Acute Neurological Events Research Articles

A Transient Acute Neurological Event in a Patient Undergoing GPi Microelectrode Mapping

Chowdhury, Tumul MD, DM*; Wilkinson, Marshall F. PhD†; Krcek, Jerry P. BA, MSc PhD, MD, FRCSC† Author Information

Persistent Giant U Wave Inversion with Anoxic Brain Injury

Various electrocardiographic changes have been reported in the setting of acute neurological events, among them large, upright U waves. In contrast, the occurrence of inverted U waves is strongly suggestive of cardiovascular disease, most commonly hypertension, coronary artery disease, or valvular abnormalities. Presented herein is the case of a 29-year-old man with previous anoxic brain injury (but without apparent cardiovascular disease) whose electrocardiogram demonstrated persistent giant inverted U waves.

Painful Vaso-occlusive Crisis as a Prodromal Phase of Acute Chest Syndrome. Is Only One Chest X-ray Enough? A Case Report

The predominant pathophysiological feature of homozygous sickle cell anemia (SCA) is the vaso-occlusion. Vaso-occlusion can be associated with painful crises, which are the primary reason for those patients to seek medical care. Vaso-occlusion is responsible for the acute chest syndrome (ACS) with large morbidity and mortality or more rarely (and especially in adults) for priapism and acute neurological events (strokes). A 10-year-old boy with homozygous SCA was admitted to the Pediatric Emergencies with painful vaso-occlusive crisis and fever. Initially he had normal chest X-ray but, after 24-hour-hospitalization, he developed ACS with new chest X-ray findings. He was treated with broad spectrum antibiotics, blood transfusions and bronchodilators and after a six-day treatment, he was significantly improved. The patient was discharged 13 days later with no other therapy at home. The possibility of ACS development should be still considered, even when a known patient with SCA presents a painful vaso-occlusive crisis with an initial normal chest X-ray. Therefore, repeated clinical examination is required and possible changes in the clinical status could indicate the necessity of a new radiographic examination. In this way, early ACS could be recognized and the catastrophic consequences due to this syndrome could be avoided.

Neuropsychiatric Lupus, the Blood Brain Barrier, and the TWEAK/Fn14 Pathway

Patients with systemic lupus erythematosus (SLE) can experience acute neurological events such as seizures, cerebrovascular accidents, and delirium, psychiatric conditions including depression, anxiety, and psychosis, as well as memory loss and general cognitive decline. Neuropsychiatric SLE (NPSLE) occurs in between 30 and 40% of SLE patients, can constitute the initial patient presentation, and may occur outside the greater context of an SLE flare. Current efforts to elucidate the mechanistic underpinnings of NPSLE are focused on several different and potentially complementary pathways, including thrombosis, brain autoreactive antibodies, and complement deposition. Furthermore, significant effort is dedicated to understanding the contribution of neuroinflammation induced by TNF, IL-1, IL-6, and IFN-γ. More recent studies have pointed to a possible role for the TNF family ligand TWEAK in the pathogenesis of neuropsychiatric disease in human lupus patients, and in a murine model of this disease. The blood brain barrier (BBB) consists of tight junctions between endothelial cells (ECs) and astrocytic projections which regulate paracellular and transcellular flow into the central nervous system (CNS), respectively. Given the privileged environment of the CNS, an important question is whether and how the integrity of the BBB is compromised in NPSLE, and its potential pathogenic role. Evidence of BBB violation in NPSLE includes changes in the albumin quotient (Qalb) between plasma and cerebrospinal fluid, activation of brain ECs, and magnetic resonance imaging. This review summarizes the evidence implicating BBB damage as an important component in NPSLE development, occurring via damage to barrier integrity by environmental triggers such as infection and stress; cerebrovascular ischemia as result of a generally prothrombotic state; and immune mediated EC activation, mediated by antibodies and/or inflammatory cytokines. Additionally, new evidence supporting the role of TWEAK/Fn14 signaling in compromising the integrity of the BBB in lupus will be presented.

