How is plaque ulceration best assessed with ultrasound?

• A. Ulceration can always be definitively diagnosed on a single grayscale image
• B. Irregular surface contour with cavity within plaque and blood flow within cavity on color Doppler across multiple views
• C. Rely on grayscale alone
• D. Color Doppler cannot assess ulceration

Answer: (B)

Ultrasound identification of a plaque ulcer hinges on showing a communication between the lumen and a cavity within the plaque that contains blood flow. The irregular surface of the plaque alone isn’t enough, because surface roughness can mimic ulcers or be an artifact. The key is detecting a cavity inside the plaque that fills with color Doppler flow from the lumen, and doing this across multiple views to confirm the finding.

So, an irregular plaque surface with an intraplaque cavity that demonstrates flow on color Doppler in more than one plane is the best evidence of ulceration. This approach cannot be achieved by grayscale alone, and it relies on Doppler to confirm perfused communication with the lumen.