Pathology and vulnerability of atherosclerotic plaque: identification, treatment options, and individual patient differences for prevention of stroke.

OPINION STATEMENT: Vulnerable carotid plaques at risk for rupture/ulceration do not always correlate with the severity of stenosis at bifurcation sites. Therefore, information on plaque morphology and composition is essential for identifying patients at high risk for acute major cerebrovascular events. Traditional imaging modalities, including angiography and ultrasound, are slowly being replaced by CT imaging, as this technology is readily available in most hospitals and provides high-resolution capabilities at relatively low cost. Improvements in MRI, particularly high-resolution gadolinium-enhanced MRI, currently make this modality the most informative technology, as it allows easy identification of lesion morphometry, calcification, and hemorrhage. Further, multimodal imaging of carotid artery plaques using fluorodeoxyglucose positron emission tomography/CT is slowly growing out of its infancy and is providing valuable information on the inflammatory component of the plaque, a critical indicator of lesion instability. These recent advancements in imaging technologies will no doubt dictate early treatment options for symptomatic and asymptomatic patients with noncritical carotid stenosis in the near future. Ultimately, however, the identification of important molecular surrogates in early lesion progression may eventually predict late-term risk and likely will provide the ideal strategy for reducing the morbidity and mortality of stroke.