Complex visual hallucinations in a patient with chronic schizophrenia and alcohol dependence: a case report and literature review

AbstractThe aim of this study was to report a patient with complex visual perceptual disturbances and a 30-year history of schizophrenia and alcohol dependence, and to formulate a comprehensive clinical approach to this unique neuropsychiatric phenomenon.The authors report subjective and objective information from the patient’s past medial history and current admission. The authors also did a comprehensive review of the literature on complex visual hallucinations.Complex visual hallucination is a frightening experience, with a pathogenesis ranging from chronic psychiatric disorders, such as schizophrenia, to acute neurological events, such as cerebrovascular accident. The hallucination content is typically described by patients as vivid with dynamic images, in striking colors and clear contours. The authors report a patient earlier diagnosed with schizophrenia and alcohol dependence disorder who became agitated following a sudden onset of visions of vivid, interactive images of people and animals.Due to the scope of the differential diagnosis, identifying the exact underlying etiology of complex visual hallucinations is often challenging, yet critical, in preventing the high risk of morbidity and mortality associated with some of the root causes of this neuropsychiatric phenomenon.

Newborn Screening for Sickle Cell Disease in Brussels, a Program with an Ongoing Clinical Outcome Improvement

AbstractAbstract 4757Early identification of sickle cell disease (SCD) by newborn screening (NS) is well established to be an efficient and practical tool in enhancing the health care of affected patients with SCD. The aim of our study, conducted in Brussels Region, was to assess whether there is an ongoing improvement of clinical outcome of children with SCD detected by the NS program.Universal NS was progressively implemented in Brussels starting within a few maternity wards in 1994 and extending to all maternity wards in 2000. Children identified with SCD progressively benefited from comprehensive expert medical care in three dedicated reference centers. Care included education, prevention, emergency and specific out-patient and in-patient treatments. To evaluate the improvement in comprehensive care, we reviewed data of children born from January 1st 2000 to December 31st 2003 (group A) and from January 1st 2005 to December 31st 2008 (group B). All data were recorded from January 1st 2000 to December 31st 2005 for group A and from January 1st 2005 to December 31st2010 for group B. Both groups had the same follow-up period accounting for 118 patient-years in group A and 259 patient-years in group B. Median follow-up was 3.5 yrs (range 2.06–5.83 yrs) and 4.1 yrs (range 2.08–5.96 yrs) in group A and B respectively. The major events such as septicemia, anemia, dactylitis, vaso-occlusive event (VOC), acute chest syndrome (ACS), symptomatic neurological events and hospital days were reviewed and compared during the study follow-up between the two groups. The reasons for hospitalization that were selected were: septicemia, pneumonia, urinary tract infection, osteomyelitis, gastroenteritis, VOC crisis, dactylitis, ACS, acute splenic sequestration, aplastic episodes and neurologic events. Several biological parameters were also reviewed.Among the 98 patients identified with SCD at birth, 33 (16 girls and 17 boys) and 65 (37 girls and 28 boys) belonged to group A and B, respectively. In group A, 25 children were HbSS, 2 HbSβ+ and 6 HbSC. In group B, 53 were HbSS, 5 HbSβ°, 5 HbSβ+ and 2 had an other genotype. Most of the patients developed at least one major adverse event during the study period. The proportion of patients having presented severe anemia and acute chest syndrome was significantly lower in group B than in group A (table 1). The higher rate of septicemia in group A could be due to the delayed implementation of national vaccination for Streptococcus pneumonia or to the poor prophylactic penicillin compliance. No difference was observed between both groups for dactylitis, VOC and clinical neurological event. No patient died during the study period. Hematological parameters at one year of age were not different between both groups.In conclusion, newborn screening is obviously recognized as a precious tool to identify patients with SCD. However, it must be part of a comprehensive care program. Our results demonstrated that its sustained effectiveness is really and clearly proven when it is coupled with a comprehensive and dedicated treatment program including close and regular parent education. This ongoing assessment should be performed to monitor and improve the screening program. Thereby the progressively implementation of comprehensive care has improved over time the quality of SCD management and then the outcome of patients in Brussels Region.Table 1Patients identified by neonatal screening in Brussels with SCD related eventsSCD related eventsGroup A (N=33) Follow-up from 2000–2005 Number of patients (%)Group B (N=65) Follow up from 2005–2010 Number of patients (%)P valueDactylitis9 (27.3)19 (29.2)1.0Acute Chest Syndrome14 (42.4)10 (15.4)0.005Vaso-Occlusive Crisis21 (63.6)29 (44.6)0.09Anemia ≤ 6 g/dl22 (66.7)26 (40.00)0.02Septicemia3 (9.1)1 (1.5)0.10Neurological Event0 (0.0)2 (3.1)0.55 Disclosures:No relevant conflicts of interest to declare.

