Review articleInternational Union of Angiology (IUA) consensus paper on imaging strategies in atherosclerotic carotid artery imaging: From basic strategies to advanced approaches☆
Graphical abstract
Section snippets
Targets of carotid imaging
Detailed imaging assessment of extracranial carotid artery disease is critical for appropriate risk stratification and management of those presenting with cerebrovascular ischemia as well as of selected asymptomatic individuals [1].
The degree of luminal stenosis in the carotid bifurcation has historically served as the primary imaging feature for determining ischemic stroke risk and the potential need for surgery. Contemporary multimodality imaging including ultrasound, magnetic resonance
Stenosis
Grading and stratification of carotid stenosis is manly based on multiparametric, hemodynamic criteria on Duplex ultrasound [4] (Table 2). The most important parameters are the measurement of the peak systolic and the end-diastolic flow velocity within the stenosis. The accuracy of Duplex ultrasound compared with angiography for detecting >50% and ≥70% stenosis, respectively, is very good, with a positive predictive value of >90% and a specificity of >85% [5]. Duplex ultrasound is recommended
Stenosis
CTA has evolved along with the technological advances of CT hardware and software. Modern CTA, performed with multidetector high-speed CT hardware and evaluated with 3D reformatting software, accurately and reliably depicts carotid disease and allows for direct quantification of carotid stenosis in millimeters [[66], [67], [68], [69], [70], [71], [72]].
CTA is an anatomic study of arteries, allowing for direct evaluation of carotid stenosis. CTA is fast, with images of the head and neck acquired
Stroke risk assessment and characterization of low-grade carotid atherosclerosis
Risk assessment of carotid atherosclerotic plaque for cerebrovascular ischemic events has historically relied on angiographic measures of stenosis, with thresholds for revascularization defined by randomized clinical trials that date back to the early 1990's [93,110,111]. The established threshold for SCS is 70%, although revascularization is often considered for stenosis beginning at 50% when symptomatic and 60% when asymptomatic [93,110,112,113]. Stenosis has worked well in these studies
PET
PET enables molecular imaging of biological and biochemical processes in vivo, whereas hybrid PET/CT [137] or PET/MRI [138,139] also provides additional information on plaque morphology. The glucose analogue 18F-Fluorodeoxyglucose (FDG) is taken up by cells with a high metabolic rate, such as macrophages within an atherosclerotic plaque, and therefore enables to quantify the inflammatory activity within carotid atherosclerotic plaques [140]. In order to correct for uptake of the tracer in the
Artificial intelligence
As stroke is the second leading cause of global mortality, this demonstrated the need for improved tools in the management of occlusive vascular disease [163,164]. Patients with cardiovascular disease leading to stroke often require significant medical imaging in the acute, sub-acute, and chronic settings, using a range of imaging modalities. Vascular imaging is then used as a key source of information in the determination of appropriate clinical management. In the era of modern medicine, AI is
Summary and conclusion
Ultrasonography is the first-line imaging modality for the evaluation of atherosclerotic carotid artery disease, as it is non-invasive, cost-effective, readily available, well-tolerated, and safe [213,214]. Anatomic information is provided with traditional B-mode (greyscale) ultrasound, while hemodynamic information is provided with color Doppler, power Doppler, and pulsed-wave Doppler technique [213,214].
The image quality provided by ultrasound can be enhanced by the use of a contrast agent [
CRediT authorship contribution statement
Luca Saba: Conceptualization, Methodology, Validation, Writing – review & editing. Pier Luigi Antignani: Conceptualization, Methodology, Validation, Writing – review & editing. Ajay Gupta: Conceptualization, Writing – original draft. Riccardo Cau: Conceptualization, Writing – original draft, Writing – review & editing. Kosmas I. Paraskevas: Methodology, Writing – original draft. Pavel Poredos: Methodology, Writing – original draft. Bruce A. Wasserman: Writing – original draft. Hooman Kamel:
Declaration of competing interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Seemant Chaturvedi is on the executive committee of CREST 2 and ACT I and serves as an Associate Editor for Stroke. Dr. Luis Savastano is equity owner and CMO of VerAvanti Inc.
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J. Pitha was supported by Ministry of Health of the Czech Republic, grant No. NU22-02-00051.