Contrast‐enhanced ultrasound for the evaluation of symptomatic and asymptomatic carotid plaques: A systematic review and meta‐analysis

Abstract Background Contrast‐enhanced ultrasound (CEUS) is a promising imaging modality for the assessment of plaque vulnerability. We aimed to systematically review and meta‐analyze the ability of CEUS parameters to differentiate between symptomatic and asymptomatic carotid plaques and to assess its reproducibility. Methods PubMed, EMBASE, and Cochrane Library databases were searched for studies that potentially evaluated carotid plaques using CEUS. From the initial 2870 searches, 11 relevant publications comprising a total of 821 carotid plaques were reviewed. Data on CEUS parameters including quantitative and semi‐quantitative parameters were extracted and analyzed. Results The overall analysis showed significantly higher CEUS parameters in symptomatic carotid plaques compared to asymptomatic carotid plaques (standardised mean difference (SMD) .95, 95% confidence interval (CI) .56–1.27, p < .01). Intra and inter‐observer reproducibility of quantitative CEUS parameters were excellent (intra‐observer, r = .95, 95% CI .87–1; inter‐observer, r = .93, 95% CI .80–.1). Semi‐quantitative CEUS parameters showed good intra‐observer reliability and moderate inter‐observer reliability (intra‐observer, r = .77, 95% CI .64–.89; inter‐observer, r = .75, 95% CI .61–.89). Heterogeneity among studies compared CEUS parameters in symptomatic and asymptomatic plaques and studies assessed inter‐observer reproducibility, and significant biases in studies assessing CEUS reproducibility were present. Conclusion CEUS is a useful vascular imaging method to differentiate between symptomatic and asymptomatic carotid plaques with moderate to excellent reproducibility. Quantitative CEUS analysis appeared to be more sensitive and reliable in assessing carotid plaques than semi‐quantitative parameters. Further longitudinal prospective trials evaluating carotid plaque in asymptomatic population using CEUS to determine plaque characteristics that can become symptomatic are required.