Value of Intraplaque Neovascularization on Contrast-Enhanced Ultrasonography in Predicting Ischemic Stroke Recurrence in Patients With Carotid Atherosclerotic Plaque

Fig. 1. Flow chart of patient recruitment. This flowchart shows the patient selection process, including the inclusion criteria, and finally 130 patients were included in this study. CEUS = contrast-enhanced ultrasonography

Fig. 2. Typical examples of conventional longitudinal carotid ultrasonographic images (left panel) and grades of carotid intraplaque neovascularization, based on contrast-enhanced ultrasonography examination (right panel). A. Grade 1: absence of enhancement in the core of plaque, and enhancement limited to the adventitia side of the plaque (arrows). B. Grade 2: extensive contrast enhancement throughout the plaque (arrows).

Fig. 3. Kaplan–Meier recurrence-free survival curves according to the contrast-enhanced ultrasonography (CEUS) findings. Recurrence-free survival in patients with plaque enhancement is significantly worse than that in those without plaque enhancement. HR = hazard ratio, IPN = intraplaque neovascularization

Fig. 4. Kaplan–Meier recurrence-free survival curves according to risk groups by Essen Stroke Risk Score (ESRS) and ESRS + contrast-enhanced ultrasonography (CEUS). A. Recurrence-free survival in the high-risk group is significantly worse than that in the low-risk group classified by the ESRS alone. B. Recurrence-free survival in the high-risk group is significantly worse than that in the low-risk group classified by CEUS plus ESRS. Note that when the presence of plaque enhancement was added to the ESRS, the hazard ratio (HR) for stroke recurrence was higher in high-risk groups than that of ESRS alone.

Fig. 5. Added value of carotid plaque enhancement (intraplaque neovascularization [IPN] grade 2) on Essen Stroke Risk Score for prediction of stroke recurrences. Over 19 months of follow-up, among 130 patients with carotid plaque, stroke recurrences occurred in 25 patients. Among patients with a low risk on the Essen Stroke Risk Score (n = 33), 2 (6.1%) were appropriately reclassified into the high-risk category.