To the Editor.
—We found the hypothesis of carotid plaque disruption proposed by Fisher et al1 interesting but at variance with our clinicopathologic data in Toronto, Canada. The authors emphasize surface events in carotid plaques, but we believe that events within the body of the plaque may be equally, or even more, important.We evaluated 71 consecutive symptomatic carotid plaques, and found 85% had large hemorrhages, about half of which were massive and destructive to the plaque. The hemorrhages were mainly deeply situated, rarely connected to the lumen, but occurred mainly at the "shoulder" of the plaque, often the site of rich vascularity. Intraluminal clot was microscopic and infrequent except in one occluded case. Intraplaque hemorrhages were often older than the elapsed time, since symptoms, apparently preceding clinical events by weeks, were presumably not directly related. One patient underwent bilateral carotid surgery, and the pathologic findings of the symptomatic
Norris JW, Krajewski A, Bornstein NM, Lewis AJ. Carotid Plaque Disruption. Arch Neurol. 1989;46(6):605. doi:10.1001/archneur.1989.00520420023011
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