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Carotid plaque inflammation in a patient with unstable angina
Antonella Lombardo1, Stefano Coli, Luigi Natale
1Department of Cardiology, Catholic University, Rome, Italy. ant.lombardo@tin.it
Insights
Systemic inflammation may drive multifocal plaque instability. Magnetic resonance imaging revealed an inflamed carotid plaque in a patient with coronary instability, preceding a stroke after cardiac surgery, suggesting widespread atherosclerotic disease.
Area of Science:
- Cardiovascular Medicine
- Radiology
- Neurology
Background:
- Coronary instability is linked to multifocal plaque activation, suggesting a systemic inflammatory cause.
- Magnetic resonance imaging (MRI) shows promise for detecting plaque inflammation.
Observation:
- A 73-year-old female presented with unstable angina, elevated C-reactive protein, and three-vessel disease.
- Carotid ultrasound revealed a 50% stenotic atherosclerotic plaque in the left internal carotid artery with irregular and heterogeneous features.
Findings:
- Pre- and post-contrast MRI demonstrated carotid plaque inflammation, including increased vessel wall thickness, edema (high signal intensity on triple inversion recovery-fast spin-echo), and neovascularization (homogeneous enhancement).
- The patient underwent coronary bypass surgery due to coronary disease; however, she subsequently suffered an ischemic stroke.
Implications:
- The case suggests simultaneous coronary and carotid plaque instability, with inflammation potentially linking them.
- Inflamed carotid plaques, even with <70% stenosis, may pose a stroke risk, particularly in patients undergoing cardiac surgery.
- This highlights the potential of MRI in identifying high-risk plaques and understanding systemic inflammatory processes in atherosclerosis.
Abstract:
Coronary instability has been associated with multifocal plaque activation in the coronary circulation and in remote vascular districts, suggesting a systemic cause of instability, possibly inflammation. Magnetic resonance imaging offers a great potential for the detection of plaque inflammation. We describe the case of a 73-year-old female admitted for unstable angina, elevated levels of C-reactive protein and three-vessel disease, in whom carotid ultrasound examination revealed an atherosclerotic plaque of the left proximal internal carotid artery with an irregular profile and a heterogeneous echographic texture, determining a 50% stenosis. Magnetic resonance imaging of the plaque before and after contrast enhancement by gadolinium-DTPA showed the following signs of inflammation: an increased vessel wall thickness, an increased triple inversion recovery-fast spin-echo signal intensity indicative of tissue edema, and a homogeneous plaque contrast enhancement indicative of an increased capillary permeability and neovasculature. As the carotid stenosis was < 70% and did not give rise to any symptom, the patient was submitted to coronary bypass surgery without concomitant carotid endarterectomy. Two days later she developed an ischemic stroke with right brachiocrural hemiplegia. In the present case report, the simultaneous presence of coronary instability and a carotid plaque with magnetic resonance features suggestive of inflammation, which was probably responsible for the stroke complicating cardiac surgery, may indicate a multifocal plaque instability.