Carotid-artery imaging in the diagnosis and management of patients at risk of stroke

Carotid atherosclerotic disease is one of the major preventable causes of ischaemic strokes. In clinical practice, decision making with regard to carotid endarterectomy or stenting is still primarily based on the extent of luminal stenosis. In most centres worldwide, luminal stenosis is now mainly assessed with non-invasive techniques, such as Doppler ultrasound, magnetic resonance angiography, and CT angiography, either alone or in combination. Although intra-arterial digital subtraction angiography remains the historical gold standard, it has now mostly been replaced by these non-invasive techniques. Moreover, in addition to luminal stenosis, certain morphological features of carotid plaques, such as large lipid cores, intraplaque haemorrhage, or thin or ruptured fibrous caps, are increasingly believed to be associated with heightened risk of stroke. In this Review, we discuss current state-of-the-art non-invasive diagnostic imaging strategies for luminal stenosis and describe the most promising novel imaging techniques, such as high-resolution MRI and CT combined with PET imaging, which can be used to characterise vulnerable carotid-plaque features in vivo.