Vulnerable Plaque in Focus: A Multimodal Ultrasound Case Study with Triplex, High-Resolution Flow, and 3D Imaging [November 2025]

A 51-year-old patient presents with a feeling of tension in the left neck area that has persisted for six weeks with increasing intensity. He denies any associated pain or breathing difficulties. He has not experienced similar symptoms in the past. The patient reports occasional headaches, but no episodes of dizziness or transient visual disturbances - status post right-sided neck dissection for a progressively enlarged lymph node 20 years ago. The performed histopathological examination revealed reactive lymphadenopathy with no evidence of malignancy. Now, a sonography of the neck was performed using a LOGIQ E10 ultrasound system (GE Healthcare, Chicago, IL, USA) in combination with the PIUR tUS Infinity v4.1.2 General Imaging App (PIUR Imaging GmbH, Vienna, Austria) inside the system for 3D reconstruction.

A: B-Mode imaging in the sagittal plane (A1) shows a markedly echogenic and inhomogeneous vessel wall of the common carotid artery with a thickened intima-media complex and irregular echogenic wall changes. Notably, multiple echogenic, wall-adherent formations with partial distal acoustic shadowing are observed (yellow arrow), indicative of significant plaque formation. Speckle Reduction Imaging (SRI) and Cross Beam techniques were employed to optimize the B-Mode image (A2), which is illustrated in sepia for enhanced visualization.

B: B-Mode in sepia and high-resolution flow imaging (B-Flow) along the longitudinal axis of the vessel reveals ulcerated plaque formations with notches and vasa vasorum showing transmural vascular ingrowth into the plaque (red arrow).

C: Triplex, B-Mode, and Duplex imaging with color coding and pulsed wave Doppler reveal significantly increased systolic flow velocities (>200 cm/s) in the CCA, accompanied by aliasing in the region of luminal narrowing (yellow arrow) caused by echogenic plaque formation.

D: Visualization of the vessel with the PIUR tUS Infinity v4.1.2 General Imaging App in the transverse plane (D1), reconstructed sagittal plane (D2), and reconstructed coronal plane (D4). The coronal plane particularly highlights the vessel narrowing caused by the plaques (yellow arrow). The additional 3D reconstruction (D3) provides an "external" view of the multiple plaques, illustrating the resulting irregular vessel morphology.

Pronounced plaques in the common carotid artery with notches and vascular ingrowths and increased flow velocities detectable on pulsed wave, color doppler, and high-resolution flow imaging (B-Flow) as well as 3D imaging with PIUR tUS Infinity v4.1.2 General Imaging App, causing significant luminal stenosis. There is a suspicion of active/vulnerable plaques, indicating an elevated risk profile for cardiovascular events.

The detection of vulnerable plaques (Fig. A) is critical for assessing cardiovascular risk. Color-Coded Doppler Ultrasound enables the evaluation of hemodynamics, providing essential insights into blood flow dynamics. B-Flow offers high-resolution imaging of blood flow and detailed visualization of vessel walls, particularly near-wall blood flow in cases of ulcerated plaques, and facilitates the detection of vasa vasorum in soft plaques (Fig. B). It also enables precise visualization of plaque features, such as surface irregularities and vascular ingrowths. Unlike color Doppler, B-Flow eliminates artifacts such as aliasing, ensuring superior image clarity.

Triplex ultrasound integrates B-Mode, Color Doppler, and Spectral Doppler to provide comprehensive structural and hemodynamic data, including flow velocity quantification and the detection of microvascular activity (Fig. C). Furthermore, tomographic three-dimensional (3D) ultrasound uniquely enhances understanding of vessel anatomy (Fig. D) and serves as an innovative adjunct imaging modality.

Together, these techniques significantly improve the accuracy of identifying high-risk plaques, aiding in risk stratification and supporting clinical decision-making.

• Enhanced Plaque Visualization with High-Resolution Flow Imaging: Advanced ultrasound flow imaging techniques with high spatial and temporal resolution enable detailed visualization of intravascular hemodynamics and vessel wall morphology. These methods provide angle-independent, bidirectional flow assessment and are less susceptible to Doppler-related artifacts such as aliasing or blooming. This allows for improved detection of plaque surface irregularities, microvascularization, and intraplaque neovascularization—features commonly associated with plaque vulnerability.

• Comprehensive Hemodynamic Assessment with Triplex Ultrasound: Triplex ultrasound combines B-Mode (structural imaging), Color Doppler (flow visualization), and Spectral Doppler (velocity quantification), providing both anatomical and functional data. This is essential for identifying stenotic lesions, flow velocity changes, and areas of turbulent flow associated with high-risk plaques.

• Enhanced Understanding with 3D Ultrasound: Three-dimensional (3D) ultrasound provides a unique perspective by offering tomographic imaging of vascular anatomy. This modality enables superior spatial visualization of complex plaque morphology and vessel wall structures, aiding in identifying subtle irregularities and refining risk assessment.

1. Yao Y, Zhang P. Novel ultrasound techniques in the identification of vulnerable plaques—an updated review of the literature. Frontiers in Cardiovascular Medicine 2023; 10. doi:10.3389/fcvm.2023.1069745

2. Hofmann AG, Mlekusch I, Wickenhauser G et al. Clinical Applications of B-Flow Ultrasound: A Scoping Review of the Literature. Diagnostics (Basel) 2023; 13. doi:10.3390/diagnostics13030397

3. Jung EM, Clevert DA, Rupp N. [B-flow and color-coded B-flow in sonographic diagnosis of filiform stenosis of the internal carotid artery]. Rofo 2003; 175: 1251-1258. doi:10.1055/s-2003-41936