Advances in Noninvasive Carotid Wall Imaging with Ultrasound: A Narrative Review

Carotid atherosclerosis is a major cause for stroke, with significant associated disease burden morbidity and mortality in Western societies. Diagnosis, grading and follow-up of carotid atherosclerotic disease relies on imaging, specifically ultrasound (US) as the initial modality of choice. Traditionally, the degree of carotid lumen stenosis was considered the sole risk factor to predict brain ischemia. However, modern research has shown that a variety of other imaging biomarkers, such as plaque echogenicity, surface morphology, intraplaque neovascularization and vasa vasorum contribute to the risk for rupture of carotid atheromas with subsequent cerebrovascular events. Furthermore, the majority of embolic strokes of undetermined origin are probably arteriogenic and are associated with nonstenosing atheromas. Therefore, a state-of-the-art US scan of the carotid arteries should take advantage of recent technical developments and should provide detailed information about potential thrombogenic (/) and emboligenic arterial wall features. This manuscript reviews recent advances in ultrasonographic assessment of vulnerable carotid atherosclerotic plaques and highlights the fields of future development in multiparametric arterial wall imaging, in an attempt to convey the most important take-home messages for clinicians performing carotid ultrasound.

Automated summary

Carotid atherosclerosis is a major risk factor for stroke. Ultrasonography is the preferred method for diagnosing and grading carotid atherosclerotic disease. Modern research has identified multiple imaging biomarkers, such as plaque echogenicity and morphology, neovascularization, and vasa vasorum, that play a role in predicting the risk of carotid plaque rupture and subsequent cerebrovascular events. Additionally, nonstenosing atheromas may be associated with embolic strokes of undetermined origin. Therefore, state-of-the-art carotid ultrasound should incorporate recent technical advancements to provide detailed information on thrombogenic and emboligenic arterial wall features.