{"product_id":"three-dimensional-ultrasound-a-more-complete-picture-of-carotid-artery-disease-and-stroke-risk","title":"Three-Dimensional Ultrasound: A More Complete Picture of Carotid Artery Disease and Stroke Risk","description":"\u003cp\u003eStroke is a leading cause of disability and death worldwide, and roughly 20–30% of ischemic strokes are caused by the rupture of fatty plaques that build up inside the carotid arteries — the main blood vessels that carry oxygen-rich blood to the brain. For decades, doctors have measured the degree of narrowing (stenosis) in these arteries as the main predictor of stroke risk, but this approach has significant limitations. This review from researchers at Pisa University in Italy examines a more advanced imaging technology called three-dimensional echography (3D ultrasound) that measures the actual volume, surface features, and texture of carotid plaques. The authors demonstrate that 3D ultrasound can detect dangerous plaque features that traditional two-dimensional (2D) imaging misses, predict future heart attacks and strokes more accurately than conventional risk scores, and monitor whether treatments like statins are actually shrinking plaque — all without radiation or invasive procedures.\u003c\/p\u003e\n\n\u003ch1\u003eThree-Dimensional Ultrasound: A More Complete Picture of Carotid Artery Disease and Stroke Risk\u003c\/h1\u003e\n\n\u003ch2\u003eTable of Contents\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\u003ca href=\"#ddn-key-points\"\u003eKey Points\u003c\/a\u003e\u003c\/li\u003e\n\n  \u003cli\u003e\u003ca href=\"#background\"\u003eWhy This Research Matters: The Stroke Risk Problem\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#methods\"\u003eHow the Researchers Conducted This Review\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#history\"\u003eThe History of Measuring Plaque in 3D\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#clinical\"\u003eWhy 3D Imaging Changes the Clinical Approach\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#plaque-volume\"\u003eTotal Plaque Volume and Risk Prediction\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#vessel-wall\"\u003eVessel Wall Volume: Another Way to Measure Disease\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#plaque-composition\"\u003eUlceration and Plaque Texture: The Dangerous Features\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#comparison\"\u003eHow 3D Ultrasound Compares to Angiography and MRI\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#implications\"\u003eWhat This Means for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#limitations\"\u003eLimitations of the Technology\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#recommendations\"\u003eRecommendations for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#ddn-faq\"\u003eFrequently Asked Questions\u003c\/a\u003e\u003c\/li\u003e\n\u003cli\u003e\u003ca href=\"#source\"\u003eSource Information\u003c\/a\u003e\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003c!-- ddn:keypoints:start --\u003e\n\u003ch2 id=\"ddn-key-points\"\u003eKey Points\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003ePlaque volume and area predict stroke risk better than the percentage of carotid narrowing alone.\u003c\/li\u003e\n\u003cli\u003e3D ultrasound detects plaque features 2D imaging misses, including ulceration and texture changes.\u003c\/li\u003e\n\u003cli\u003eStatin therapy can change plaque volume within 3 months, allowing early treatment monitoring.\u003c\/li\u003e\n\u003cli\u003ePatients with 3 or more carotid ulcers had 18% stroke\/death risk over 3 years vs. 2%.\u003c\/li\u003e\n\u003cli\u003e3D ultrasound is radiation-free, noninvasive, and takes 10–15 minutes for repeated monitoring.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c!-- ddn:keypoints:end --\u003e\n\n\n\u003ch2 id=\"background\"\u003eWhy This Research Matters: The Stroke Risk Problem\u003c\/h2\u003e\n\n\u003cp\u003eApproximately 20–30% of ischemic strokes (strokes caused by blocked blood flow, rather than bleeding in the brain) are caused by the rupture of carotid artery plaques. Carotid arteries are located on both sides of the neck and supply blood to the brain. When a plaque inside one of these arteries breaks open, blood clots can form on the damaged surface and travel to the brain, blocking blood vessels and causing a stroke.\u003c\/p\u003e\n\n\u003cp\u003eCurrently, the percentage of diameter reduction in the carotid arteries is used as the main indicator for stroke risk. But the authors point out that this approach has serious problems.\u003c\/p\u003e\n\n\u003cp\u003eFirst, the risk factors that lead to plaque rupture remain incompletely understood. Second, stroke rates achieved after guideline-directed carotid endarterectomy (CEA — a surgical procedure to remove plaque from the carotid artery) for high-grade carotid stenosis in symptomatic patients (those who have already experienced a stroke or transient ischemic attack, or TIA, often called a \"mini-stroke\") are significantly lower than those observed with best medical therapy alone. Third, in asymptomatic patients (those with no prior symptoms), the majority of medically treated patients remain stroke-free during follow-up, meaning surgery may not be necessary for everyone.\u003c\/p\u003e\n\n\u003cp\u003ePerhaps most importantly, in asymptomatic people, increasing degrees of stenosis have \u003cstrong\u003enot\u003c\/strong\u003e been associated with a correspondingly increased risk for stroke or TIA. Patients with less narrowing can have dangerous plaques, and patients with severe narrowing may never have a stroke. This disconnect between narrowing and stroke risk is one of the central puzzles in stroke prevention.\u003c\/p\u003e\n\n\u003cp\u003eIt is, therefore, important to identify additional markers to assess the risk of stroke and to identify patients who would benefit most from revascularization (restoring blood flow through surgery or stenting).\u003c\/p\u003e\n\n\u003ch2 id=\"methods\"\u003eHow the Researchers Conducted This Review\u003c\/h2\u003e\n\n\u003cp\u003eThe authors conducted a comprehensive literature search covering research published from the 1990s to the present day, using three major medical databases: PubMed, MEDLINE, and the Cochrane Library. They assessed articles written in English, including reviews, clinical trials, meta-analyses, and interventional\/observational studies.