Keeps going up and down. Okay. Well, I'm going to go ahead and click start and then we'll get started. Okay Good evening. My name is Lori Lisansky and I'm the chairperson for the FUE learning educational committee. I said earlier that we work to present talks from head to toe this year So last month we started at the toes and tonight we're moving up to the head the carotid specifically And we have a presentation from Dr. Emily Ho tonight. It's called beyond stenosis assessing plaque morphology using plaque wrap Before we begin There are a couple of notes from the FUE office that I need to share especially for our first-time attendees The on-demand version of this webinar will be available in seven to ten business days in the FUE catalog on the website and it's free to members Now I'm going to ask that you please use the Q&A feature Not the chat not the raise your hand if you want to ask any questions that come to mind during the presentation And then at the end of the presentation, we should have some time for discussion You will receive an email containing an evaluation that must be completed in order to obtain your CMEs for tonight's webinar This email will be sent to you within seven to ten business days That concludes our announcement. So let's begin We're honored to have dr. Emily Ho as our speaker tonight. Dr. Ho is an MD PhD RPNI Neurologist from Seattle, Washington and similar to the RPVI credential that most of you are probably familiar with the RPNI Credential that dr. Ho has earned assures that she's a position proficient in the interpretation of neurosynology evaluation Dr. Ho is a neuro hospitalist affiliated with Swedish Medical Center and Harborview Medical Center Dr. Ho is an interpreting physician for the carotid and transcranial Doppler studies at Swedish Medical Center and is also a clinical associate professor in neurology at the University of Washington Dr. Ho's clinical interests are in stroke Neuro infectious disease and hospital-based neurologic care and then in her spare time Dr. Ho likes to engage in a unique Hobby, it's called extreme bread-making and it's using a sourdough starter that was born in the Pacific Northwest Very interesting And now if you will, please join me in welcoming our speaker tonight. Dr. Emily Ho Thank you everyone So I'm speaking to you from Seattle, Washington where it's early evening and the sun is about to set and I Will go on to talk to you about plaque morphology specifically using the plaque rad scoring system and So here is the overview as well as the objectives The CME statement of activity with disclaimers And finally, this is these are the disclosures specifically my disclosure I had a relationship with Imaging Monitoring USA that has ended and is not connected to this talk So I'm going to start off with this list of abbreviations because I'll be using these pretty frequently During this talk and it's for your reference in case you're not familiar with these terms And I'm going to start off with some facts about stroke What's the current state of stroke in the United States? And it's a big problem over over 795,000 strokes occur every year 795,000 strokes occur every year 76% are first-time attacks with the majority 87% being ischemic strokes 13% are intracerebral and subarachnoid hemorrhages and stroke is really deadly. It kills 140,000 Americans every year and so on average an American is having a stroke every 40 seconds and An American is dying of a stroke every three minutes Stroke is also expensive from 2019 to 2020 it cost Americans 56 billion dollars including health care services being in the hospital medications as well as missed days of work and Stroke is really disabling. It's the leading cause of serious Long-term disability it reduces mobility and more than half of stroke survivors who are aged 65 and older So with these sobering statistics, it's really Trying to predict and potentially intervene on patients who are at higher risk of stroke. It is really important So now I'm going to move on and talk about an actual patient who had recurrent strokes He's 82 years old and all of his strokes are occurring in the left hemisphere He has multiple stroke risk factors including heart disease high blood pressure hyperlipidemia And he presented to a local emergency department with stroke symptoms including new onset right-sided weakness and speech change specifically aphasia So now before we go So now before we go And talk about his current stroke symptoms. I want to go back in time And go over his brain imaging prior to this current ED presentation So let's go back to april 2015 When the patient had new onset right face and arm numbness And here's his MRI of the brain and as you can see He has multiple small strokes in the left hemisphere as indicated by these arrows About a year later he experienced new cognitive change He noticed he couldn't do math and so he went to an outside ed And was present and was diagnosed with an acute left parietal stroke Unfortunately, I don't have that MRI available to show you But I do have this head CT That was done several weeks after his stroke And as you can see the arrow indicates the new left parietal stroke In 2017 the patient experienced right face and arm weakness And he went to the hospital and he had even more strokes all in the