Skip to main content


Log in

Carotid artery plaque characterization with a wide-detector computed tomography using a dedicated post-processing 3D analysis: comparison with histology

  • Published:
La radiologia medica Aims and scope Submit manuscript



The characterization of atherosclerotic carotid plaque plays a key role in the identification of patients at risk. The aim of our work was to evaluate the potentialities of carotid computed tomography angiography (CCTA) in assessing composition of atherosclerotic plaque.

Materials and methods

We retrospectively evaluated 29 patients (7 women and 22 men, age range 54–81; mean age 69) who underwent carotid endarterectomy. All patients underwent pre-surgical CCTA using a 320-slice scanner. Post-processing reconstructions and analysis were performed using a specific software. Percentage of three different components of the atherosclerotic plaque (adipose, fibrotic and calcific) were classified based on Hounsfield unit values. Post-processing results were compared with histological analysis. Vessel and plaque parameters were compared using the Pearson correlation coefficient (r). Bland–Altman plots with 95% confidence intervals were calculated for correlation. McNemar’s test was used for comparison of dichotomous variables.


A significant correlation between histology and CCTA was found with respect to the areas corresponding to adipose, fibrotic and calcified plaques. The existence of proportional bias was observed between the two quantifying methods with lower discrepancies found for the adipose and fibrotic plaque areas. The Bland–Altman analyses showed a mean bias of 3.2%, 2.5% and 0.6% between histology and CCTA, for adipose, fibrotic and calcified plaque areas, respectively.


Multi-detector CT angiography represents a valuable technique to assess quantitatively the composition of atherosclerotic plaques, with particular reference to the prevalence of fibrotic tissue, and is a useful diagnostic tool to improve risk stratification of patients for cerebral stroke.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others


  1. Saba L, Anzidei M, Cavallo Marincola B et al (2014) Imaging of the carotid artery vulnerable plaque. Cardiovasc Intervent Radiol 37(3):572–585

    Article  Google Scholar 

  2. Paonessa A, Limbucci N, Tozzi E, Splendiani A, Gallucci M (2010) Radiological strategy in acute stroke in children. Eur J Radiol 74(1):77–85

    Article  Google Scholar 

  3. Splendiani A, Catalucci A, Limbucci N, Turner M, Krings T, Gallucci M (2012) Pediatric inflammatory diseases. Part III: small vessels vasculitis. Neuroradiol J 25(6):715–724

    Article  CAS  Google Scholar 

  4. Fuster V, Badimon L, Badimon JJ, Chesebro JH (1992) The pathogenesis of coronary artery disease and the acute coronary syndromes. N Engl J Med 326(4):242–250

    Article  CAS  Google Scholar 

  5. van Rugge FP, van der Wall EE, Spanjersberg SJ, de Roos A et al (1994) Magnetic resonance imaging during dobutamine stress for detection and localization of coronary artery disease. Quantitative wall motion analysis using a modification of the centerline method. Circulation 90(1):127–138

    Article  Google Scholar 

  6. Falk A, Schmieder K, Hentsch A, Harders A, Heuser L (1996) 3-D-tone magnetic resonance angiography in the detection of intracranial aneurysms compared with digital subtraction angiography. A prospective study. Rofo 164(1):31–37

    Article  CAS  Google Scholar 

  7. Davis MJ (1996) Stability and instability: two faces of coronary atherosclerosis. The Paul Dudley White Lacture 1995. Circulation 94:2013–2020

    Article  Google Scholar 

  8. Fayad ZA (2001) The assessment of the vulnerable atherosclerotic plaque using MR imaging: a brief review. Int J Cardiovasc Imaging 17(3):165–177

    Article  CAS  Google Scholar 

  9. Crisby M, Nordin-Fredriksson G, Shah PK, Yano J, Zhu J, Nilsson J (2001) Prevastatin treatment increases collagen content and decreased lipid content, inflammation metalloproteinases and cell death in human carotid plaques: implication for plaque stabilization. Circulation 103(7):926–933

