Embolic Stroke Due to Symptomatic Nonstenotic Carotid Disease

Atherosclerosis of the internal carotid artery (ICA) can lead to clinically significant stenosis. Cerebral vascular events are often caused by plaque rupture and embolization. However, there are options in the management of symptomatic, low-grade CAS (<50%), with vulnerable plaque features. An 80-year-old man presented with an acute onset of right-sided weakness. Neurologic examination revealed pronounced right lower-extremity weakness. Head computed tomography (CT) showed no acute hemorrhage or ischemia. CT angiogram (CTA) of the head and neck revealed an ulcerated plaque with 40% stenosis of the left carotid bifurcation. Magnetic resonance imaging (MRI) of the brain showed scattered infarcts in the territory of the left anterior cerebral artery. The patient was deemed an ideal candidate for carotid revascularization and underwent endarterectomy with no complications. He was discharged home with no recurrence of stroke.  A 79-year-old man presented to the emergency department with an acute onset of right arm weakness and incoordination. Head CT showed chronic-appearing infarcts in the left paracentral gyri, corona radiata, and centrum semiovale. A CTA of the head and neck revealed an ulcerated plaque of the left cervical ICA origin with 45-50% stenosis per NASCET criteria. MRI of the brain showed multifocal acute left cerebral infarcts in a linear distribution, suggesting watershed territory ischemia. The patient was deemed an ideal candidate for revascularization of the left common carotid/ ICA for stroke prevention and underwent endarterectomy. He was discharged home with no recurrence of stroke. Our two cases emphasize the importance of considering ICA with vulnerable plaque as a source of embolic stroke, regardless of the degree of stenosis, and the benefit of revascularization for stroke prevention.