left hemisphere as indicated by these arrows And that brings us to the present ED visit where he had his right-sided weakness and his speech change and as you can see The MRI showed subsequent new strokes, which are much bigger than the previous strokes that were diagnosed about a week before So let's go over the rest of his stroke workup including Vessel imaging. This is his CTA head neck and as you can see on the right ICA There is mild calcified plaque present in the right carotid bifurcation And this is the left ICA There is also calcified plaque resulting in 40% stenosis and compared to previous imaging the neuroradiologist Thought that the amount of plaque was stable Now let's take another look at his carotid bifurcation the right ICA and the left ICA is indicated by the arrows And you can get a different view an oblique view of his carotid bifurcation And to me, it looks pretty crunchy So the patient was admitted to the hospital and neurology was consulted and They ordered a carotid duplex and a TCD study So Let's go over the carotid duplex So this is the patient's left common carotid artery and you can see that there is hyperechoic plaque present in in the mid portion of the left common carotid artery and there's calcified plaque that's resulting in an acoustic shadow Seen in the mid portion of the left common carotid artery Here is the patient's left ICA and I think you can appreciate that the plaque is mixed Echogenicity, I'll use my laser pointer here to show you So this is axial view And with measurements one can estimate that the diameter reduction is approximately 45% And then here's a longitudinal view of the left ICA and you can appreciate that there is hyperechoic and hypoechoic regions in this plaque So this is the summary of the carotid duplex study, I won't show you the right side We'll just focus on the left side, but it results in less than 50% stenosis in the left ICA Here's the patient's TCD emboli monitoring the first study didn't show any emboli in the left ICA TCD emboli monitoring the first study didn't show any emboli in the bilateral middle cerebral arteries However, the second study was an extended study It was done for one hour and while the right MCA didn't show any emboli The left MCA as indicated by the arrow there was one microembolic signal So in summary, this is a patient who's having recurrent left hemispheric strokes And on both CTA and carotid duplex, he has mild left ICA stenosis And he has had an extensive stroke workup There hasn't been any evidence of atrial fibrillation despite multiple periods of cardiac monitoring He was wearing an implantable loop recorder He even had consultation with hematology and oncology and they didn't show any evidence of a clotting Disorder such as thrombophilia on lab testing However, the patient had a TCD study that showed an embolus from a proximal left source and it was In general, this was a very puzzling case for the patient's providers and he was discussed in the multidisciplinary cerebrovascular conference that we have every week to talk about the etiology of his stroke and The consensus was that the left ICA was probably the the etiology of the patient's stroke despite the mild degree of carotid stenosis So now let's talk a little bit more about carotid stenosis And carotid plaque and as you can see from this gross anatomical specimen from an actual patient I think we can all appreciate that carotid plaque can be complex and there may be more to the story than just carotid stenosis As a reminder, how do we currently assess carotid stenosis? Well the most common protocol, the most common method is the NACIP protocol in which the stenosis is calculated From a ratio from the narrowest portion of the diseased artery compared to the diameter of the artery beyond any post-stenotic dilatation And here's the equation There is a second method to calculate carotid stenosis as published by the European Carotid Surgery Trial But in the interest of time, I won't be using or talking about this method any further but I think we know from stroke trials that patients who have a high grade stenosis 70 to 99 percent and at ischemic strokes benefited from carotid intervention including carotid endarterectomy and carotid stent placement So now let's talk a little bit more about how a carotid plaque develops And I'm going to take you through this sort of what I think of as the life cycle of a carotid plaque And it includes pictures of pentachrome histological stains of actual carotid plaque tissue and We'll start with panel A. So panel A shows the adaptive intimal thickening That is characterized by smooth muscle cell accumulation within the intima Moving on to panel B We then can appreciate that there's this anthoma Which corresponds to the accumulation of foam cells within the intima? Panel C is pathological intimal thickening where there's accumulation of extracellular lipid pools in the intima And then D is a fibroatheroma which indicates there's presence of a necrotic core below the fibrous cap and finally E is when the fibroatheroma undergoes tissue remodeling and the tissue may actually become calcified as shown here So Why do we care about carotid plaque? Well besides stenosis carotid plaques can cause a thrombus which can then break off and go downstream into the