Pearls & Oy-sters: Recurrent Stroke From a Nonstenotic Carotid Plaque

In the etiologic assessment of ischemic stroke, conventional imaging techniques may underestimate the clinical significance of high-risk plaques that do not exhibit significant luminal stenosis. Here, we report the case of a 66-year-old male patient who experienced 3 recurrent strokes. Carotid ultrasound and digital subtraction angiography showed no apparent carotid stenosis. However, high-resolution MRI and postoperative pathology revealed a plaque in the common carotid artery with vulnerable features including positive remodeling, fibrous cap rupture, and intraplaque hemorrhage. This case highlights that vulnerable plaques can pose a risk of stroke even when stenosis is only mild and underscores the pivotal role of high-resolution imaging techniques in identifying plaque characteristics to refine stroke etiology assessment. This case provides valuable insight into the high-risk nature of nonstenotic plaques and supports the optimization of stroke risk stratification strategies.