Abstract

Background
Identifying the aetiology of ischemic stroke can be challenging, especially when critical findings are overlooked. Stroke assessment often relies on standardised guidelines, primarily focused on carotid stenosis severity (>50%) as an intervention criterion. However, this approach may neglect high-risk plaque features. This case report highlights the importance of integrating diagnostic findings with clinical presentation to guide management.
Case presentation
A 68-year-old male presented with sudden-onset transient right arm weakness. Initial imaging, including MRI and CT angiography, revealed a subtle diffusion-weighted imaging (DWI) abnormality in the left hemisphere and moderate carotid atherosclerosis (<50%) that did not meet guideline criteria for endarterectomy. Despite antiplatelet and anticoagulant therapy, the patient experienced multiple recurrent ischemic episodes. Due to the persistence of symptoms, the multidisciplinary team (MDT) recommended advanced vessel wall MRI, which identified intraplaque haemorrhage and plaque ulcerations in the left internal carotid artery—critical findings missed on conventional imaging. This led to a decision to perform carotid endarterectomy. Histology confirmed atheromatous disease with intraplaque haemorrhage. Following surgery, the follow-up scans showed no new infarcts with no clinical recurrence.
Discussion
This case underscores the limitations of relying solely on carotid stenosis degree in stroke management and highlights the importance of identifying high-risk plaque characteristics. Advanced vessel wall imaging proved instrumental in guiding treatment, while MDT collaboration ensured a tailored approach. The findings emphasise the need to prioritise carotid stenosis characteristics over stenosis degree alone when guiding clinical decisions to optimise outcomes in ischemic stroke management.