brain and cause an ischemic stroke And how does a carotid plaque cause a thrombus? Well, it becomes it happens through plaque rupture. That's the most frequent cause of causing thrombus So it's a structural defect in the fibrous cap that exposes the material in the fibroatheroma to the blood and this material is very very sticky And then it causes a clot to form And this this is the clot that can break off and cause an ischemic stroke in the brain now there are times when the thrombus is non-fatal and there can be times when there's healing of this thrombus becomes fibrosed and there's tissue remodeling, but this is how a carotid stenosis can occur I'm now going to turn to carotid plaque RADs which is a scoring system to assess carotid plaque morphology And this manuscript was published a little bit over a year ago and you can see there's a lot of work involved It was published in the Journal of the American College of Cardiovascular Imaging And I'm proud to point out that several of the authors are actually from Seattle, Washington including Dr. Tom Hatsukami who is a treasured colleague So this is a step-by-step flow chart to help you through the different plaque RADs categories and It's a little bit busy so we'll go through each score So plaque RADs the lowest score is a one and the highest score is a four So starting with plaque RADs score of one That means there isn't any carotid plaque If there is carotid plaque and the plaque is Less than three millimeters in thickness that gives the patient plaque RAD score of two When the plaque is thicker greater than or equal to three millimeters Then it becomes a plaque RAD score of three and there's three different subcategories With 3a being a thick fibrous cap 3b being a thin fibrous cap 3c being ulcerated plaque And then we reach the highest plaque RAD score which is four And there are again three subcategories for plaque RADs of four These are high risk plaque features with 4a being intraplaque hemorrhage 4b being ruptured plaque And 4c being intraluminal thrombus So i'm now going to go through every category in more detail and and just to make it more fun I've recruited some friends Specifically Spongebob to help us go through and think about plaque morphology and the different plaque RADs scoring categories So, thank you Spongebob And we'll start with plaque RAD score of one So, this is when there's a normal vessel wall without disease There isn't any carotid plaque and we know from population-based cohort studies such as the Rotterdam study that patients without a carotid plaque are really not at risk of having atherosclerosis related heart disease or strokes And so in Spongebob's world, what would plaque RADs one look like? Well for those of you kids, it looks like the seafloor here. The seafloor is smooth. It's very calm There there really isn't any screaming yelling or mayhem And you you really hope that it stays that way So here's what plaque RAD score looks like on ultrasound in the upper row of images as well as MRI Everything looks really great normal study Plaque RAD score of two It means that there is presence of a plaque and a maximal wall thickness is less than three millimeter There may be some possible features such as small areas of calcification or a small lipid rich in the carotid core And these plaque features could be the hallmarks of a relatively stable plaque Or they could be the hallmark of something that could progress and become a more worrisome lesion. It's really hard to say so in Spongebob's world There's something on the seafloor and it's something we we should pay attention to So How do we measure maximal wall thickness or MWT? Well, it's a linear measurement of the greatest Area of thickness of the vessel wall on axial images as shown in these pictures picture A and picture B And so it's perpendicular to the vessel's long axis and it should include both the arterial vessel wall As well as calcified and non-calcified components of the plaque And so here's an example of ultrasound where a patient has a maximal wall thickness of 2.4 millimeters and you can appreciate the hyper-echoic plaque present in this patient's carotid Moving on the plaque red score of three. Well, this is when things get a little bit more complex Um The maximal wall thickness is three millimeters or more and in Spongebob's world. Well, there's a lot going on The seafloor is lumpy. It's bumpy. There's coral growing. Maybe other things are happening So let's go over the three subcategories of plaque red street The first being 3a in which there's a thick fibrous cap So this is an image taken from a patient's ultrasound in which they have 50 to 69 percent stenosis The maximal wall thickness is six millimeters and you can appreciate the area of the the plaque It's pretty hyper-echoic. It's smooth Um, so this is thick fibrous cap. You can actually see it on image B on the axial imaging 3b 3b is a thin fibrous cap and I think this is a little bit more complicated Uh, for instance this in this ultrasound Um, the maximal wall thickness is 3.6 millimeters But as you can appreciate on the longitudinal views, there is both hyper and hypoechoic Uh regions of this plaque In fact, there's an area that we would call a jva or a juxtaluminal black area where you just can't see the material But it's much