A Case of Asymptomatic Calcified Cerebral Emboli Harboring a Vulnerable Calcified Carotid Plaque: Diagnostic and Therapeutic Considerations

Punctate intracranial calcifications observed on non-contrast computed tomography (CT) as sequelae of calcified cerebral emboli (CCE) may be easily overlooked, particularly in asymptomatic patients. However, such findings can serve as critical indicators of underlying embolic sources, such as unstable or heavily calcified carotid plaques. Accurate recognition is essential, as timely therapy can significantly reduce the risk of future cerebrovascular events. We report the case of an 84-year-old man with a past history of carotid artery stenting for symptomatic left internal carotid artery (ICA) stenosis performed five years earlier. At that time, no evidence of stenosis was observed in the right ICA. The patient remained asymptomatic, until non-contrast brain CT incidentally revealed multiple punctate calcific foci in the right cerebral hemisphere, exhibiting the characteristic "salted pretzel sign". Suspected newly proved CCE, subsequent diagnostic evaluations were performed to reveal a heavily calcified carotid plaque in the right ICA, suggestive of a potential embolic source. The patient subsequently underwent an uneventful carotid endarterectomy to prevent future ischemic events. This case highlights the clinical significance of the accurate diagnosis of asymptomatic CCE and its underlying embolic source such as a high-risk carotid plaque. Furthermore, importance of optimal preventative intervention is emphasized to reduce the risk of subsequent ischemic insults.