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To the Editor: Dr Barnett and colleagues¹ have pointed out that not all strokes can be explained by the presence of flow-limiting stenosis. Several other causes of stroke, including cardioembolism, large artery postthrombotic hematologic conditions, and lacunae were considered. However, they did not mention that different forms of plaque, which can be characterized using ultrasound, can also lead to embolic stroke. Heterogeneous plaque is an independent risk factor for stroke regardless of the degree of stenosis.^2-6 Barnett et al have wisely pointed out that the identification of risk for stroke is complicated, and further study is needed to understand this significant risk factor. In thinking about and analyzing the issues surrounding risk for stroke, the role of characterization of plaque must not be forgotten. Unfortunately, the data on which their study was based originated in the North American Symptomatic Carotid Endarterectomy Trial (NASCET). In the NASCET, plaque type was not . . . [Full Text of this Article]

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