Mild Carotid Stenosis with Recurrent Symptoms Triggered by Eating

Carotid atherosclerosis is a known risk factor for acute ischemic stroke. Although severe luminal narrowing is a well-established risk factor for future ischemic events, 10% of patients with acute ischemic stroke or transient ischemic attacks are thought to have ischemic events secondary to vulnerable carotid plaques in the setting of mild to moderate carotid artery stenosis.

A 78-year-old man presented with multiple recurrent strokes and transient ischemic attacks that consistently occurred with eating. Based on the anatomic relationships of the proximal internal carotid artery harboring the plaque, we hypothesized that multiple recurrent emboli occurred secondary to the mechanical effect of the esophagus "squeezing" the vulnerable plaque against the surrounding fixed tissues despite a mild degree of stenosis (approximately 20% stenosis on magnetic resonance angiography and angiography). Despite the mild stenosis, a carotid endarterectomy was performed, which resulted in immediate resolution of the ischemic events.

We postulate that the likely mechanical "squeeze" of the vulnerable plaque involving the retropharyngeal proximal internal carotid artery was responsible for the multiple recurrent transient ischemic attacks, which characteristically occurred only while eating. Resolution of the episodes after carotid endarterectomy supports this hypothesis.