Rupture of Nonstenotic Carotid Plaque as a Cause of Ischemic Stroke Evidenced by Multimodality Imaging

A 34-year-old woman was admitted for sudden onset of left-sided hemiparesis. Diffusion-weighted magnetic resonance imaging (MRI) 12 hours after symptom onset was positive, with hypersignal in the territory of the right middle cerebral artery consistent with acute cerebral infarction. Magnetic resonance angiography confirmed occlusion of the right middle cerebral artery and found a 30% stenosis (North American Symptomatic Carotid Endarterectomy Trial criteria) of the origin of the right internal carotid artery. Carotid ultrasound (Figure, A–D) evidenced the presence of a noncalcified plaque of the right carotid causing a stenosis of the origin of the internal carotid artery evaluated at 40% (North American Symptomatic Carotid Endarterectomy Trial criteria). Results of electrocardiography, Holter monitoring, transthoracic and transesophageal echocardiography, and laboratory investigations were all normal.Figure. A–D , Carotid ultrasound of the right carotid showed the presence of a noncalcified plaque with gray-scale 2-dimensional imaging (white arrow; A , longitudinal view; C , axial view) that caused a …