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A 58-year-old woman presented 1 week after a single episode of left-eye blindness that lasted 30 seconds. It spontaneously resolved, and she had no further visual disturbances. She denies weakness, numbness, paralysis, paresthesias, speech disturbance, or gait disturbance. A carotid duplex ultrasound suggested a less than 50% left internal carotid artery (ICA) stenosis, but there was a suggestion of a complex plaque. Further imaging with computed tomography (CT) angiography was performed, and showed a left ICA eccentric, ulcerative complex plaque not associated with a significant stenosis.


  • While degree of carotid stenosis is related to stroke risk, plaque morphology may also play a role.

  • Increased risk for neurologic events is seen in patients with less organized, soft, echolucent, complex, or ulcerated plaque, regardless of the degree of stenosis. Plaque that is echolucent, heterogeneous, and ulcerated, and has a high lipid content core may be more unstable and prone to rupture with embolization.1

  • Intraplaque hemorrhage, or plaque with thin or ruptured fibrous caps, may also present a higher stroke risk (Figure 23-1).


An ulcerated complex carotid lesion on angiography (red arrow).


  • Gross characteristics of plaque morphology, such as presence of ulceration, thrombus, calcification, or eccentricity, can be defined by standard carotid duplex or angiography.

  • Duplex imaging has the additional capability of identifying homogeneous or heterogeneous plaque and echogenic or echolucent plaque.

  • Intravascular ultrasound performed at the time of carotid angiography can provide even more detail about plaque characteristics.

  • Studies on the use of high-resolution computed tomography (CT) and magnetic resonance (MR) imaging, as well as fluorodeoxyglucose positron emission tomography (FDG-PET) imaging, to define what constitutes high- and low-risk carotid plaque are ongoing.

  • As these imaging techniques improve at predicting the behavior of carotid plaque, it may become possible to predict which patients are more likely to benefit from intervention for asymptomatic carotid stenosis.2,3, and 4


  • Diagnosis and clinical features of ulcerative cervical carotid disease are similar to those of nonulcerative disease. However, risk of stroke from these lesions is less well defined.

  • All patients should receive optimal medical therapy. Aspirin is indicated for all patients with atherosclerotic carotid disease.

  • Warfarin may be indicated to treat patients who have had stroke from cardiac embolization, but there is no evidence supporting the use of heparin and warfarin or clopidogrel to prevent or treat stroke related to ulcerative (or stenotic) cervical carotid disease.

  • Management of hypertension and hypercholesterolemia, smoking cessation, and dietary and activity modification are all mainstays of treatment.

  • Some advocate intervention when patients have had stroke or transient ischemic attack (TIA), even when the degree of carotid stenosis is less than 50%.

  • Intervention for asymptomatic ulcerative lesions that produce a high-grade stenosis ...

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