\u003c\/p\u003e\n\n\u003cp\u003eManual cross-referencing was also performed — meaning the authors checked the reference lists of relevant papers to find additional studies. Relevant references from selected articles were also reviewed. The search was limited to studies conducted in humans only.\u003c\/p\u003e\n\n\u003cp\u003eSearch terms, retrieved using PubMed's Advanced search function with AND\/OR Boolean operators (mainly appearing in titles and abstracts), included: \u003cstrong\u003ethree-dimensional\u003c\/strong\u003e, \u003cstrong\u003eecho\u003c\/strong\u003e, \u003cstrong\u003estroke\/transient ischemic attack\u003c\/strong\u003e, \u003cstrong\u003epredictors\u003c\/strong\u003e, \u003cstrong\u003ecarotid\u003c\/strong\u003e, \u003cstrong\u003eimaging\u003c\/strong\u003e, and \u003cstrong\u003ebiomarkers\u003c\/strong\u003e.\u003c\/p\u003e\n\n\u003ch2 id=\"history\"\u003eThe History of Measuring Plaque in 3D\u003c\/h2\u003e\n\n\u003cp\u003eThe journey toward 3D plaque measurement began in 1994, when a volumetric method was introduced to assess plaque burden. The initial approach — called the \u003cstrong\u003edisk segmentation method\u003c\/strong\u003e — was technically difficult. It required collecting a set of 2D cross-sectional slices by moving the ultrasound probe on the neck along the carotid artery using a mechanical device. The plaque area was traced using continuous cross-sections of the artery, stepping through the plaque at intervals of approximately 1 mm, and all the slices were summed together to calculate the total plaque volume.\u003c\/p\u003e\n\n\u003cp\u003eEarly research established important technical details such as the inter-slice distance, reliability, and reproducibility of this method. Several research groups tested it, and studies by Ludwig et al. in 2008, followed by articles in 2014 and 2015, confirmed good reproducibility. Notably, researchers discovered that reproducibility was \u003cstrong\u003esuperior for large plaques than for thin ones\u003c\/strong\u003e — meaning the technique was better at reliably measuring bigger, more dangerous plaques.\u003c\/p\u003e\n\n\u003cp\u003eThe disk segmentation method had a major drawback: it was not only difficult but also required \u003cstrong\u003e2–3 months of preparation\u003c\/strong\u003e to perform correctly. This made it impractical for routine clinical use.\u003c\/p\u003e\n\n\u003cp\u003eEventually, semi-automated techniques were developed. These reduced the number of plaque slices that required manual input. Instead of tracing every slice, the operator only had to delineate slices at the midpoint, and at 25% and 75% of the plaque's length, with automated interpolation (mathematical estimation) filling in the surface of the rest of the plaque.\u003c\/p\u003e\n\n\u003cp\u003eIn 2013, an automatic technique was developed using mechanical movement of the probe along the artery. This method showed good agreement with manual segmentation performed by experts. However, the mechanism used to move the ultrasound probe was described as \"big and clumsy,\" and difficult to use in overweight patients and in patients with small necks.\u003c\/p\u003e\n\n\u003cp\u003eA better solution arrived in the form of the \u003cstrong\u003emechanical sweep\u003c\/strong\u003e — where the probe is kept in one spot and the angle is changed mechanically. This approach is quicker and more suitable for everyday use. Recent research by Græbe et al. showed that the mechanical sweep gave enhanced reproducibility of plaque volume determination compared with manually moving the probe along the artery.\u003c\/p\u003e\n\n\u003ch2 id=\"clinical\"\u003eWhy 3D Imaging Changes the Clinical Approach\u003c\/h2\u003e\n\n\u003cp\u003eFrom a clinical standpoint, the introduction of 3D imaging in the field of carotid ultrasound stems from at least three main concepts:\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003eThe recognition of plaque pathophysiology (how plaques form and behave), morphology (their shape and structure), and progression over time\u003c\/li\u003e\n  \u003cli\u003eThe importance of directly evaluating the arteries themselves (especially the carotids) with tight follow-up, rather than simply assessing conventional risk factors — suggesting an \"arterial target-based\" approach instead of a risk factor–based approach in cardiovascular preventive strategies\u003c\/li\u003e\n  \u003cli\u003eThe inherent limitations in measuring intimal media thickness (IMT) — the thickness of the inner two layers of the artery wall — and the potential implications for reassessing how we stratify risk (plaque burden)\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003cp\u003ePaired with technological advances in 3D reconstruction and validation (such as magnetic resonance angiography, or MRA), together with an important reassessment of Doppler methodology (which measures blood flow), 3D carotid ultrasound is expected to contribute to the re-evaluation of the entire construct of the atherosclerotic process behind stroke, TIA, and cardiovascular risk stratification.\u003c\/p\u003e\n\n\u003ch2 id=\"plaque-volume\"\u003eTotal Plaque Volume and Risk Prediction\u003c\/h2\u003e\n\n\u003cp\u003eAtherosclerotic plaque is a three-dimensional phenomenon that is irregular in shape. Measurements performed solely in a 2D plane may miss the true extent of the plaque if the plaque extends outside that particular scanning plane. Compared with 2D imaging, \u003cstrong\u003e3D quantification of carotid plaque was shown to be more sensitive for detecting clinically important angiographic stenosis in symptomatic patients\u003c\/strong\u003e — meaning it finds blockages that 2D imaging might miss.\u003c\/p\u003e\n\n\u003cp\u003eOne of the most important findings highlighted in this review is that plaques progress along the vessel \u003cstrong\u003e2.4 times faster than the thickening of the artery wall itself\u003c\/strong\u003e. This means that methods that capture both longitudinal (lengthwise) and circumferential (around the artery) growth — i.e., area and volume measurements — are inherently more sensitive than methods limited to thickness measurements (like diameter-reducing stenosis).\u003c\/p\u003e\n\n\u003cp\u003eThe numbers are striking. The 5-year risk of stroke, myocardial infarction (heart attack), and vascular death is \u003cstrong\u003e19% for plaques with a longitudinal sectional area of 1.2–6.7 cm²\u003c\/strong\u003e, compared to only \u003cstrong\u003e6% for areas of 0–0.1 cm²\u003c\/strong\u003e. This means that even a modest-looking plaque area on a 2D image can quadruple or triple the risk of a serious cardiovascular event.