EJVES Vascular Forum (Jan 2020)
Management of a Mobile Floating Carotid Plaque Responsible for Calcified Cerebral Emboli: A Double Sword of Damocles
Abstract
Introduction: The management of a rare case of calcified cerebral emboli associated with a mobile carotid plaque (MCP) is reported and discussed. Report: A 76 year old patient presented with sudden weakness of the left lower limb one month ago, which resolved spontaneously. A cerebral magnetic resonance imaging showed recent multiple infarcts in the right middle cerebral artery (MCA) territory. Computed tomography cerebral angiogram (CTA) revealed calcified cerebral emboli (CCE) in the right MCA territory and an isolated calcified embolus in the M3 segment of the right MCA. No calcification was observed in the aorta. The echocardiogram findings were normal. Trans-oesophageal echocardiography did not show aortic or mitral valve calcifications. A cervical duplex ultrasound (DUS) was performed and demonstrated a highly mobile carotid plaque located in the right carotid bifurcation, contrasting with static CTA imaging showing a common calcified plaque, probably because the plaque appeared against the carotid wall during image acquisition. Antiplatelet and anticoagulation therapy were initiated, and carotid endarterectomy was performed on day two to prevent further embolisation. One month follow up including carotid DUS was satisfactory. Discussion: A case of mobile carotid plaque responsible for CCE which was diagnosed with DUS dynamic imaging is described, emphasizing the importance of multimodal imaging in such settings. Though the treatment of MCP remains controversial because of the paucity of published cases, carotid endarterectomy was considered to be the safest option to prevent recurrent stroke. Additional clinical data including large series and controlled trials are required to determine the best management of mobile carotid plaques with less than 50% diameter carotid stenosis.