easier to see with color flow And the authors of the paper actually show uh panel c in which they outline the area of plaque using a thin dotted white line 3c Plaque red score 3c is an ulcerated plaque And so I think you can appreciate on the upper row of images An ultrasound in which the patient has both hyper and hypoechoic plaque in which the area of ulceration Is indicated by the small asterisk The lower row of images is a cta of a patient with an ultra With an ulcerated plaque in the left ICA. And I think you can see best on the sagittal view where the arrows indicated the area of ulceration. We reached the highest plaque red score. It's a score of four and this is high risk plaque and it's independent of the plaque thickness. And it includes intra-plaque hemorrhage, ruptured fibrous cap, as well as intraluminal thrombus. And I think here SpongeBob is getting really scared because something dangerous is poking out of the sea floor. I think pretty soon he's going to start yelling and screaming for help. So the first subcategory of plaque red score four is 4A. And this is intra-plaque hemorrhage. And I won't go into a lot of detail using ultrasound because MRI is the most sensitive diagnostic imaging to diagnose intra-plaque hemorrhage. But we'll discuss this in a little bit more on a later slide. 4B is ruptured fibrin plaque. And so this is an ultrasound that shows a ruptured plaque in the left carotid bulb. And the calcified area is observed adjacent to the vessel wall. But there's also a free flap visible that's going into the lumen of this vessel. And looking at color flow, you can see that the flow is very perturbed. In fact, it's actually going reverse behind the fibrin flap. And I think what we can appreciate is that with ultrasound, there is a power to actually diagnose movement of the fibrin flap sometimes because it is dynamic imaging. And then finally, we have intraluminal thrombus. And wow, this ultrasound, lots going on here. There's like mixed echogenicity in the lesion with this very severe stenosis. This patient had 72% stenosis. And I think you can see how a stenosis area is in the patient's carotid on a power doppler. But you can see that there are both hyperechoic and hypoechoic regions in this lesion, including the area of thrombus where my laser pointer is showing you. And on the lower row of images is a patient's CTA showing a thrombus. And the arrow in panel D shows what we call the donut sign because it looks like a donut. Sometimes I use the term worm in a hole and that's seen in axial images of this patient's CTA. And then on sagittal and coronal image, you can see the area of thrombus that's going into the lumen of the vessel. So why do we care about intraluminal thrombus? Well, it's high risk. It's associated with stroke symptoms, neurological symptoms in up to 92% of cases. And as published by this manuscript back in 2015, intraluminal thrombus is the strongest predictor of carotid sores of stroke. And I'm now gonna take you through another case of intraluminal thrombus. This is a patient who is 36 years old and he unfortunately has a clotting propensity to form clots. And so he's had multiple lung clots or pulmonary emboli and he was prescribed anticoagulation. Unfortunately, he stopped taking the anticoagulation for the past six months. And then he presented with new stroke symptoms, including left-sided weakness. He went to an outside emergency department and his NIH stroke scale was scored as a 17, which is a pretty severe stroke. This is a CTA of the head and neck. And what you can see on axial imaging is that we have the donut or the worm in the hole sign in his right carotid bifurcation. Other views of the thrombus is shown on the coronal and sagittal images and indicated the area of thrombus is indicated by the arrow. And this is the patient's follow-up. So he went to the interventional suite and underwent thrombectomy. And this is his follow-up carotid duplex study. You can see on longitudinal views, there's like a hint of a hypoechoic object within the vessel, but it's much easier to see with power Doppler. And I actually took a video of the CINE loop using my smartphone. And so this is a longitudinal view of that thrombus. I actually turned up the brightness to make it easier to see. So let's see if this video plays. So you can see the thrombus, it's attached to the vessel wall in the right carotid bulb. And then here is on axial imaging. Again, you can appreciate the presence of the thrombus. It looks a little speckled. Okay, so we've gone through the plaque red scoring system. Again, it starts with one and it goes to four. And I think you can appreciate that the higher the score plaque reds, the more vulnerable the carotid plaque is. And I think for the patient, the higher the plaque red score, the higher the risk of stroke. Now, because we're talking about carotid ultrasound, I wanna go over some nuances and limitations of carotid ultrasound, especially with using plaque reds. So the first point is that hypoechoic plaque are large lipid-rich necrotic cord. We often use the term soft plaque. And this gives you a score on plaque reds of 3A or 3B. Lipid-rich necrotic cord with a thin fibrous cap often look like juxtaluminal black areas or JBA, and it's a plaque red score of 3B. Now, as I talked