\u003c\/p\u003e\n\n\u003cp\u003eTherefore, plaque area and volume (rather than diameter-reducing stenosis alone) may be better predictors of future plaque rupture.\u003c\/p\u003e\n\n\u003ch3\u003eTotal Plaque Area and the 5-Year Risk Numbers\u003c\/h3\u003e\n\n\u003cp\u003eAfter adjusting for age, cholesterol, blood pressure, sex, homocysteine (an amino acid linked to heart risk), smoking, diabetes, and treatment of cholesterol and blood pressure, patients in the \u003cstrong\u003etop quartile (the highest 25%) of total plaque area (TPA) had a three times higher 5-year risk of death, stroke, or myocardial infarction\u003c\/strong\u003e.\u003c\/p\u003e\n\n\u003cp\u003eThe 5-year risks were approximately:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e5% in the first (lowest) quartile\u003c\/li\u003e\n  \u003cli\u003e10% in the second quartile\u003c\/li\u003e\n  \u003cli\u003e15% in the third quartile\u003c\/li\u003e\n  \u003cli\u003e20% in the fourth (highest) quartile\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eImportantly, TPA was actually \u003cstrong\u003ebetter than the Framingham risk profile\u003c\/strong\u003e (a widely used tool that estimates 10-year cardiovascular risk based on age, sex, cholesterol, blood pressure, smoking, and diabetes) in predicting risk. During the first year of follow-up, almost half of the patients had plaque progression, a quarter had retrogression (plaque shrinking), and a quarter remained stable.\u003c\/p\u003e\n\n\u003cp\u003eEven more importantly, those with plaque development had \u003cstrong\u003etwice the risk of cardiovascular events\u003c\/strong\u003e, even after adjustment for the risk factors listed above. TPA significantly improves risk prediction when added to risk calculation using scores based on risk factors.\u003c\/p\u003e\n\n\u003ch3\u003eReliability and Reproducibility\u003c\/h3\u003e\n\n\u003cp\u003eAlMuhanna and colleagues investigated the variability, reliability, and the least amount of change detectable by one-dimensional plaque measures, as well as 2D and 3D measures of plaque morphometry, in patients with carotid stenosis. They found that carotid plaque diameter measurements from standard B-mode images had \u003cstrong\u003ehigh variability\u003c\/strong\u003e, while plaque burden was readily and reliably measurable with a 3D ultrasound technique using a clinical scanner.\u003c\/p\u003e\n\n\u003cp\u003eIn 2011, Makris and colleagues performed a systematic review of seven studies on the reproducibility of plaque volume. They reported an \u003cstrong\u003eoverall good intra- and inter-observer reproducibility\u003c\/strong\u003e — meaning the same observer and different observers both got consistent results. In addition, in ten further studies evaluating 3D plaque progression, volume performed better than IMT for assessing plaque response to therapy.\u003c\/p\u003e\n\n\u003cp\u003eOne of the most practical findings was the time commitment: the time taken to complete the quantification was \u003cstrong\u003enot longer than 10–15 minutes\u003c\/strong\u003e. This makes 3D ultrasound feasible in a busy clinical environment. The technology also reliably detects plaque volume changes as low as \u003cstrong\u003e4%–6% with 95% confidence\u003c\/strong\u003e, making it sensitive enough to track whether plaques are growing or shrinking.\u003c\/p\u003e\n\n\u003ch3\u003eThe Wannarong Study: 5 Years of Follow-Up\u003c\/h3\u003e\n\n\u003cp\u003eWannarong and colleagues measured TPA, total plaque volume (TPV), and IMT with 3D ultrasound in \u003cstrong\u003e349 patients\u003c\/strong\u003e and followed them annually for \u003cstrong\u003e5 years\u003c\/strong\u003e.\u003c\/p\u003e\n\n\u003cp\u003eThe results were clear: using Cox regression analysis (a statistical method that examines how risk factors affect the timing of events), survival free of any cardiovascular events (stroke, vascular death, TIA, or heart attack) was predicted by \u003cstrong\u003eTPV progression or regression\u003c\/strong\u003e — meaning changes in plaque volume were the strongest predictor of future events. TPA was a predictor of stroke, death, and TIA, but not of overall cardiovascular events.\u003c\/p\u003e\n\n\u003cp\u003eCritically, \u003cstrong\u003eprogression or regression of IMT thickness did not predict any of these events\u003c\/strong\u003e. This is a major finding: the traditional metric used in thousands of studies and clinical practices may be far less useful than simply tracking plaque volume.\u003c\/p\u003e\n\n\u003ch3\u003eWhy Plaque Volume Responds Faster to Treatment\u003c\/h3\u003e\n\n\u003cp\u003eThe review also explains why carotid 3D plaque volume is more sensitive to the effects of therapy than coronary intravascular ultrasound (IVUS, an invasive test that uses ultrasound inside the heart arteries). Carotid plaques are focal (localized, discrete) and can change in three dimensions. By contrast, coronary plaques are present along the entire length and entire circumference of the artery, so change is reduced to a change in average thickness, which is harder to detect.\u003c\/p\u003e\n\n\u003cp\u003eThis has practical implications for clinical trials: drug effects on plaque can be detected more quickly and with smaller patient groups when using carotid 3D plaque volume as the endpoint.\u003c\/p\u003e\n\n\u003cp\u003eA study on the effects of statins (cholesterol-lowering medications) on plaque progression\/regression indicates that \u003cstrong\u003echange in TPA or TPV can be observed after just 3 months\u003c\/strong\u003e of treatment.\u003c\/p\u003e\n\n\u003ch3\u003eThe Sillesen Study: 6,101 Patients\u003c\/h3\u003e\n\n\u003cp\u003eSillesen et al. in 2012 studied \u003cstrong\u003e6,101 asymptomatic patients without known cardiovascular disease\u003c\/strong\u003e using a 3D-based ultrasound approach to measure plaque burden. They compared carotid plaque burden (CPB), carotid intima-media thickness (cIMT), ankle–brachial index (ABI, a blood pressure comparison between the ankle and arm that screens for peripheral artery disease), and abdominal aortic diameter (AAD) against coronary artery calcium score (CACS, a CT scan measurement of calcium buildup in the heart arteries).