Toward recognizing the vulnerable asymptomatic atheromatous plaque from B-mode ultrasound: The importance of the morphology of the plaque shoulder

Efficient management of the asymptomatic carotid disease remains a crucial challenge in clinical practice, because the ultrasonographically estimated degree of stenosis, which is currently used to determine treatment decisions, has been shown to be inadequate. In this study, texture (morphological) characteristics were investigated in a sample of asymptomatic male subjects, at the atheromatous plaque, the adjacent arterial wall and the plaque shoulder, i.e. the boundary between plaque and adjacent wall. A total of 25 arteries were interrogated, 11 with low (50-69%) and 14 with high (70-100%) degrees of stenosis. The two groups had similar ages. Texture characteristics were estimated from systolic and diastolic B-mode ultrasound images, and included four second-order statistical parameters (contrast, correlation, energy and homogeneity), each calculated at four different image directions (0°, 45°, 90°, 135°), yielding a total of 16 characteristics. Between high and low stenosis groups, 8 out of 16 characteristics were statistically different at the plaque shoulder at systole and 6 at diastole. No differences were observed between the two groups for any of the texture characteristics at the plaque nor at the adjacent wall. Differences in morphology along the arterial wall (wall - shoulder - plaque) were more pronounced in cases of high stenosis. The findings indicated that (a) the plaque shoulder is a particular area, requiring additional investigation so as to better understand the pathophysiology of atherosclerosis, (b) the phase of the cardiac cycle (systole or diastole) is important in texture analysis, and (c) the variability of morphology along the arterial wall, which is indicative of areas of tissue discontinuities, and therefore more vulnerable to rupture, can be characterized quantitatively with texture indices, toward an improved assessment of cardiovascular risk. It can be concluded that ultrasound-based texture indices may reveal novel markers for early detection and monitoring of subjects at high risk of cerebrovascular events, in the context of individualized, noninvasive and affordable diagnosis.