Abstract
Intracranial atherosclerotic disease (ICAD) accounts for 9–15% of ischemic stroke in the United States. Although highly stenotic ICAD accounts for most of the strokes, it is assumed that nonstenotic ICAD (nICAD) can result in stroke, despite being missed on standard luminal imaging modalities. We describe a patient with nICAD who suffered recurrent thromboembolic stroke and TIA but had a negative conventional stroke workup. As a result, they were referred for high-resolution magnetic resonance imaging (HR-MRI) of the arterial vessel wall, which identified a nonstenotic plaque with multiple high-risk features, identifying it as the etiology of the patient's thromboembolic events. The diagnosis resulted in a transition from anticoagulation to antiplatelet therapy, after which the patient's clinical events resolved. HR-MRI is an imaging technique that has the potential to guide medical management for patients with ischemic stroke, particularly in cryptogenic stroke.
Highlights
Intracranial atherosclerotic disease (ICAD) accounts for 9– 15% of ischemic stroke in the United States, approximately 70,000 cases yearly, with even higher incidence in Asian, African American, and Hispanic populations [1,2,3]
With the development of high-resolution magnetic resonance imaging (HR-MRI) of the arterial vessel wall it has become apparent that nonstenotic ICAD can result in stroke [4,5,6] despite being missed on standard luminal imaging modalities, which may depict a symptomatic plaque as a normal vessel due to the predilection of lesions to outwardly remodel [7, 8]
We report the first case of symptomatic nonstenotic ICAD (nICAD) from thrombus attributable to plaque rupture seen on HR-MRI
Summary
Intracranial atherosclerotic disease (ICAD) accounts for 9– 15% of ischemic stroke in the United States, approximately 70,000 cases yearly, with even higher incidence in Asian, African American, and Hispanic populations [1,2,3]. With the development of high-resolution magnetic resonance imaging (HR-MRI) of the arterial vessel wall it has become apparent that nonstenotic ICAD (nICAD) can result in stroke [4,5,6] despite being missed on standard luminal imaging modalities, which may depict a symptomatic plaque as a normal vessel due to the predilection of lesions to outwardly remodel [7, 8]. The features of high-risk extracranial carotid atherosclerosis include intraplaque hemorrhage, thinning/rupture of the fibrous cap, and prominent lipid-rich necrotic core [9]. These risk factors are less well established for ICAD but are presumably similar and hold promise as prognostic indicators of future or recurrent stroke. We report the first case of symptomatic nICAD from thrombus attributable to plaque rupture seen on HR-MRI
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