AIMS: There is increasing evidence that plaque instability in the extracranial carotid artery may lead to an increased stroke risk independently of the degree of stenosis. We aimed to determine diagnostic accuracy of vulnerable and stable plaque using noninvasive imaging modalities when compared to histology in patients with symptomatic and asymptomatic carotid atherosclerosis. METHODS AND RESULTS: Medline Ovid, Embase, Cochrane Library, and Web of Science were searched for diagnostic accuracy of noninvasive imaging modalities (CT, MRI, US) in the detection of 1) vulnerable/stable plaque, and 2) vulnerable/stable plaque characteristics, compared to histology. The quality of included studies was assessed by QUADAS-2 and univariate and bivariate random-effect meta-analyses were performed. We included 36 vulnerable and 5 stable plaque studies in the meta-analysis, and out of 211 plaque characteristics from remaining studies, we classified 169 as vulnerable and 42 as stable characteristics (28 CT, 120 MRI, 104 US characteristics). We found that MRI had high accuracy [90% (95% CI: 82-95%)] in the detection of vulnerable plaque, similar to CT [86% (95% CI: 76-92%); P > 0.05], whereas US showed less accuracy [80% (95% CI: 75-84%); P = 0.013]. CT showed high diagnostic accuracy in visualizing characteristics of vulnerable or stable plaques (89% and 90%) similar to MRI (86% and 89%; P > 0.05); however, US had lower accuracy (77%, P < 0.001 and 82%, P > 0.05). CONCLUSION: CT and MRI have a similar, high performance in detecting vulnerable carotid plaques, whereas US showed significantly less diagnostic accuracy. Moreover, MRI visualized all vulnerable plaque characteristics allowing for a better stroke risk assessment. REGISTRATION: PROSPERO ID CRD42022329690.

Center for Primary Care and Public Health Division of Biostatistics University of Lausanne Route de la Corniche 10 1010 Lausanne Switzerland

Centre for Health Research Department of Clinical Neurosciences Faculty of Medicine University of Ostrava Syllabova 19 703 00 Ostrava Czech Republic

Division of Nephrology Department of Pediatrics Children's Hospital of Eastern Ontario University of Ottawa 401 Smyth Road ON K1H8L1 Ottawa Canada

Medical Library Lausanne University Hospital and University of Lausanne Rue du Bugnon 46 1011 Lausanne Switzerland

Neurology Unit Department of Internal Medicine Riviera Chablais Hospital Route du Vieux Séquoia 20 1847 Rennaz Switzerland

Stroke Center Service of Neurology Department of Clinical Neurosciences Lausanne University Hospital Rue du Bugnon 46 1011 Lausanne Switzerland

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