    Article  CAS  Google Scholar 

  10. Gupta A, Mtui EE, Baradaran H et al (2015) CT angiographic features of symptom-producing plaque in moderate-grade carotid artery stenosis. AJNR Am J Neuroradiol 36(2):349–354

    Article  CAS  Google Scholar 

  11. Barnett HJ, Taylor DW, Eliasziw M et al (1998) Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American symptomatic carotid endarterectomy trial collaborators. N Engl J Med 339(20):1415–1425

    Article  CAS  Google Scholar 

  12. Huibers A, de Borst GJ, Wan S et al (2015) Non-invasive carotid artery imaging to identify the vulnerable plaque: current status and future goals. Eur J Vasc Endovasc Surg 50(5):563–572

    Article  CAS  Google Scholar 

  13. Chalela JA (2009) Evaluating the carotid plaque: going beyond stenosis. Cerebrovasc Dis 27(Suppl 1):19–24

    Article  Google Scholar 

  14. Li Q, Zhou Y, Dong K et al (2015) The association between serum uric acid levels and the prevalence of vulnerable atherosclerotic carotid plaque: a cross-sectional study. Sci Rep 5:10003–10009

    Article  CAS  Google Scholar 

  15. Brinjikji W, Huston J 3rd, Rabinstein AA et al (2016) Contemporary carotid imaging: from degree of stenosis to plaque vulnerability. J Neurosurg 124(1):27–42

    Article  CAS  Google Scholar 

  16. Leipsic J, Abbara S, Achenbach S, Cury R, Earls JP et al (2014) SCCT guidelines for the interpretation and reporting of coronary CT angiography: a report of the society of cardiovascular computed tomography guidelines committee. J Cardiovasc Comput Tomogr 8(5):342–358

    Article  Google Scholar 

  17. Tarkin JM, Dweck MR, Evans NR, Takx RAP, Brown AJ, Tawakol A, Fayad ZA, Rudd JHF (2016) Imaging atherosclerosis. Circ Res 118:750–769

    Article  CAS  Google Scholar 

  18. Chopard R, Boussel L, Motreff P et al (2010) How reliable are 40 MHz IVUS and 64-slice MDCT in characterizing coronary plaque composition? An ex vivo study with histopathological comparison. Int J Cardiovasc Imaging 26:373–383

    Article  Google Scholar 

  19. De Weert TT, Ouhlous M, Meijering E et al (2006) In vivo characterization and quantification of atherosclerotic carotid plaque components with multidetector computed tomography and histopathological correlation. Arterioscler Thromb Vasc Biol 26(10):2366–2372

    Article  Google Scholar 

  20. Saba L, Francone M, Bassareo PP, Lai L, Sanfilippo R, Montisci R, Suri JS, De Cecco CN, Faa G (2018) CT attenuation analysis of carotid intraplaque hemorrhage. Am J Neuroradiol 39(1):131–137.

    Article  CAS  PubMed  Google Scholar 

  21. Saremi F, Achenbach S (2015) Coronary plaque characterization using CT. Am J Roentgenol 204(3):W249–W260.

    Article  Google Scholar 

  22. Obaid DR, Calvert PA, Gopalan D et al (2013) Athero-sclerotic plaque composition and classification identified by coronary computed tomography: assessment of computed tomography-generated plaque maps compared with virtual histology intravascular ultrasound and histology. Circ Cardiovasc Imaging 6:655–664

    Article  Google Scholar 

  23. van Gils MJ, Vukadinovic D, van Dijk AC et al (2012) Carotid atherosclerotic plaque progression and change in plaque composition over time: a 5-year follow-up study using serial CT angiography. AJNR Am J Neuroradiol 33:1267–1273

    Article  Google Scholar 

  24. Rozie S, de Weert TT, de Monyé C et al (2009) Atherosclerotic plaque volume and composition in symptomatic carotid arteries assessed with multidetector CT angiography; relationship with severity of stenosis and cardiovascular risk factors. Eur Radiol 19:2294–2301

