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 in 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 harbour unique information regarding plaque vulnerability: maximum plaque thickness and volume, calcification, ulceration, intraplaque haemorrhage, 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 are of 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 identification of individuals at high risk of ischemic stroke.