Cerebrospinal fluid biomarker supported diagnosis of Creutzfeldt–Jakob disease and rapid dementias: a longitudinal multicentre study over 10 years

To date, cerebrospinal fluid analysis, particularly protein 14-3-3 testing, presents an important approach in the identification of Creutzfeldt–Jakob disease cases. However, one special point of criticism of 14-3-3 testing is the specificity in the differential diagnosis of rapid dementia. The constant observation of increased cerebrospinal fluid referrals in the national surveillance centres over the last years raises the concern of declining specificity due to higher number of cerebrospinal fluid tests performed in various neurological conditions. Within the framework of a European Community supported longitudinal multicentre study (‘cerebrospinal fluid markers’) we analysed the spectrum of rapid progressive dementia diagnoses, their potential influence on 14-3-3 specificity as well as results of other dementia markers (tau, phosphorylated tau and amyloid-β1–42) and evaluated the specificity of 14-3-3 in Creutzfeldt–Jakob disease diagnosis for the years 1998–2008. A total of 29 022 cerebrospinal fluid samples were analysed for 14-3-3 protein and other cerebrospinal fluid dementia markers in patients with rapid dementia and suspected Creutzfeldt–Jakob disease in the participating centres. In 10 731 patients a definite diagnosis could be obtained. Protein 14-3-3 specificity was analysed for Creutzfeldt–Jakob disease with respect to increasing cerebrospinal fluid tests per year and spectrum of differential diagnosis. Ring trials were performed to ensure the comparability between centres during the reported time period. Protein 14-3-3 test specificity remained high and stable in the diagnosis of Creutzfeldt–Jakob disease during the observed time period across centres (total specificity 92%; when compared with patients with definite diagnoses only: specificity 90%). However, test specificity varied with respect to differential diagnosis. A high 14-3-3 specificity was obtained in differentiation to other neurodegenerative diseases (95–97%) and non-neurological conditions (91–97%). We observed lower specificity in the differential diagnoses of acute neurological diseases (82–87%). A marked and constant increase in cerebrospinal fluid test referrals per year in all centres did not influence 14-3-3 test specificity and no change in spectrum of differential diagnosis was observed. Cerebrospinal fluid protein 14-3-3 detection remains an important test in the diagnosis of Creutzfeldt–Jakob disease. Due to a loss in specificity in acute neurological events, the interpretation of positive 14-3-3 results needs to be performed in the clinical context. The spectrum of differential diagnosis of rapid progressive dementia varied from neurodegenerative dementias to dementia due to acute neurological conditions such as inflammatory diseases and non-neurological origin.

Urgent carotid endarterectomy to prevent recurrence and improve neurologic outcome in mild-to-moderate acute neurologic events

Urgent carotid endarterectomy to prevent recurrence and improve neurologic outcome in mild-to-moderate acute neurologic events

Intraoperative neurological event during cesarean section under spinal anesthesia with fentanyl and bupivacaine: Case report and review of literature

Neurological events similar to transient ischemic attack in a peripartum woman are uncommon. Cerebral complications of preeclampsia, thrombo-embolic phenomena, or high spinal can mimic such situations. Spinal anesthesia with local anesthetic and opioid is an established anesthetic technique for cesarean section. Although intrathecal opioids are safe for both the mother and fetus; some unusual complications such as dysphagia alone or associated with facial numbness, aphasia, have been reported. We report a case of transient aphonia and tingling sensation over the face without any dysphagia after intrathecal administration of bupivacaine and fentanyl for cesarean section.

Postoperative Complications and Long-Term Survival Among Patients Treated Surgically for Renal Cell Carcinoma

In addition to their acute implications, adverse events after oncological surgery may have late or long-term consequences for patient outcomes. We assessed the relationship between postoperative complications and long-term survival among patients treated surgically for kidney cancer. Using Surveillance, Epidemiology and End Results-Medicare data we identified patients with kidney cancer treated surgically from 1995 through 2005. After excluding from analysis those who died during the index hospitalization or within 30 days of surgery we compared overall survival for patients with or without a postoperative complication. We then fit multivariate Cox proportional hazard models to estimate the association between complications and long-term survival, adjusting for patient characteristics, cancer severity and surgical approach. We identified 4,687 (37%) and 7,931 patients (63%) with and without a postoperative complication, respectively. During a median followup of 32 months (range 1 to 132) 3,425 patients (27.1%) died of any cause. Patients with at least 1 postoperative complication had lower unadjusted 5-year survival (59.9% vs 69.5%, p <0.001). On multivariate analyses the occurrence of a complication was also associated with significantly worse long-term survival (HR 1.24, 95% CI 1.16-1.33). This relationship was consistent with time, across surgical approaches and among patients with various specific complications, including acute renal failure, cardiac and neurological events, postoperative infection and sepsis. The occurrence of a postoperative complication is associated with decreased long-term survival after surgery for kidney cancer. Clarification of the cascade of events underlying this relationship may lead to new strategies to improve outcomes among cancer survivors.

Control of methicillin-resistant Staphylococcus aureus (MRSA): the impact of active surveillance for MRSA in a non-acute hospital in Madrid (Spain)

Because of the frequent interchange of patients between acute hospitals and rehabilitation hospitals, infections caused by multidrug-resistant bacteria will continue to emerge. There are limited data concerning the epidemiology of nosocomial infection among patients admitted for rehabilitation in non acute hospitals after stabilization of an acute surgical or neurological event. Recognition of such threats has prompted new interest in the prevention and control of infections associated with those health-care facilities.

Transient Ischaemic Attacks

Atransient ischaemic attack (TIA) is defined as an acute neurological event causing loss of focal cerebral or ocular function lasting less than 24 hours and thought to be due to inadequate cerebral or ocular blood supply. More than 46 000 people suffer a TIA in the UK each year. Of these, approximately 10% will go on to suffer a stroke within the next 5 days and 20% within the next 4 weeks. The importance of this diagnosis both to the individual and to the National Health Service (NHS) is therefore huge. This article will discuss the diagnosis and management of TIA in general practice including primary and secondary preventative strategies.

Safety and efficacy of bone marrow-derived autologous CD133 stem cell therapy

The Phase I clinical study was designed to assess the safety and feasibility of a dose escalating intracoronary infusion of autologous bone marrow (BM)-derived CD133+ stem cell therapy to the patients with chronic total occlusion (CTO) and ischemia. Nine patients were received CD133+ cells into epicardial vessels supplying collateral flow to areas of viable ischemic myocardium in the distribution of the CTO. There were no major adverse cardiac events (MACE), revascularization, re-admission to the hospital secondary to angina, or acute myocardial infarction (AMI) for the 24-month period following cellular infusion. In addition, there were no periprocedural infusion-related complications including malignant arrhythmias, loss of normal coronary blood flow or acute neurologic events. Cardiac enzymes were negative in all patients. There was an improvement in the degree of ischemic myocardium, which was accompanied by a trend towards reduction in anginal symptoms. Intracoronary infusion of autologous CD133+ marrow-derived cells is safe and feasible. Cellular therapy with CD133+ cells to reduce anginal symptoms and to improve ischemia in patients with CTO awaits clinical investigation in Phase II/III trials.

Comparison of Adverse Cardiovascular Events and Bleeding Complications of Loading Dose of Clopidogrel 300 mg Versus 600 mg in Stable Patients Undergoing Elective Percutaneous Intervention (from the CADICE Study)

In large clinical trials enrolling patients with acute coronary syndromes, a high loading dose of clopidogrel (600 mg) has been found to be more effective compared to a low loading dose (300 mg). However, the applicability of these data to stable patients who undergo elective percutaneous coronary intervention is still unclear. A total of 400 patients who underwent elective PCI were prospectively randomized to receive either 600 mg (n = 200) or 300 mg (n = 200) of clopidogrel, followed by a daily maintenance dose of 75 mg. The primary end point was the presence of major adverse cardiovascular events (combined death, myocardial infarction, acute neurologic event, stent thrombosis, and need for percutaneous or surgical revascularization of the target vessel) during hospitalization and at 30 days. The secondary end point was periprocedural vascular complications, major bleeding, and cardiac enzyme elevation. There were no differences in the primary end point among the groups immediately after the procedure (3.5% of patients in the 300-mg group vs 4.5% of those in the 600-mg group, p = 0.799) or at 30 days (6% vs 5%, respectively, p = 0.826). The rates of periprocedural vascular complications (2.5% vs 3%, respectively, p = 1.00), bleeding complications (9% vs 8.5%, respectively, p = 1.00), and cardiac enzyme elevation (11% vs 15.5%, respectively, p = 0.317) were similar between the 2 groups. In conclusion, adverse cardiovascular events and bleeding complications during the initial hospitalization and at 30-day follow-up were similar when a 600-mg loading dose of clopidogrel was used compared to the conventional dose of 300 mg.