\u003c\/p\u003e\n\n\u003cp\u003eThe results were striking:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eIn the 3D analysis, more than half of the patients had an intermediate Framingham Risk Score (6%–20% 10-year risk)\u003c\/li\u003e\n  \u003cli\u003eCarotid plaques were identified in \u003cstrong\u003e78% of cases\u003c\/strong\u003e\n\u003c\/li\u003e\n  \u003cli\u003eAbnormal ABI was found in only 10%\u003c\/li\u003e\n  \u003cli\u003e\u003cstrong\u003eCPB demonstrated a higher correlation with CACS than did cIMT, AAD, and ABI\u003c\/strong\u003e\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThis means that measuring carotid plaque volume with 3D ultrasound was a better proxy for coronary artery disease than several other established noninvasive tests.\u003c\/p\u003e\n\n\u003ch3\u003eThe Johri Study: Predicting Coronary Disease\u003c\/h3\u003e\n\n\u003cp\u003eJohri and colleagues performed 2D and 3D carotid ultrasound scans on \u003cstrong\u003eseventy consecutive patients\u003c\/strong\u003e who were referred for coronary angiography (an invasive X-ray test of the heart arteries) on the same day, to quantify plaques in the carotid bulbs (the widened part of the carotid artery where it divides).\u003c\/p\u003e\n\n\u003cp\u003eThe results showed that \u003cstrong\u003e3D carotid ultrasound resulted in a higher negative predictive value and sensitivity relative to 2D carotid ultrasound\u003c\/strong\u003e, and accurately predicted the absence of significant coronary artery disease (CAD). In plain terms, 3D ultrasound was better at reassuring patients that they did \u003cem\u003enot\u003c\/em\u003e have significant heart artery blockages than 2D ultrasound.\u003c\/p\u003e\n\n\u003ch3\u003eThe BioImage Study: Predicting Events in 3 Years\u003c\/h3\u003e\n\n\u003cp\u003eIn the BioImage Study (A Clinical Study of Burden of Atherosclerotic Disease in an At-Risk Population), the authors validated this approach to identify imaging biomarkers that could predict near-term (3-year) atherothrombotic events. Bilateral carotid artery plaque areas were summed to obtain a carotid plaque burden (CPB) measurement.\u003c\/p\u003e\n\n\u003cp\u003eOver a \u003cstrong\u003emedian follow-up of 2.70 years\u003c\/strong\u003e, after correction for risk factors and matching with individuals without any CPB, the hazard ratios for major adverse cardiovascular events (MACE) were:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003e0.780\u003c\/strong\u003e (95% confidence interval: 0.31–1.91) in the lowest CPB tertile (third of patients)\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e1.45\u003c\/strong\u003e (95% CI: 0.670–3.140) in the middle CPB tertile\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003e2.36\u003c\/strong\u003e (95% CI: 1.13–4.92) in the highest CPB tertile\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eComparable results were observed for CACS. The net reclassification improvement (a statistical measure of how much a new test improves risk classification compared to standard methods) improved appreciably with either CPB (0.23) or CACS (0.25). MACE rates increased concurrently with higher levels of both CPB and CACS.\u003c\/p\u003e\n\n\u003cp\u003eThis finding demonstrates that subclinical carotid or coronary atherosclerosis (disease that is present but hasn't yet caused symptoms) actually \u003cstrong\u003eincreases risk predictions and reclassification compared with traditional risk factors alone\u003c\/strong\u003e, with similar results for either imaging modality.\u003c\/p\u003e\n\n\u003ch2 id=\"vessel-wall\"\u003eVessel Wall Volume: Another Way to Measure Disease\u003c\/h2\u003e\n\n\u003cp\u003eIn patients without plaque — such as children and healthy volunteers — it has been common practice to measure IMT (intima-media thickness). However, a viable alternative is the measurement of \u003cstrong\u003evessel wall volume (VWV)\u003c\/strong\u003e, which is calculated as the volume of the artery wall itself (the volume of the entire artery minus the volume of the open channel through which blood flows, called the lumen).\u003c\/p\u003e\n\n\u003cp\u003eThat measurement, which is conceptually equivalent to a \"3D IMT,\" has significant advantages over IMT. First, like TPV, VWV has a much greater dynamic range — meaning it can change much more as disease progresses, making changes easier to detect. This also potentially reduces the sample size and duration of therapy needed in clinical trials, compared with IMT and IVUS.\u003c\/p\u003e\n\n\u003cp\u003eThe clinical evidence for VWV is already promising:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAtorvastatin significantly reduced VWV in just 3 months\u003c\/strong\u003e in the same patients in which TPV was measured in the study discussed previously\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDietary weight loss\u003c\/strong\u003e, probably through reduction of blood pressure, \u003cstrong\u003esignificantly reduced VWV in 2 years\u003c\/strong\u003e\n\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThese findings show that 3D imaging can detect the benefits of both medication and lifestyle changes on the artery wall earlier and more sensitively than traditional 2D measurements.\u003c\/p\u003e\n\n\u003ch2 id=\"plaque-composition\"\u003eUlceration and Plaque Texture: The Dangerous Features\u003c\/h2\u003e\n\n\u003cp\u003eBeyond just measuring how much plaque exists, 3D imaging offers an improved ability to evaluate the \u003cstrong\u003eplaque surface\u003c\/strong\u003e. This matters because the surface of a plaque is where dangerous events happen.\u003c\/p\u003e\n\n\u003ch3\u003eUlceration: A Key Marker of Instability\u003c\/h3\u003e\n\n\u003cp\u003eUlceration (a crater-like break or irregularity on the plaque surface, detected as surface irregularity) is an important indicator of plaque instability. An ulcerated plaque is strongly associated with:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eThe presence of rupture\u003c\/li\u003e\n  \u003cli\u003ePlaque hemorrhage (bleeding inside the plaque)\u003c\/li\u003e\n  \u003cli\u003eA large lipid core (a big pool of cholesterol and fat)\u003c\/li\u003e\n  \u003cli\u003eLess fibrous tissue (the structural \"caps\" that stabilize a plaque)\u003c\/li\u003e\n  \u003cli\u003eOverall plaque instability\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eAngiographic studies of carotid arteries have shown that patients with ulceration and high stenosis (85% narrowing) are \u003cstrong\u003etwice as likely to have a stroke\u003c\/strong\u003e than patients who have high stenosis but no ulcers. Similarly, patients with carotid plaque surface irregularities are more likely to have a history of heart attack and to develop a fatal acute heart attack, non-stroke vascular disorders, and sudden cardiac death, compared to patients with smooth plaque surfaces.