Two conjoined plaques or a flap?

Sir,

We read Petar et al.’s case report with great interest.[1] In this manuscript, ultrasonography (USG) and magnetic resonance imaging (MRI) angiography findings of the left carotid artery after a 1 year follow-up of a patient with hemiparesis and speech disturbance were presented. It has been stated that within a year, the two plaques were conjoined, forming a membranous plaque dividing the lumen of the common carotid artery. However, we felt obliged to specify our views to avoid some misunderstandings. The authors have used power Doppler USG method to evaluate the plaque of the carotid artery and presented the images obtained. However, because of the pulsatile nature, vessels like the carotid artery have significant motion, thus, the power Doppler method causes pulsation and blooming artefacts complicating the evaluation of the wall and plaque surface, and fine details as intimal flap or free thrombus can be missed. Therefore, there may be missed thin intimal flap continuity especially, in the evaluation of intimal flap and/or free luminal thrombus, high-resolution probes with well-focused B-mode and/or B-flow USG could have been an ideal diagnosing method. While power Doppler can be affected by pulsation and blooming artefacts, B-flow USG imaging allows accurate evaluation of vessel intimal surface and lumen without aliasing and without the blooming flow artefacts.[2] It has been specified that 5 years earlier the patient had undergone bilateral endarterectomy. Our opinion is that in this patient a flap might have remained secondary to the endarterectomy. We believe that by time or secondary to leaving the anti-platelet therapy a blood clot aggregated on the flap and these blood clots may have caused stroke. The occluded part may have been defined as a plaque and with the treatment given within 1 year the lumen may have reformed again. Furthermore, axial source image of the MRI angiography has been presented. On this image, the luminal linear formation is more consistent with a thin intimal flap. If on the work station, sagittal and/or coronal reformatted images were reconstructed from the source images and re-evaluated or shared by the authors, we think that a longitudinal continuity of an intimal flap may possibly be seen.