Objectives: Atherothrombosis in the carotid arteries is a main cause of ischemic stroke, and may depend on plaque propensity to complicate with rupture or erosion, in turn related to qualitative features amenable to in vivo imaging. This would provide an opportunity for risk stratification and – potentially – local treatment of more “vulnerable” plaques. We here review current information on this topic.

Methods: We systematically reviewed the literature for concepts derived from pathophysiological, histopathological and clinical studies on imaging techniques attempting at identifying vulnerable carotid lesions.

Results: Magnetic resonance imaging, computed tomography, ultrasound- and nuclear medicine-based techniques, alone or with multimodality approaches, all have a link to pathophysiology, and describe different – potentially complementary – aspects of lesions prone to complication. There is also, however, a true paucity of head-to-head comparisons of such techniques for practical implementation of a thorough and cost-effective diagnostic strategy. Especially in asymptomatic patients, major international societies leave wide margins of indecision in the advice to techniques guiding interventions to prevent atherothrombotic stroke.

Conclusions: To improve practical management of such patients – in addition to patient’s vulnerability for systemic reasons – a more precise identification of the vulnerable plaque is needed. A better definition of the diagnostic yield of each imaging approach in comparison with the others should be pursued for a cost-effective translation of the single techniques. Practical translation to guide future clinical practice should be based on improved knowledge of the specific pathophysiologic correlates and on a comparative modality approach, linked to subsequent stroke outcomes.

Supplemental materials for Neurology paper