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Summary Objectives To describe normal and pathological findings with three-dimensional (3D) ultrasound of the carotid bifurcation. Methods Patients admitted to our ultrasound laboratory for vascular screening were submitted to standard carotid duplex and to 3D ultrasound reconstruction of the carotid bifurcation. Volume 3D scans were performed manually, on the axial plane, and the software presented the volume rendering from the inward blood flow signal detected with the Power Color Mode. Results Forty normal subjects, 7 patients with caliber alterations (4 carotid bulb ectasia and 3 internal carotid lumen narrowing), 45 patients with course variations (tortuosities and kinkings) and 35 patients with internal carotid artery stenosis of various degrees have been investigated. Conclusions 3D ultrasound is a feasible technique. It can improve carotid axis general imaging through a global image presentation “at a glance”, visualizing caliber variations and vessels course. Imaging of stenosis from inward flow can be provided, but complete stenosis characterization requires the assessment of plaque morphology and vessel wall.

Summary The identification of vulnerable and unstable carotid atherosclerotic lesions is up-to-date an important topic of research, in order to adopt the adequate strategy for preventing cerebrovascular events. Plaque inflammation, presence of adventitial vasa vasorum, intimal angiogenesis and plaque neovascularization have been identified in histological studies as indicators of the instability of the atheroma of carotid arteries in cerebrovascular patients and of coronary arteries in cardiovascular patents. Consequently, the identification “in vivo” of these pathophysiological aspects has been objective for the development of new imaging techniques. Ultrasound of carotid arteries, with ultrasound contrast agents, is not only able to provide an enhanced visualization of the arterial lumen and plaque morphology, but also allows to directly visualize adventitial vasa-vasorum and carotid plaque neovascularization. This technique and its clinical implications in the unstable plaque identification are discussed in the present paper.

Summary Contrast Enhanced Carotid Ultrasonography (CCU) is capable of detecting angiogenesis within the carotid plaque as a potential index of plaque vulnerability. However, due to a lack of standard of examination technique and documentation, results are not sufficiently, reliably comparable. To improve this situation and in order to support wide acceptance of this promising technique, experts in this field met in the Consensus conference in May 22, 2011, held during the 16th ESNCH Meeting (20–23 May 2011) in Munich, Germany, to discuss the limitations and problems and to determine guidelines for its proper use in scientific investigations and clinical practice. The main results of this conference are presented here. The discussion is still in progress and individual conclusions may not reflect the opinion of all participants. It aims to provide a basis for a later comprehensive consensus statement.

Summary Background Saddle thrombosis is less frequently detected in carotid arteries than in peripheral arterial embolism. The clot and the distal vessel patency have to be promptly recognized in these cases, because if the carotid vessel is open distally, chances may arise for successful emergent surgical procedures to remove the thrombus. At conventional static imaging, mobile floating thrombi may be difficult to differentiate from thrombosis on carotid complicated lesions of atherosclerotic origin. High-resolution ultrasound (US), with its unique capability of real-time imaging, adds fundamental data for interpretation of the findings. Methods Carotid ultrasound has been performed in acute stroke patients with high-resolution probes. Real-time clips are analyzed and imaging is presented. Results Saddle carotid bifurcation thrombosis of cardiac origin has been identified in 2 patients with acute homolateral ischemic stroke, with prompt successful surgical removal in one case. Moreover, an example of a thrombus attached on the ruptured surface of a complicated atherosclerotic plaque in an acute symptomatic stroke patient that was successfully operated in emergency is presented. Conclusions Early high-resolution ultrasound with real-time imaging can easily identify peculiar characteristics of carotid vulnerable diseases in acute stroke phase. Different clinical implications result from the early identification of these different conditions, modifying the therapeutical strategies.