right limb weakness, 3 days before hospitalization. She had non-regulated hyperthyreoidism and a history of smoking. Brain computed tomography (CT) showed a several occipital and high parietal ischemic lesions of the left hemisphere [ Figure 1a and b]. Duplex ultrasonography scan (DUS) showed the existence of fibrolipid plaque located on the back wall of the common carotid artery, that extended to the external as well as internal carotid artery making an uneven plaque, a part of which moved up and down with the heart beat, creating stenosis of 80-90% [ Figure 1c and d]. CT angiography revealed unstable plaque in left internal carotid artery that protrudes into the lumen as well as moderate stenosis in the proximal segment of the external carotid artery [ Figure 2]. She underwent total carotid endarterecotomy of symptomatic left internal carotid artery, 25 days after being admitted. Histopathological finding indicated that the plaque was atherosclerotic. In the prevention of stroke recurrence, the patient was given 75 mg of clopidogrel and 100 mg of aspirin daily. The patient did well, with residual discrete right-sided weakness and no recurrent strokes. Follow-up DUS was done and it showed no signs of plaque or restenosis.Mobile carotid plaques are unstable and associated with recurrent stroke, [1] with the estimated prevalence of 1 in 2000. [2] They bear high risk of embolic cerebrovascular incidents, as was the case in our patient. This type of plaque usually represents degenerated atherosclerotic flap, ruptured plaque with mobile thrombus or intimal dissection plaque. The only method that can show the mobility of the plaque is ultrasonography. [1] Mobile floating carotid plaques can be treated with urgent carotid endarterectomy, delayed carotid endarterectomy and carotid angioplasty and stenting. [2,3] Beside surgery, patients are treated with antiplatelet therapy. [2] Neuroimage Figure 1: Brain computed tomography showed several occipital and high parietal ischaemic leasions of the left hemisphere (a, b). Duplex ultrasonography scan revealed fibrolipid plaque located on the back wall of the common carotid artery, that extended to the external as well as internal carotid artery making an uneven plaque (c, d) d c b a Figure 2: Computed tomographic angiography of the neck showed unstable plaque in left internal carotid artery that protrudes into the lumen as well as moderate stenosis in the proximal segment of external carotid artery. Axial source imaging (a, b) and 3D reconstruction imaging (c, d) d c b a

Case of symptomatic mobile atheromatous plaque (MAP) at origin of internal carotid artery and management discussion: A case report

“…Meanwhile, for symptomatic lesions specifically described as mobile plaques, Ko et al, reported two cases with symptomatic MAP that were treated with ticlodipine 200mg daily [6,7]. Similar to the case that is presented here, follow up post one year in Ko et al, showed disappearance of floating plaque [7,8]. Granted that our patient can be classified as symptomatic, it is evident that medical management was both logical and sufficient.…”

A Patient with Carotid Mobile Plaques Treated by Carotid Artery Stenting Using a Double-layer Micromesh Stent

“…Several cases of plaque regression achieved by medical treatment alone including oral antithrombotic drugs have been reported 12,13) ; however, mobile plaques are accompanied by a pathologically degenerated arteriosclerotic flap, and ruptured plaques are accompanied by a mobile thrombus, intimal dissection, thin or defective fibrous capsule, lipid-rich necrotic core, and hemorrhage, and have been treated by CEA in many cases. [2][3][4][5]14,15) However, CAS may be a treatment choice for carotid artery stenosis patients with a past medical history specified as a risk factor for CEA in the stenting and angioplasty with protection in patients at a high risk for endarterectomy, 16) mobile plaques accompanied by clinically significant cardiac disease, severe pulmonary disease, contralateral carotid artery occlusion, contralateral laryngeal nerve palsy, previous radical neck surgery or radiation therapy to the neck, recurrent stenosis after endarterectomy, and age of 80 of vulnerable plaques using optical coherence tomography, and confirmed that the CASPER stent significantly reduced the incidence and volume of PP, suggesting it to prevent embolic complications of vulnerable plaques. 22) The CASPER stent, GORE Carotid Stent, and CGuard have achieved favorable early treatment outcomes in clinical studies performed in Western countries.…”

“…Several cases of plaque regression achieved by medical treatment alone including oral antithrombotic drugs have been reported 12 , 13) ; however, mobile plaques are accompanied by a pathologically degenerated arteriosclerotic flap, and ruptured plaques are accompanied by a mobile thrombus, intimal dissection, thin or defective fibrous capsule, lipid-rich necrotic core, and hemorrhage, and have been treated by CEA in many cases. 2 – 5 , 14 , 15) …”

“…1) They are considered a risk factor for ischemic stroke recurrence, but no treatment strategy has been established. 1) A few cases treated by carotid endarterectomy (CEA) [2][3][4][5] or carotid artery stenting (CAS) using an existing stent 6,7) have been reported, but mobile plaques are pathologically fragile and embolic complication caused by plaque protrusion (PP) is problematic; therefore, CAS is considered as a high-risk treatment. 8) On the other hand, new stents such as CASPER stent (MicroVention, Terumo, Tustin, CA, USA), a double-layer micromesh stent (Fig.…”