Unmasking complicated atherosclerotic plaques on carotid magnetic resonance angiography: A report of three cases

In stenotic lesions of the extracranial carotid arteries, the presence of intraplaque hemorrhage or thrombosed ulceration is considered to pose an additional risk. Although contrast-enhanced magnetic resonance angiography (MRA) is a powerful means for looking at the vascular lumen, it provides little information on the vessel wall, particularly when mask subtraction methods are used. We report three cases in which the maximal intensity projections obtained from gadolinium-enhanced MRA source images showed only internal carotid artery stenoses, whereas source images revealed a focal increased T1 signal in the wall of the internal carotid artery, representing either intraplaque hemorrhage or thrombosed ulceration. Hence, the physicians interpreting an MRA in an acute stroke patient should not limit themselves to the synthetic maximal intensity projections but should also always review the source partitions, which can contain information related to an acute intraplaque accident.