Imaging of the ulcerated carotid atherosclerotic plaque: a review of the literature

Fig. 1. Diagrammatic representations and MDCTA images illustrating the classification of carotid plaques based on their surface morphology as smooth (a), irregular (b) and ulcerated (c)

Fig. 2. Diagrammatic representations illustrating the classification of ulcerated carotid plaques in relation to the blood flow direction

Fig. 3. Ultrasonographic images and diagrammatic representations illustrating the various ulcer types (arrowheads showing the ulcers) (from left to right: eFlow, Power Doppler, xFLow and Power Doppler technique). eFlow and xFlow are high-definition blood flow imaging modes available in certain ultrasound devices

Fig. 4. MDCTA images showing carotid plaques with ulcers of type 1a (a), 1b (b), 2 (c), 3 (d) and 4 (e) (arrowheads showing ulcers)

Fig. 5. Ultrasonographic images and diagrammatic representations of potential previously undescribed types of ulcerated plaques. eFlow technique delineating a V-shaped ulcer (a) and an ulcer resembling a bucket handle (b), both in common carotid artery plaques

Fig. 6. Imaging findings of an ulcerated carotid plaque with intraplaque neovascularisation. B-mode image (a) identified the presence of an anechoic cavity possibly representing an ulceration. Colour Doppler image (b) showing flow reversal within the ulcer cavity. CEUS (c) a few seconds after the intravenous administration of microbubbles confirms the presence of ulceration while the plaque appears anechoic. Delayed CEUS image (d) revealed the presence of moving microbubbles within the plaque and near its adventitial side representing intraplaque neovascularisation (arrow). MDCTA image (e) showing the ulcerated plaque in correlation with ultrasonographic techniques

Fig. 7. Imaging findings in a symptomatic patient with ulcerated carotid plaque. B-mode image (a) showing a smooth atherosclerotic plaque, appearing predominantly hypoechoic. Colour Doppler image (b) confirming the plaque’s smooth surface and showing severe luminal stenosis of the internal carotid artery. Note that the flow is not adequately visualised in the internal carotid artery as parts of the lumen contain no flow signals. CEUS (c) improved visualisation of blood flow in the whole field of view and provided detailed delineation of the plaque surface. Note the presence of a small superficial ulceration (arrow) and intraplaque neovessels (arrowheads). MDCTA (d) confirming the presence of a small ulceration (arrowhead) in an otherwise smooth plaque causing stenosis of the internal carotid artery. Axial contrast-enhanced T1-weighted MRI image (e) of the same patient performed 1 week later for follow-up of stroke confirmed the presence of ulceration (arrowhead)

Fig. 8. Differential diagnosis of ulceration and focal calcification with MDCTA. Axial MDCTA image (a) showing a potential small superficial ulceration (arrow). Respective unenhanced MDCT image (b) proving that this hyperdense material represents a focal calcification and not an ulcer. Axial MDCTA image (c) showing an ulcer (arrow). The unenhanced MDCT image (d) confirms the absence of calcification at this point of the vessel

Fig. 9. MRA findings in ulcerated carotid plaques. Axial T2-weighted image (a) showing flow void in the vessel lumen and slightly higher signal intensity within the origin of internal carotid artery, possibly representing a stenotic plaque (arrowhead). Contrast-enhanced MRA (b) identifying a type 3 ulcerated carotid plaque (arrowhead, same patient with Fig. 4d). Axial T2-weighted image (c) showing a projection of the luminal flow void within a high-signal intensity area, consistent with an ulcerated fatty plaque (arrowhead). Contrast-enhanced MRA (d) confirming the presence of a type 1a ulceration (arrowhead, same patient as in Fig. 4a). Axial contrast-enhanced T1-weighted image confirming the presence of contrast material within the ulcer’s cavity (arrow) (e)