Carotid Imaging: Current Concepts and Advanced Imaging
Luca Saba1, Alessandro Pinna1, Jasjit S Suri2,3,4,5
1Department of Radiology, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
Insights
Carotid atherosclerosis management is shifting from stenosis severity to plaque biology. Advanced imaging techniques and artificial intelligence offer precise stroke risk stratification and personalized prevention strategies.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Radiology
Background:
- Carotid atherosclerosis is a primary cause of ischemic stroke.
- Traditional management relies on luminal stenosis, which doesn't fully capture plaque vulnerability.
- Plaque characteristics like intraplaque hemorrhage (IPH) and inflammation significantly impact stroke risk.
Purpose of the Study:
- To review advances in multimodal imaging for carotid plaque phenotyping.
- To highlight the role of novel imaging biomarkers in stroke risk stratification.
- To discuss the integration of imaging, AI, and molecular biology for precision stroke prevention.
Main Methods:
- Review of current and emerging imaging modalities including ultrasound, CTA, MRI, PCCT, and PET.
- Discussion of advanced techniques like contrast-enhanced ultrasound, radiomics, and AI.
- Exploration of standardized reporting frameworks like Plaque-Reporting and Data System.
Main Results:
- Multimodal imaging provides comprehensive morphological and biological plaque information.
- MRI is key for IPH detection; CTA and PCCT enhance tissue characterization.
- PET tracers assess inflammatory and calcification pathways; AI and radiomics improve risk stratification.
Conclusions:
- Imaging is evolving from lumen quantification to detailed plaque phenotyping.
- Multimodal imaging, AI, and molecular data are crucial for personalized stroke prevention.
- Future carotid imaging aims for precision medicine to optimize patient outcomes.
Abstract:
Carotid atherosclerosis is a major cause of ischemic stroke, historically managed according to luminal stenosis severity. However, stenosis alone fails to capture plaque biology, as features such as intraplaque hemorrhage (IPH), lipid-rich necrotic core, fibrous cap rupture, ulceration, and perivascular inflammation strongly influence vulnerability and clinical outcomes. Advances in imaging have shifted the focus from lumen quantification to multimodal plaque phenotyping. Ultrasound, computed tomography angiography (CTA), magnetic resonance imaging (MRI), digital subtraction angiography, photon-counting CT (PCCT), and positron emission tomography (PET) provide complementary morphological and biological information, while contrast-enhanced ultrasound, radiomics, and artificial intelligence (AI) enhance risk stratification beyond conventional parameters. MRI remains the reference for detecting IPH, while CTA and PCCT improve lumen and tissue characterization. PET tracers further interrogate inflammatory and calcification pathways. Emerging frameworks such as Plaque-Reporting and Data System aim to standardize reporting and integrate multimodal biomarkers. The future of carotid imaging lies in precision medicine, combining advanced imaging, AI, and molecular biology to optimize individualized stroke prevention strategies.
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