Abstract
ObjectiveThe degree of stenosis of a carotid plaque is a well-established risk factor for ischemic stroke. Nevertheless, the risk of ipsilateral stroke in asymptomatic carotid stenosis remains low and new imaging markers are needed to better target which patients would benefit most from endarterectomy or intensive medical therapy. Ultrafast ultrasound imaging offers parameters helping at characterizing the carotid plaque by shear wave elastography and Ultrafast Doppler (UFD). We aimed at using these techniques to characterize 3 different ultrasound biomarkers: plaque stiffness heterogeneity, wall shear stress (WSS) and intraplaque micro-flows and to correlate these biomarkers with findings on computed tomography angiography (CTA) and the pathological examination.MethodsWe present the case of a multimodal evaluation of a carotid plaque using ultrasound. Elastography has been coupled to the WSS assessment and the detection of intraplaque micro-flows by UFD. The data have been compared to CTA and to the pathology examination of the tissue after carotid endarterectomy.ResultsElastography allowed at identifying stiff areas corresponding to calcifications, as well as a soft area corresponding to an intraplaque hemorrhage. The flow evaluation with UFD showed an increase of the WSS along the plaque and identified the presence of a plaque rupture, confirmed by the pathologist.ConclusionUltrafast ultrasound imaging is an innovative, easily accessible technique that provides imaging modalities on top of the conventional B-mode. Ultrafast ultrasound biomarkers such as plaque stiffness heterogeneity, WSS and intraplaque micro-flows could help to define the vulnerability of the carotid plaque in order to stratify patients that could benefit most from endarterectomy or intensive medical therapy.
Highlights
Carotid endarterectomy in case of asymptomatic plaque has been tested by 2 large randomized trials, ACAS and ACST trials (Walker et al, 1995; Halliday et al, 2010)
According to Lovett et al, the presence of a rupture of the fibrous cap and an intraplaque hemorrhage were significantly associated with irregularity of the carotid plaque on angiography, which appeared as a strong independent predictor of ipsilateral ischemic stroke on medical treatment at all degrees of stenosis (Rothwell et al, 2000), categorizing the plaque as vulnerable (Eliasziw et al, 1994; Streifler et al, 1994; Rothwell et al, 2000; Lovett et al, 2004)
High wall shear stress (WSS) values were found associated with the presence of intraplaque hemorrhage (Tuenter et al, 2016), as we report in our case
Summary
The degree of stenosis of a carotid plaque is a well-established risk factor for ischemic stroke. The risk of ipsilateral stroke in asymptomatic carotid stenosis remains low and new imaging markers are needed to better target which patients would benefit most from endarterectomy or intensive medical therapy. Ultrafast ultrasound imaging offers parameters helping at characterizing the carotid plaque by shear wave elastography and Ultrafast Doppler (UFD). We aimed at using these techniques to characterize 3 different ultrasound biomarkers: plaque stiffness heterogeneity, wall shear stress (WSS) and intraplaque micro-flows and to correlate these biomarkers with findings on computed tomography angiography (CTA) and the pathological examination
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