\u003c\/p\u003e\n\n\u003cp\u003eHowever, the accuracy of detecting ulceration by angiography is relatively low, with high rates of both false positives and false negatives. B-mode ultrasound has been found to be a more accurate method for ulcer detection.\u003c\/p\u003e\n\n\u003ch3\u003eThe Kuk Study: Quantifying Ulcer Volume\u003c\/h3\u003e\n\n\u003cp\u003eKuk and colleagues quantified carotid global ulcer volume using 3D ultrasound to analyze the relationship between total ulcer volume and vascular events (heart attack, death due to cardiovascular reasons, strokes, TIA, revascularization procedures, or cardiovascular death).\u003c\/p\u003e\n\n\u003cp\u003eUlcer volume was defined as a clear discontinuity (gap) in an atherosclerotic lesion, with a volume of \u003cstrong\u003e≥1 mm³\u003c\/strong\u003e, measured using traditional manual segmentation. The sum of the volumes of any ulcers seen in both carotids was recorded as the total ulcer volume. Participants were monitored for a \u003cstrong\u003e5-year follow-up\u003c\/strong\u003e period.\u003c\/p\u003e\n\n\u003cp\u003eThe key finding: participants with a \u003cstrong\u003eglobal ulcer volume ≥5 mm³ had a considerably greater risk\u003c\/strong\u003e of experiencing stroke, TIA, or death, as well as the combined endpoint including heart attack-related death and revascularization. Smaller ulcer volumes predicted neither events nor ulcer depth.\u003c\/p\u003e\n\n\u003ch3\u003eThe Madani Study: Counting Ulcers and Micro-Emboli\u003c\/h3\u003e\n\n\u003cp\u003eMadani and colleagues recognized carotid ulcerations with 3D ultrasound in asymptomatic patients with carotid stenosis exceeding 60%. These authors also performed a \u003cstrong\u003etranscranial Doppler (TCD)\u003c\/strong\u003e — an ultrasound test that measures blood flow in the brain's arteries — to detect micro-embolization (tiny blood clots traveling to the middle cerebral artery, a major brain artery).\u003c\/p\u003e\n\n\u003cp\u003eThe results were dramatic:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003ePatients with \u003cstrong\u003e3 or more ulcers\u003c\/strong\u003e were much more likely to have a stroke or die during a 3-year follow-up: \u003cstrong\u003e18% vs. only 2%\u003c\/strong\u003e in patients with fewer ulcers\u003c\/li\u003e\n  \u003cli\u003ePatients in whom TCD detected micro-emboli also had an elevated risk of stroke or death: \u003cstrong\u003e20% vs. 2%\u003c\/strong\u003e\n\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThese numbers show that both the number of ulcers on the plaque surface and the presence of circulating micro-emboli are powerful predictors of future stroke.\u003c\/p\u003e\n\n\u003ch3\u003eDistinguishing Ulcers from Gaps Between Plaques\u003c\/h3\u003e\n\n\u003cp\u003e3D ultrasound is superior to 2D ultrasound in allowing doctors to differentiate between true ulceration and the normal gaps that exist between consecutive plaques located adjacent to one another. This is a crucial diagnostic distinction: a gap between two separate plaques can look like an ulcer on a 2D image, potentially leading to unnecessary treatment or anxiety.\u003c\/p\u003e\n\n\u003cp\u003e3D ultrasound has also been used to detect changes in the morphology (shape and structure) of ulcers by comparing the 3D surface features of ulcerated plaque. The identification and quantification of ulcers by 3D ultrasound, in association with carotid stenosis of 60% or more, has demonstrated a correlation between the number of ulcers (three or more) and the risk of stroke or death.\u003c\/p\u003e\n\n\u003ch3\u003eComputer-Assisted Detection of Ulcers\u003c\/h3\u003e\n\n\u003cp\u003eComputer-assisted methods for analyzing ultrasound imaging are constantly evolving for greater accuracy in plaque quantitative analysis. Chiu and colleagues demonstrated that \u003cstrong\u003emean and Gaussian curvatures\u003c\/strong\u003e (mathematical measures of how curved a surface is) can be used to identify ulcers from in-vivo 3D ultrasound images. The algorithm was validated using synthetic surfaces and vascular phantoms (artificial models of blood vessels) containing \"ulcers\" that were \u003cstrong\u003e2–4 mm in diameter\u003c\/strong\u003e.\u003c\/p\u003e\n\n\u003cp\u003eIn \u003cstrong\u003e124 patients\u003c\/strong\u003e, the total ulcer volume was found to be predictive of a higher risk for cardiovascular disease events.\u003c\/p\u003e\n\n\u003cp\u003eIt's worth noting that quantification of plaque volume and ulceration can be conducted with most commercially available software, but \u003cstrong\u003ethere is currently no standard procedure\u003c\/strong\u003e for measuring ulceration by either 2D or 3D ultrasound. As suggested by Muraki and colleagues, current classification criteria may actually be too conservative for accurate ulcer detection.\u003c\/p\u003e\n\n\u003ch3\u003eEcholucency and Plaque Texture\u003c\/h3\u003e\n\n\u003cp\u003eIt has long been thought that \u003cstrong\u003eecholucent plaque\u003c\/strong\u003e — plaque that appears dark on ultrasound because it contains less fibrous tissue and more fatty material — represented \"soft plaque\" that was more likely to rupture and embolize (shed debris that blocks blood flow). Several studies have shown that echolucency predicts a higher risk of cardiovascular events.\u003c\/p\u003e\n\n\u003cp\u003eMore recently, \u003cstrong\u003eradiofrequency analysis\u003c\/strong\u003e (as opposed to traditional gray-scale analysis) has been used to study plaque \"texture\" — a way of assessing plaque composition that looks at the ultrasound signal at a much finer level of detail. Inhomogeneity of plaque texture (irregular patterns within the plaque) and some other features of plaque texture have been shown to identify patients at higher risk of events.