Diagnostic Performance of Deep Learning and Radiomics in Extracranial Carotid Plaque Detection: Systematic Review and Meta-Analysis

Background: Artificial intelligence-enhanced imaging techniques have demonstrated promising diagnostic potential for carotid plaques, a key cardiovascular and cerebrovascular risk factor. However, previous studies did not systematically synthesize their diagnostic accuracy. Objective: This study aimed to quantitatively explore the diagnostic efficacy of deep learning (DL) and radiomics for extracranial carotid plaques and establish a standardized framework for improving plaque detection. Methods: We searched the PubMed, Embase, Cochrane, Web of Science, and Institute of Electrical and Electronics Engineers databases to identify studies involving the use of radiomics or DL models to diagnose extracranial carotid artery plaques from inception up to September 24, 2025. The quality of the studies was determined using Quality Assessment of Diagnostic Accuracy Studies for Artificial Intelligence (QUADAS-AI). A meta-analysis was conducted using StataMP (version 17.0; StataCorp) with a bivariate mixed-effects model to calculate pooled sensitivity and specificity, generate summary receiver operating characteristic (SROC) curves, assess Cochran Q statistic and I²-based heterogeneity, and conduct subgroup analyses and regression analysis. Results: Among 40 studies comprising 17,246 patients, 34 integrated independent test sets or validation sets in the quantitative statistical analysis. Among them, 24 focused on DL models, 10 on machine learning models based on radiomics. The combined sensitivity, specificity, and area under the SROC curve were 0.88 (95% CI 0.85-0.91; P<.001; I2=93.58%), 0.89 (95% CI 0.85-0.92; P<.001; I2=91.38%), and 0.95 (95% CI 0.92-0.96), respectively. Compared with the machine learning models based on radiomics algorithms, DL models achieved comparable improvements in specificity and area under the SROC curve. It was observed that transfer learning and a large sample size enhanced the diagnostic performance of models. Models used to identify plaque stability and presence had similar diagnostic performances, both of which were more effective in identifying symptomatic plaque models. A total of 7 studies demonstrated that the models that combined clinical features exhibited comparable diagnostic capability to pure DL and radiomics models. Additionally, 7 studies performed external validation, obtaining lower diagnostic performance than in testing groups. Limited regression analysis failed to identify significant sources of heterogeneity, and the limited number of eligible studies restricted more comprehensive subgroup analyses. The high heterogeneity in the study results may be due to different scanning parameters, model architecture, image segmentation, and algorithms. Conclusions: Radiomics algorithms and DL models can effectively diagnose extracranial carotid plaque. However, there are concerns regarding irregularities in research design and the absence of multicenter studies and external validation. Future research should aim to reduce bias risk and enhance the generalizability and clinical orientation of the models.