Advances in Multimodality Carotid Plaque Imaging: AJR Expert Panel Narrative Review

Contemporary imaging methods provide detailed visualization of carotid atherosclerotic plaque, enabling a major evolution of in vivo carotid plaque imaging evaluation. The degree of luminal stenosis in the carotid artery bifurcation, as assessed by ultrasound, has historically served as the primary imaging feature for determining ischemic stroke risk and the potential need for surgery. However, stroke risk may be more strongly driven by the presence of specific characteristics of vulnerable plaque, as visualized on CT and MRI, than by traditional ultrasound-based assessment of luminal narrowing. This review highlights six promising imaging-based plaque characteristics that harbor unique information regarding plaque vulnerability: maximum plaque thickness and volume, calcification, ulceration, intraplaque hemorrhage, lipid-rich necrotic core, and thin or ruptured fibrous cap. Increasing evidence supports the association of these plaque characteristics with risk of ischemic stroke, although these characteristics have varying suitability for clinical implementation. Key aspects of CT and MRI protocols for carotid plaque imaging are also considered. Practical next steps and hurdles are explored for implementing routine imaging assessment of these plaque characteristics in addition to, or even as replacement for, traditional assessment of the degree of vascular stenosis on ultrasound, in the identification of individuals at high risk of ischemic stroke.

Automated summary

Contemporary imaging methods have allowed for detailed visualization of carotid atherosclerotic plaque, which has led to significant advancements in in vivo evaluation of carotid plaque imaging. While traditional ultrasound-based assessment of luminal stenosis has historically been used to determine ischemic stroke risk, newer imaging techniques such as CT and MRI have shown that specific characteristics of vulnerable plaque may be more indicative of stroke risk. This review highlights six promising imaging-based plaque characteristics that provide unique information on plaque vulnerability and their potential impact on risk of ischemic stroke.