\u003c\/p\u003e\n\n\u003cp\u003eNoninvasive characterization of \u003cstrong\u003eintraplaque hemorrhage\u003c\/strong\u003e (bleeding inside the plaque) and \u003cstrong\u003eenlarging lipid cores\u003c\/strong\u003e may identify individuals at risk for stroke. While 2D longitudinal sectional B-mode images have been used to predict plaque histology (the microscopic structure of the plaque), a single slice provides limited information. Tissue characterization from 3D ultrasound may offer more comprehensive information about the plaque as a whole.\u003c\/p\u003e\n\n\u003cp\u003eThis approach may improve risk stratification, monitoring for the effectiveness of pharmacological management (whether medications are working), and the selection of patients for carotid revascularization procedures.\u003c\/p\u003e\n\n\u003ch3\u003eThe Van Engelen Study: Texture Changes Predict Events\u003c\/h3\u003e\n\n\u003cp\u003eVan Engelen and colleagues examined carotid ultrasound plaque texture and its changes in \u003cstrong\u003e298 patients at risk of cardiovascular events\u003c\/strong\u003e, comparing texture measurements with plaque volume and other risk factors as predictors of vascular events. Patients were followed for \u003cstrong\u003e1 year\u003c\/strong\u003e for initial assessment, and up to \u003cstrong\u003e5 years\u003c\/strong\u003e for heart attack, TIA, and stroke.\u003c\/p\u003e\n\n\u003cp\u003eThe findings were remarkable: in multivariate Cox regression analysis (which accounts for multiple risk factors simultaneously), \u003cstrong\u003echanges in plaque texture and TPV were both significant predictors\u003c\/strong\u003e of future events — while the Framingham risk score, one of the most widely used clinical tools in cardiology, \u003cstrong\u003ewas not a significant predictor\u003c\/strong\u003e in this model.\u003c\/p\u003e\n\n\u003ch2 id=\"comparison\"\u003eHow 3D Ultrasound Compares to Angiography and MRI\u003c\/h2\u003e\n\n\u003cp\u003eThe review also examined studies directly comparing 3D ultrasound with other imaging methods.\u003c\/p\u003e\n\n\u003ch3\u003eComparison with Carotid Angiography\u003c\/h3\u003e\n\n\u003cp\u003eYao and colleagues studied \u003cstrong\u003e14 patients\u003c\/strong\u003e with both 3D ultrasound and carotid angiography (CA, an X-ray-based test that uses contrast dye to visualize the carotid arteries). A 3D ultrasound examination was also performed after surgery. The volume and length of \u003cstrong\u003etwenty randomly selected lesions\u003c\/strong\u003e were measured from the 3D datasets.\u003c\/p\u003e\n\n\u003cp\u003eThe severity of stenosis was measured by 3D ultrasound using both the area and the diameter of several cross-sectional examinations at the most narrowed location. The results were compared with angiography, showing \u003cstrong\u003egood correlation\u003c\/strong\u003e between 3D ultrasound and angiography in the quantitative analysis of carotid stenosis.\u003c\/p\u003e\n\n\u003cp\u003eIn another study, the degree of luminal narrowing, measured as percentage area reduction in the 3D dataset, correlated well with the degree of stenosis estimated by angiography. In particular, 3D ultrasound showed \u003cstrong\u003egood sensitivity and diagnostic accuracy\u003c\/strong\u003e for the detection of significant stenosis of the extracranial carotid artery (the part of the carotid artery outside the skull). For stenosis between \u003cstrong\u003e40% and 70%\u003c\/strong\u003e, 3D ultrasound actually showed a \u003cstrong\u003ehigher degree of detection than angiography\u003c\/strong\u003e — an important finding because this is the range where treatment decisions are most uncertain.\u003c\/p\u003e\n\n\u003ch3\u003eComparison with Magnetic Resonance Imaging\u003c\/h3\u003e\n\n\u003cp\u003eIn 2014, Pelz and colleagues performed 3D ultrasound of carotid vessels, including 3D ultrasound quantification of internal carotid artery (ICA) stenosis, and contrast-enhanced magnetic resonance angiography (CE-MRA) of the neck vessels. The results showed \u003cstrong\u003egood inter-rater and inter-method agreement\u003c\/strong\u003e between 3D ultrasound and CE-MRA.\u003c\/p\u003e\n\n\u003cp\u003eChiu and colleagues developed an accurate, surface-based \u003cstrong\u003e3D iterative closest point registration method\u003c\/strong\u003e — a computer algorithm used to align surfaces reconstructed from outer artery wall boundaries segmented from both 3D ultrasound and MRI. The 3D ultrasound image was transformed according to the registration result and re-sliced to match the corresponding 2D transverse MRIs, demonstrating that these imaging modalities can be precisely aligned for research comparison. This is technically important because it allows 3D ultrasound findings to be validated against the gold standard of MRI.\u003c\/p\u003e\n\n\u003ch3\u003eBeyond Carotid Stenosis: Other Uses\u003c\/h3\u003e\n\n\u003cp\u003eVicenzini and colleagues described the use of 3D ultrasound in conditions other than carotid stenosis, such as evaluating bifurcations (where arteries branch) and changes in the caliber (width) or course (path) of neck vessels.\u003c\/p\u003e\n\n\u003cp\u003eTheir study included:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eForty normal controls (healthy people with no artery problems)\u003c\/li\u003e\n  \u003cli\u003eSeven patients with caliber alterations (four with carotid bulb ectasia — abnormal widening of the carotid bulb — and three with internal carotid lumen narrowings)\u003c\/li\u003e\n  \u003cli\u003e45 patients with course variations (tortuosity and kinking — twisted and bent arteries)\u003c\/li\u003e\n  \u003cli\u003e35 patients with internal carotid artery stenosis of various degrees\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThey demonstrated the feasibility of 3D ultrasound and showed an improvement in carotid axis imaging through better presentation of caliber variations and vessel course — meaning 3D ultrasound helps doctors simply see the anatomy of the vessels more clearly.\u003c\/p\u003e\n\n\u003ch2 id=\"implications\"\u003eWhat This Means for Patients\u003c\/h2\u003e\n\n\u003cp\u003eThe research reviewed in this article points to several important implications for anyone concerned about stroke risk:\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFirst, \"how blocked\" your carotid artery is may be less important than \"how much plaque\" and \"what kind of plaque\" you have.\u003c\/strong\u003e Traditional risk assessment focused on the percentage of diameter reduction in the carotid artery. This review presents strong evidence that plaque area and volume are better predictors of future rupture and events. Two patients with the same percentage of stenosis can have very different plaque volumes, and very different risks.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eSecond, 3D ultrasound can detect changes in plaque much sooner than traditional measurements.\u003c\/strong\u003e Statin therapy can produce measurable changes in plaque volume in just 3 months. This means doctors could potentially tell patients whether their treatment is working much more quickly, rather than waiting years to see if an event occurs.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eThird, plaque surface features matter enormously.\u003c\/strong\u003e Ulcerated plaques and plaques with high ulcer volume (≥5 mm³) carry dramatically higher risks. Patients with three or more ulcers had an 18% risk of stroke or death over 3 years, compared with just 2% in patients with fewer ulcers. These are numbers that can guide treatment decisions.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFourth, 3D ultrasound is practical.\u003c\/strong\u003e It takes only 10–15 minutes, requires no radiation, no contrast dye, no needles, and no hospitalization. It can reliably detect changes as small as 4–6% in plaque volume. These features make it suitable for repeated monitoring over time.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFifth, 3D plaque measurements can outperform traditional risk scores.\u003c\/strong\u003e In the Van Engelen study, changes in plaque texture and TPV were significant predictors of events, while the Framingham risk score was not. TPA was better than the Framingham risk profile in predicting risk. This suggests that imaging-based assessment could supplement — or someday even replace — risk calculators based solely on blood tests and medical history.\u003c\/p\u003e\n\n\u003ch2 id=\"limitations\"\u003eLimitations of the Technology\u003c\/h2\u003e\n\n\u003cp\u003eWhile the evidence is compelling, the authors are honest about the limitations of 3D carotid ultrasound:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eCost:\u003c\/strong\u003e The cost of dedicated 3D ultrasound probes remains a barrier. This is one of the main reasons the technique remains \"niche\" rather than routine clinical practice.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eNeed for dedicated laboratories:\u003c\/strong\u003e 3D ultrasound requires specialized equipment and trained operators, which limits its availability to specialized centers.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eNo standard procedure for measuring ulceration:\u003c\/strong\u003e There is currently no standardized protocol for measuring ulcers by either 2D or 3D ultrasound. Current classification criteria may be too conservative, potentially under-detecting dangerous ulcers.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eTechnical limitations with older equipment:\u003c\/strong\u003e Some early 3D methods required large, clumsy probe-moving mechanisms that were difficult to use in overweight patients and individuals with small necks. While mechanical sweep technology has improved this, older equipment and techniques may still have these issues.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eThe noninvasive morphologic features of pre-embolic unstable plaques (plaques that are about to shed debris) and their correlation with stroke remain \"ill-defined.\"\u003c\/strong\u003e This is partly due to the low incidence of stroke in asymptomatic patients with carotid plaques, which makes it difficult to study which features truly predict events.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eMost of the studies reviewed are observational.\u003c\/strong\u003e While the data are strong and consistent, the authors note the ongoing need to develop and validate plaque features that will identify patients at risk for future plaque disruption and athero-embolic cerebral infarction.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003ch2 id=\"recommendations\"\u003eRecommendations for Patients\u003c\/h2\u003e\n\n\u003cp\u003eBased on this review, here is what patients should understand and discuss with their healthcare providers:\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003e\n\u003cstrong\u003eIf you have carotid plaque, ask your doctor about 3D ultrasound.\u003c\/strong\u003e Standard 2D ultrasound can miss the true extent of plaque that grows out of the scanning plane. A 3D evaluation gives a more complete picture of plaque volume and surface features.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDon't rely solely on the \"percentage of blockage\" number.\u003c\/strong\u003e Two people with the same percentage of stenosis can have very different plaque volumes and risks. Ask about plaque burden, plaque volume, and ulceration status if 3D imaging is available.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eIf you are taking statins or other cholesterol-lowering medications, ask whether follow-up 3D ultrasound is appropriate.\u003c\/strong\u003e Studies show that changes in plaque volume can be detected in as little as 3 months, providing early evidence of whether treatment is working.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eTake plaque regression seriously as a goal.\u003c\/strong\u003e Lifestyle changes — including dietary weight loss — have been shown to reduce vessel wall volume over 2 years. Plaque regression is associated with reduced cardiovascular event risk.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eIf you have multiple ulcers (3 or more) on your carotid plaques, this represents a substantially higher risk zone (18% vs. 2% over 3 years).\u003c\/strong\u003e Patients with this finding should have a careful discussion with their specialist about the risks and benefits of more aggressive treatment, including possible revascularization.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eKeep in mind that 3D ultrasound is radiation-free and noninvasive.\u003c\/strong\u003e Unlike CT angiography (which uses X-rays) and conventional angiography (which requires a catheter threaded into the artery), 3D ultrasound carries no radiation exposure and no injection of contrast agents. This makes it safe for repeated imaging over time.\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003cp\u003eThe authors of this review hope that presenting the clinical power and practical feasibility of 3D carotid ultrasound will encourage more widespread adoption. In their vision, the future of stroke prevention lies not just in measuring risk factors like cholesterol and blood pressure, but in directly imaging and tracking the disease process itself — the plaque in the artery wall. For patients, this could mean more accurate risk prediction, earlier feedback on whether treatments are working, and better targeting of interventions to those who truly need them.\u003c\/p\u003e\n\n\u003c!-- ddn:faq:start --\u003e\n\u003ch2 id=\"ddn-faq\"\u003eFrequently Asked Questions\u003c\/h2\u003e\n\u003ch3\u003eWhy is the percent of carotid artery blockage not enough to predict my stroke risk?\u003c\/h3\u003e\n\u003cp\u003eTraditional risk assessment relies on the percentage of diameter reduction, but this can be misleading. Studies show that plaque area and volume are better predictors of future rupture and events. Patients with less narrowing can have dangerous plaques, while those with severe narrowing may never have a stroke.\u003c\/p\u003e\n\u003ch3\u003eWhat is 3D ultrasound and how is it different from a standard carotid ultrasound?\u003c\/h3\u003e\n\u003cp\u003e3D ultrasound measures the actual volume, surface features, and texture of carotid plaques, rather than just a 2D slice. It captures longitudinal and circumferential growth, detecting dangerous plaque features that 2D imaging misses. The scan takes 10–15 minutes, uses no radiation, and reliably detects small changes in plaque volume.\u003c\/p\u003e\n\u003ch3\u003eCan 3D ultrasound predict my risk of a future heart attack or stroke?\u003c\/h3\u003e\n\u003cp\u003eYes. In a 5-year study of 349 patients, changes in plaque volume predicted stroke, vascular death, TIA, or heart attack. Total plaque area also predicted stroke, death, and TIA. Another study showed that patients with three or more ulcers had an 18% risk of stroke or death over 3 years, compared to 2% with fewer ulcers.\u003c\/p\u003e\n\u003ch3\u003eHow quickly can 3D ultrasound show whether my cholesterol medication is working?\u003c\/h3\u003e\n\u003cp\u003eChanges in total plaque area or volume can be seen after just 3 months of statin treatment. For example, atorvastatin significantly reduced vessel wall volume within 3 months. This is faster than waiting years for an event, and it helps doctors tell whether therapy is effective earlier.\u003c\/p\u003e\n\u003ch3\u003eWhat does it mean if my carotid plaque is ulcerated?\u003c\/h3\u003e\n\u003cp\u003eUlceration is a crater-like break on the plaque surface and is a marker of instability. Patients with ulceration and high stenosis are twice as likely to have a stroke as those with high stenosis but no ulcers. Total ulcer volume of 5 mm³ or more carries a considerably greater risk of stroke, TIA, or death.\u003c\/p\u003e\n\u003ch3\u003eIs 3D ultrasound safe and does it hurt?\u003c\/h3\u003e\n\u003cp\u003eYes, it is safe and painless. Unlike CT angiography or conventional angiography, 3D ultrasound involves no radiation, no contrast dye, no needles, and no hospitalization. It is noninvasive and safe for repeated imaging over time, making it practical for monitoring plaque changes.\u003c\/p\u003e\n\u003ch3\u003eMy doctor says my carotid artery is only 50% blocked and I don't need surgery, but I'm worried about stroke. Should I get a second opinion using 3D ultrasound to check my plaque?\u003c\/h3\u003e\n\u003cp\u003eIf your stroke risk has been judged mainly by the degree of narrowing in your carotid artery, a second opinion may be worth considering. The percentage of stenosis has not been consistently tied to stroke risk in people without symptoms. Patients with less narrowing can have dangerous plaques, while some with severe narrowing never have a stroke. Plaque volume, plaque area, and ulceration are stronger predictors of future heart attack or stroke. 3D ultrasound measures these features in 10–15 minutes without radiation or contrast. Diagnostic Detectives Network provides independent expert second opinions.\u003c\/p\u003e\n\u003c!-- ddn:faq:end --\u003e\n\n\u003ch2 id=\"source\"\u003eSource Information\u003c\/h2\u003e\n\n\u003cp\u003eThis patient-friendly article is based on peer-reviewed research published in the \u003cstrong\u003eJournal of Cardiovascular Echography\u003c\/strong\u003e (J Cardiovasc Echogr. 2018 Oct-Dec; 28(4): 218–227).\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eOriginal article title:\u003c\/strong\u003e Pisa Italy Three-Dimensional Echographic Evaluation of Carotid Artery Disease - PMC\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors:\u003c\/strong\u003e Enrico Calogero, Iacopo Fabiani, Nicola Riccardo Pugliese, Veronica Santini, Lorenzo Ghiadoni, Rossella Di Stefano, Fabio Galetta, Ferdinando Sartucci, Giuseppe Penno, Raffaella Berchiolli, Mauro Ferrari, Dania Cioni, Vinicio Napoli, Raffaele De Caterina, Vitantonio Di Bello, and Davide Caramella\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAffiliations:\u003c\/strong\u003e Department of Medical, Surgical, Molecular and Critical Area Pathology and Department of Cardiac, Thoracic and Vascular, Pisa University, Pisa, Italy; Department of Clinical and Experimental Medicine, Pisa University, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, Pisa University, Pisa, Italy.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003ePublication details:\u003c\/strong\u003e Published in the Journal of Cardiovascular Echography, 2018 Oct-Dec, Volume 28, Issue 4, pages 218–227. PMCID: PMC6341847. DOI: 10.4103\/jcecho.jcecho_57_18. PMID: 30746325.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCopyright:\u003c\/strong\u003e © 2018 Journal of Cardiovascular Echography. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License.\u003c\/p\u003e\n\n\u003cp\u003eThis patient-friendly article was adapted from the original peer-reviewed research and is intended for educational purposes only. It does not provide medical advice. Patients should consult their healthcare providers for guidance on their individual condition and treatment options.\u003c\/p\u003e","brand":"DiagnosticDetectives.Com","offers":[{"title":"Default Title","offer_id":47541991768220,"sku":null,"price":0.0,"currency_code":"USD","in_stock":true}],"url":"https:\/\/diagnosticdetectives.com\/products\/three-dimensional-ultrasound-a-more-complete-picture-of-carotid-artery-disease-and-stroke-risk","provider":"DiagnosticDetectives.Com","version":"1.0","type":"link"}