The “salted pretzel” sign: A radiological indication of a calcified amorphous tumor as a rare cause of embolic stroke

Abstract

Calcified amorphous tumors (CAT), also known as toothpaste tumors, are associated with a high prevalence of cerebrovascular events. Present literature provides limited information on conservative treatment strategies, as most published cases had undergone surgical treatment. Hence, this report demonstrates a conservative treatment of right middle cerebral artery syndrome in a 76-year-old woman due to a CAT. Cause for the syndrome was a high-density plaque occluding the inferior branch of the right middle cerebral artery (MCA) on the computed tomography (CT). The occlusion was resolved by only thrombolytic therapy, therefore additional mechanical thrombectomy was not necessary. Follow-up CT showed a small area of ischemic demarcation as well as a “salted pretzel” sign created by multiple calcified emboli within the distal MCA territory. Furthermore, transthoracic echocardiogram revealed a CAT of the mitral valve accompanied by severe calcified degeneration of the mitral annulus as the cause for the calcified cerebral emboli. Instead of surgical removal of the CAT the patient was started on a vitamin K antagonist for secondary prevention. This case suggests initial thrombolytic therapy can be an effective reperfusion strategy in patients presenting with calcified cerebral emboli. Moreover, treatment with an oral anticoagulant might be a conservative strategy for secondary prevention in selected cases.