    Article  CAS  Google Scholar 

  25. Komatsu S, Imai A, Kodama K (2011) Multidetector row computed tomography may accurately estimate plaque vulnerability: does MDCT accurately estimate plaque vulnerability? (Pro). Circ J 75:1515–1521

    Article  Google Scholar 

  26. Kimura S, Yonetsu T, Suzuki K et al (2012) Characterisation of non-calcified coronary plaque by 16-slice multidetector computed tomography: comparison with histopathological specimens obtained by directional coronary atherectomy. Int J Cardiovasc Imaging 28:1749–1762

    Article  Google Scholar 

  27. Di Cesare E, Gennarelli A, Di Sibio A et al (2015) Image quality and radiation dose of single heartbeat 640-slice coronary CT angiography: a comparison between patients with chronic atrial fibrillation and subjects in normal sinus rhythm by propensity analysis. Eur J Radiol 84(4):631–636.

    Article  PubMed  Google Scholar 

  28. Nordestgaard BG, Gronholdt ML, Sillesen H et al (2003) Echolucent rupture-prone plaques. Curr Opin Lipidol 14(5):505–512

    Article  CAS  Google Scholar 

  29. Sztajzel R (2005) Ultrasonographic assessment of the morphological characteristic of the carotid plaque. Swiss Med Wkly 135(43–44):635–643

    PubMed  Google Scholar 

  30. Geroulakos G, Ramaswami G, Nicolaides A et al (1993) Characterization of symptomatic and asymptomatic carotid plaques using high-resolution real-time ultrasonography. Br J Surg 80(10):1274–1277

    Article  CAS  Google Scholar 

  31. ten Kate GL, van Dijk AC, van der Oord SC et al (2013) Usefulness of contrast-enhanced ultrasound for detection of carotid plaque ulceration in patients with symptomatic carotid atherosclerosis. Am J Cardiol 112(2):292–298

    Article  Google Scholar 

  32. Gupta A, Baradaran H, Schweitzer AD et al (2013) Carotid plaque MRI and stroke risk: a systematic review and meta-analysis. Stroke 44(11):3071–3077

    Article  Google Scholar 

  33. Esposito-Bauer L, Saam T, Ghodrati I et al (2013) MRI plaque imaging detects carotid plaques with a high risk for future cerebrovascular events in asymptomatic patients. PLoS ONE 8(7):e67927

    Article  CAS  Google Scholar 

  34. Di Cesare E, Cademartiri F, Carbone I (2012) Clinical indications for cardiac computed tomography. From the Working Group of the Cardiac Radiology Section of the Italian Society of Medical Radiology (SIRM). Radiol Med 117(6):901–938

    Article  Google Scholar 

  35. Wintermark M, Arora S, Tong E et al (2008) Carotid plaque CT imaging in stroke and non stroke patients. Ann Neurol 64(2):149–157

    Article  Google Scholar 

  36. De Weert TT, Cretier S, Groen HC et al (2009) Atherosclerotic plaque surface morphology in the carotid bifurcation assessed with multidetector computed tomography angiography. Stroke 40(4):1334–1340

    Article  Google Scholar 

  37. Homburg PJ, Rozie S, van Gils MJ et al (2011) Association between carotid artery plaque ulceration and plaque composition evaluated with multidetector CT angiography. Stroke 42(2):367–372

    Article  Google Scholar 

  38. Vukadinovic D, Rozie S, van Gils M et al (2012) Automated versus manual segmentation of atherosclerotic carotid plaque and components in CTA: associations with cardiovascular risk factors. Int J Cardiovasc Imaging 28(4):877–887

    Article  Google Scholar 

Download references


The authors wish to thank Angela Martella for English revision of the manuscript.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Marco Varrassi.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Human and animal rights statement

This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was obtained from the participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Varrassi, M., Sferra, R., Gravina, G.L. et al. Carotid artery plaque characterization with a wide-detector computed tomography using a dedicated post-processing 3D analysis: comparison with histology. Radiol med 124, 795–803 (2019).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: