Is angiography still the best method to stratify stroke risk in symptomatic atherosclerotic carotid plaque?

The degree of vessel lumen narrowing is an independent predictor of ischemic stroke. New developments in carotid plaque morphology imaging (MR, CT), may bring new insights to the relationship between carotid atherosclerotic disease and stroke risk. Our aim is to review the stroke risk in a symptomatic patient with moderate carotid stenosis by CT imaging and histopathology. A 72-year-old patient with low ABCD2 scores TIA and moderate left internal carotid stenosis (50% by carotid ultrasound), was discharged with an optimized medical therapy. Four months later, he presented an ischemic stroke in the left frontal area. Carotid angiography showed a 60% stenosis in the leftinternal carotid artery with a regular surface. CT plaque imaging detected a thin fibrous cap with calcification and an intraplaque hemorrhage (highrisk plaque). These findings were confirmed in the histolopathological study of the atherosclerotic plaque performed after the endarterectomy. After 1 year of follow-up, the patient returned independently to his daily activities. We propose, in this study, the inclusion of noninvasive plaque imaging in the evaluation of acute TIA with moderate carotid stenosis to better select patients with higher risk of stroke recurrence.