Urgent carotid endarterectomy to prevent recurrence and improve neurologic outcome in mild-to-moderate acute neurologic events

This study evaluated the safety and benefit of urgent carotid endarterectomy (CEA) in patients with carotid disease and an acute stable neurologic event. The study involved patients with acute neurologic impairment, defined as ≥ 4 points on the National Institutes of Health Stroke Scale (NIHSS) evaluation related to a carotid stenosis ≥ 50% who underwent urgent CEA. Preoperative workup included neurologic assessment with the NIHSS on admission or immediately before surgery and at discharge, carotid duplex scanning, transcranial Doppler ultrasound imaging, and head computed tomography or magnetic resonance imaging. End points were perioperative (30-day) neurologic mortality, significant NIHSS score improvement or worsening (defined as a variation ≥ 4), and hemorrhagic or ischemic neurologic recurrence. Patients were evaluated according to their NIHSS score on admission (4-7 or ≥ 8), clinical and demographic characteristics, timing of surgery (before or after 6 hours), and presence of brain infarction on neuroimaging. Between January 2005 and December 2009, 62 CEAs were performed at a mean of 34.2 ± 50.2 hours (range, 2-280 hours) after the onset of symptoms. No neurologic mortality nor significant NIHSS score worsening was detected. The NIHSS score decreased in all but four patients, with no new ischemic lesions detected. The mean NIHSS score was 7.05 ± 3.41 on admission and 3.11 ± 3.62 at discharge in the entire group (P < .01). Patients with an NIHSS score of ≥ 8 on admission had a bigger score reduction than those with a lower NIHSS score (NIHSS 4-7; mean 4.95 ± 1.03 preoperatively vs 1.31 ± 1.7 postoperatively, NIHSS ≥ 8 10.32 ± 1.94 vs 4.03 ± 3.67; P < .001). In patients with acute neurologic event, a high NIHSS score does not contraindicate early surgery. To date, guidelines recommend treatment of symptomatic carotid stenosis ≤ 2 weeks from onset of symptoms to minimize the neurologic recurrence. Our results suggest that minimizing the time for intervention not only reduces the risk of recurrence but can also improve neurologic outcome.

Recurrent Hypothermia and Hypoglycemia as the Initial Presentation of Hepatitis C

Purpose: Hypothermia and hypoglycemia on initial presentation is sepsis until proven otherwise. However, hypothermia and hypoglycemia can coexist in other conditions such as severe malnutrition, neurological injury, alcoholism, hypothyroidism, and adrenal insufficiency. Hepatitis C most commonly manifests with asymptomatic elevations in transaminase levels. We describe the case of a 50-year-old African American male who had recurrent hypothermia and hypoglycemia as the initial presentation of Hepatitis C. Methods: Case: A 50-year-old African American male with a past medical history of diabetes mellitus 2, hypothyroidism, seizure disorder, and remote alcoholism presented with acute onset of altered mental status and hypothermia in the ER. He had been hypoglycemic at the nursing home in the absence of insulin or other medications associated with hypoglycemia. Laboratory evaluation on admission revealed an unremarkable complete metabolic panel, ammonia level, amylase, lipase, urine drug screen, and blood alcohol level. A head CT was unremarkable for an acute neurological event. It was presumed that the patient's disorientation was secondary to hypoglycemia at his nursing home and possible sepsis, given his hypothermia. Broad spectrum antibiotics were initiated. However, the patient continued to experience hypoglycemia despite a 10% dextrose drip and recurrent hypothermia in the absence of sepsis. Further investigations including thyroid studies, AM cortisol, insulin, proinsulin, c-peptide, insulin antibodies, adrenocorticotropic hormone (ACTH), aldosterone, HIV studies, and microbial cultures were all negative. An abdominal CT revealed a dilated common bile duct, a possible hepatoma, and a dilated pancreatic duct. An endoscopic ultrasound (EUS) was performed to evaluate for malignancy, such as a hepatoma that may secrete insulin growth factor causing hypoglycemia. EUS revealed severe chronic pancreatitis without evidence of a mass. Hepatitis studies done when there was suspicion for a hepatoma revealed the patient to be positive for hepatitis C antibody, which was confirmed by positive RNA. He was found to have a low glucagon level, which explained his hypoglycemia, while his liver disease explained his hypothermia. His mental status improved with aggressive glucose supplementation and warming blankets. Later in his hospital course, the patient developed sequelae of liver disease being ascites and coagulopathy. Conclusion: We describe a rare case of Chronic Hepatitis C that presented with recurrent hypoglycemia as a result of glucagon depletion and recurrent hypothermia from advanced liver disease without previous liver disease sequelae.

Life expectancy for people with disabilities

This article reviews the literature on life expectancy in the disabled population. The literature is surveyed with regard to the main elements that reduce life expectancy for people with disabilities. These are immobility, cognitive and intellectual impairment, swallowing problems and tube feeding, epilepsy and incontinence. The article discusses various improvements in survival in the last few years and discusses the possibility of further improvements in the future. The difficulties are discussed with regard to early prediction of life expectancy both in childhood and after an acute neurological event in adulthood. The literature is then reviewed with regard to the cohort studies on quantification of life expectancy in disabled people. The literature is discussed and pragmatic clinical conclusions are drawn.

Late stroke after foam sclerotherapy

Foam sclerotherapy is a safe, effective and increasingly widespread method of treating varicose veins. A case of ischemic stroke is described with reversible symptoms five days after polidocanol foam sclerotherapy was repeated in a 48-year-old female patient with a patent foramen ovale that was undetected at the time of sclerotherapy. The first foam sclerotherapy treatment had been tolerated well without complications. While acute neurological events immediately after sclerotherapy for varicose veins have been described repeatedly in the literature, this report is only the third case described worldwide of paradoxical embolism as a possible late complication of foam sclerotherapy for varicose veins.

Disappearing Flapping Plaque in the Internal Carotid Artery

Mobile atheromatous plaque at the origin of the internal carotid artery (ICA) is a rare finding at the carotid ultrasound examination. Acute thrombosis is unusually seen. Either may be secondary to plaque hemmorhage, plaque ulceration, carotid dissection, or proximal embolus. We report an 89-year-old male suffering from an acute neurologic event who on ultrasound had a flapping heterogeneous atheromatous plaque at the right ICA origin. This mobile atheromatous plaque is distinguished from acute thrombus by its echogenicity, narrow pedicle of attachment, and absence of underlying intima. Subsequent computed tomography angiography and repeat ultrasound within 24 hr demonstrated the disappearance of this plaque. Only three small intimal flaps remained. In the intervening period, the patient's symptoms significantly worsened. While conservative management of thrombus with intravenous thrombolysis has been shown in some settings to be appropriate, the diagnosis and management of mobile atheroma are unclear. This case suggests that differentiation between atheroma and thrombus may be valuable in determining management strategies.

Imaging the Vulnerable Carotid Artery Plaque

Imaging plays a key role in the selection of patients for carotid artery surgery. Indication for carotid endarterectomy or stenting is based on symptomatology and degree of stenosis as determined by angiography, duplex ultrasonography or computed tomographic angiography. Degree of stenosis has long time been assumed the most reliable predictor of stroke-risk in patients with carotid artery stenosis and accordingly, traditional imaging methods were focused on luminal stenosis.There is, however, growing evidence that other factors than degree of stenosis determine whether a carotid plaque will result in acute neurologic events or not. Various morphological characteristics and molecular processes have proven to be highly related to carotid plaque instability and symptomatology. As a result, the focus of imaging techniques in carotid artery disease is more and more shifting towards identification of the vulnerable plaque rather than the high-grade stenosis. In traditional imaging modalities, new insights of imaging beyond degree of stenosis have been explored and may be able to detect morphological characteristics of plaque vulnerability. In addition, advanced molecular imaging methods have been developed and are able to identify molecular and cellular processes in the vulnerable carotid artery plaque. It is clear that recent developments in carotid imaging are of great potential in the identification of the vulnerable carotid plaque.