Case Presentation: An 82-year-old male with a history of hypertension, COPD, ischemic stroke, mild carotid stenosis, and hyperlipidemia presented with expressive aphasia, dysarthria, confusion, and left-sided weakness following a coughing spell. CT angiography revealed an acute infarct in the right posterior cerebral artery (PCA) territory, along with an irregular ruptured plaque in the proximal right internal carotid artery. A 6 mm saccular aneurysm was also identified near the right internal carotid artery terminus and right M1 origin. The irregular plaque shape suggested a recent embolization, which could explain the right PCA infarct, as the right PCA is mainly supplied by the right posterior communicating artery, which was occluded. Despite blood pressure control, the patient’s delayed presentation and the aneurysm complicated the clinical management.
Discussion: The interaction between carotid stenosis, COPD-related chronic cough, and the increased risk of plaque rupture is clinically significant. In this case, the patient’s mild carotid stenosis and COPD history contributed to an acute ischemic event following a severe coughing spell. This event likely caused the rupture of an unstable plaque, leading to an embolic stroke. The role of respiratory mechanics in vascular pathology stresses the need for heightened vigilance in patients with carotid stenosis, especially those predisposed to chronic coughing. Continuous fluctuations in intrathoracic pressure, as seen in COPD, may promote plaque instability and elevate stroke risk.The presence of a saccular aneurysm near the right internal carotid artery complicates the clinical scenario. Aneurysms, particularly under hemodynamic stress such as coughing, are prone to rupture or embolization. It is plausible that the same mechanical forces exerted by coughing on the carotid plaque also destabilized the aneurysm. This interaction between vascular anomalies, such as plaques and aneurysms, under increased intrathoracic pressure requires further investigation.Management strategies for patients with carotid stenosis and COPD should be reconsidered. While antiplatelet therapy and statins are the standard for reducing embolic events, patients with chronic coughing may require more intensive monitoring and early intervention, including a lower threshold for carotid endarterectomy. Surgical management may reduce the risk of further plaque rupture and ischemic events in high-risk patients.This case also calls for further research into the relationship between chronic respiratory conditions and carotid plaque vulnerability. Studies on the effects of intrathoracic pressure fluctuations on plaque destabilization could provide valuable insights. Developing tailored guidelines for managing patients with carotid stenosis and chronic cough, particularly those with COPD, could improve outcomes and reduce stroke incidence in these populations.
Conclusions: The intricate interplay between respiratory mechanics and vascular pathology highlights the importance of recognizing and addressing the potential consequences of routine coughing spells in patients with carotid stenosis. This case reinforces the importance of patient education and awareness regarding prompt medical attention for stroke symptoms. Future research efforts should focus on elucidating the precise mechanisms underlying plaque destabilization and exploring tailored management strategies to mitigate the risk of ischemic events in this vulnerable population.
