Beyond the stenosis degree, the carotid plaque morphology assessed by computed tomography may improve the stroke risk stratification and is recommended to be considered before interventional treatment according to current guidelines. This study aimed to systematically review the accuracy of computed tomography (CT) to detect carotid plaque characteristics compared to histology in patients with symptomatic and asymptomatic carotid plaques. We registered the protocol in PROSPERO and searched Medline Ovid, Embase.com, Cochrane Library, and Web of Science for diagnostic accuracy of CT in specific carotid plaque characteristic imaging compared to histology, without any search limitation up to May 27, 2022. Out of 8,168 studies, 20 studies that evaluated seven specific plaque characteristics were included in our systematic review. The best diagnostic performance was found for the detection of ulceration (sensitivity range 39.4-100% [mean 79.6%], specificity range 74-100% [mean 93.6%]), followed by calcification (72.7-100% [88.1%], 35.7-100% [80.1%]), lipid-rich necrotic core (63.2-95.6% [81.1%], 60-100% [80.1%]), and intraplaque hemorrhage (61.5-100% [86%], 20-99.5% [67.8%]). Only a few studies evaluated specifically vulnerable, mixed, and fibrous plaque. Diagnostic studies with larger sample sizes are needed, using novel available CT techniques that enable increasing diagnostic performance and decreasing radiation and amount of contrast agent. CT allows for highly accurate detection of carotid plaque features, particularly ulceration and calcification. These results underline the role of routine CT examinations to assess not only stenosis degree but also plaque morphology and individual patient stroke risk to better guide management. Registration: PROSPERO ID CRD42022329690 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=329690).

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

Department of Diagnostic and Interventional Radiology Lausanne University Hospital and University of Lausanne Switzerland

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 Chemin des Falaises 2 1005 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 University Hospital of Lausanne and University of Lausanne Rue du Bugnon 46 1011 Lausanne Switzerland

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