Bubbles help in troubles: contrast-enhanced ultrasound (CEUS) as predictor of recurrence for TIA/stroke in low-grade internal carotid artery stenosis

Introduction Contrast-enhanced ultrasound (CEUS) allows to visualize atherosclerotic plaque neo-vessels which are the hallmark of carotid plaque instability. Aim Aim: of our prospective study was to check the correlation between carotid CEUS analysis and the recurrence of TIA/stroke in patients with a previous recent TIA/stroke and neurological impairment congruent with the vascular stenosis. Materials and Methods From November 2021 to May 2023, 62 consecutive patients (mean age 73.8 +/- 12.2, female 51) with a TIA/stroke in the previous 30 days, underwent carotid ultrasound and carotid CEUS in outpatients setting after 10 days from the acute event. Inclusion criteria was one atherosclerotic plaque inside the internal carotid artery, congruent with symptoms, which was causing a stenosis less than 50% (low-grade stenosis). Carotid plaque neovascularization scoring method was: score 0: no visible microbubbles within the plaque (A); score 1: minimal microbubbles confined to periadventitial (B); and score 2: microbubbles present throughout the plaque core (C). During the six-month follow-up, we checked TIA/stroke recurrences. A multivariable logistic regression analysis was performed. Results In our series, 22% of patients have CEUS score 0, 35% CEUS score 1, and 43% CEUS score 2. At six-month follow-up we found 21% TIA/stroke recurrences in CEUS score 2, despite of the ongoing best medical therapy as per guidelines. In Cox regression analysis, CEUS-detected neovascularization was independently associated with TIA/stroke recurrence (hazard ratio, 5.37; 95% confidence interval, 1.36–2.31). Conclusions Plaque neovascularization, detected by CEUS, is an independent predictor of TIA/stroke recurrence at six-month follow-up in patients with carotid atherosclerosis despite of low-grade stenosis.