BACKGROUND: Plaque erosions are distinct pathological entities in patients with acute cardiovascular events. However, high resolution visualization by currently available imaging modalities in patients is limited. CASE SUMMARY: A 79-year-old man presented to the hospital with left-sided paresis concerning for ischemic stroke. The etiology was suspected to be a symptomatic right internal carotid artery stenosis, for which he underwent carotid endarterectomy. The resected plaque was examined with a scanning fiber angioscope, and findings were corroborated with histology and scanning electron microscopy. DISCUSSION: Angioscopy revealed multiple flat areas of mottled red color in the arterial surface, corresponding on scanning electron microscopy to areas of loss of endothelial coverage with numerous erythrocytes entrapped and compressed by an extensive fibrin network. Cross-sectional histology confirmed plaque erosions. TAKE-HOME MESSAGES: Plaque erosions are distinct pathological entities of acute cardiovascular events. Laser angioscopy can identify erosions of the vascular surface.