"Haemorrhagic" carotid plaque does not contain haemorrhage

The presence of haemorrhage in carotid bifurcation atheromatous plaques is widely believed to be associated with the production of ischaemic neurological events. This study set out to characterise plaque composition in symptomatic (SYM) and asymptomatic (ASYM) patients and to identify, if possible, the origin of intra-plaque haemorrhage. Fifty-nine plaques (50 SYM and 9 ASYM) were serially sectioned and examined for haemorrhage, haemosiderin, fibrin, cholesterol and collagen. Immunoperoxidase and electron microscopy studies were carried out on sections from five plaques in order to identify blood breakdown products. Intra-plaque haemorrhage was identified in 40 (68%) plaques and was similar in SYM and ASYM plaques. In only one did it constitute more than 15% of plaque content, and in the remainder it consisted of small collections of erythrocytes constituting greater than 1% of plaque content in only 21 (35%) plaques. The predominant non-fibrous component was a pink amorphous material mixed with cholesterol. Apart from traces of platelet breakdown products there was no evidence of haemorrhage in this pink material. Plaque roof rupture or ulceration was seen in 39 (66%) and in almost all cases overlay the amorphous/cholesterol material. Blood vessels were identified in 51 87%) plaques but were in close proximity to haemorrhage in only nine (15%).