about before, ultrasound can't distinguish large lipid-rich necrotic cord from an intraplaque hemorrhage. MRI does a much better job, but intraplaque hemorrhage gives you a score of 4A. And JBA may also represent plaque rupture, 4B, or even intraluminal thrombus, 4C. So there is some ambiguity when using ultrasound to assess carotid plaque because it's difficult to distinguish 3B, 4A, 4B, and 4C, because these can all appear to be JBA. So the authors make the following recommendation. For a hypoechoic plaque of three millimeters or more without a visible fibrin cap that's hyperechoic, or if there's presence of a JBA, consider using MRI to further assess the carotid plaque. And specifically to look for intraplaque hemorrhage or plaque rupture or other high-risk features. So let's go back to our patient who had the recurrent strokes in the left hemisphere. And just as a reminder, he had less than 50% stenosis in the left ICA. And this is a case actually that stayed with me because we were all puzzled about what to do. Why he was having his strokes. But I think with the knowledge that we've gone over plaque reds, we can now look at this carotid duplex with some fresh eyes. And so looking at his left ICA on axial imaging, I think you can appreciate that the plaque has mixed echogenicity, and there's even presence of a fibrin cap on axial imaging. And if we were to make a measurement of the maximum wall thickness, it measures out to be 3.8 millimeters. Now, this is where things get interesting because on the longitudinal view, I think we can now appreciate that there's a JBA presence. And I do wish that there was color flow used in this study, but I just didn't have that available. So I think we could rewrite this study report as less than 50% stenosis in the left ICA. The plaque has mixed hyperechoic and hypoechoic regions. The maximum wall thickness is 3.8 millimeters. And the plaque red score, well, it's a little bit hard. It could be a 3B, could be a 4A, a 4B. I don't think we appreciated any evidence of thrombus, but I think because there is some ambiguity for this patient, it could be a plaque red score of 3B or even higher. If I know what I know now, given the limitations of ultrasound, I probably, if I saw this patient today, I'd probably send him for an MRI study of the carotid bifurcation. And we do know from the patient's history that something really bad is happening in that mildly stenotic plaque because he kept having multiple ischemic events involving the left hemisphere. So what about carotid plaque reds in the real world? You know, I think this is a new scoring system. It means learning how to use it. And our ultrasound lab in Seattle has discussed the plaque red scoring system and is actively discussing on implementing it in our carotid duplex reports. But what about how is it helpful? So there aren't any prospective studies using plaque reds, but I want to draw your attention to this publication that was published in the last year of a retrospective study looking at ischemic stroke patients and using plaque reds to predict stroke. So these patients were all admitted to the hospital with stroke from the beginning of the year and were admitted to the hospital with stroke from 2010 to 2021 in the People's Republic of China. And all of the patients underwent MRA neck, CTA neck, and carotid ultrasound. The authors looked at stroke-free survival as well as recurrence of stroke and compared them across different categories of carotid stenosis. The primary endpoint being the incidence of ischemic stroke and the secondary endpoint being mortality. And this was actually a pretty big study. 1,378 patients were included in the study. Patients with carotid revascularization, malignancy, or neck radiation therapy were excluded. The patients were followed up for almost five years on average. And what's important to note is that 32% of the patients were lost to follow-up. So in addition, the stroke diagnoses were made independently by two neurologists and recurrent stroke was defined as a stroke occurring in the same carotid territory as previously identified. Or the previous stroke event. And then images and plaque morphology were independently reviewed by two radiologists who were blinded to patient outcome. And here are the categories of carotid stenosis. As you'll see, severe carotid stenosis was 70 to 99%. What are the results? Well, as the authors showed that as the plaque risk score increased for the patients from one to four, the rate of stroke or recurrent stroke for the patients over time also increased, so not surprising. And if we look at the survival curve or ROC curve of patients and their stroke-free survival, what you can see is in this figure, the Y-axis shows the probability of being stroke-free with 100% being at the top of the Y-axis. And then time is shown on the X-axis. The patients with mild to moderate carotid stenosis did much better. They were much more likely to be stroke-free compared to patients with severe carotid stenosis. And this difference was statistically significant. Well, what about if we add plaque rats to the picture? So let's focus on the patients with mild to moderate stenosis, and that's shown here. Similar stroke-free survival curve with 100% survival at the top of the Y-axis and time at the X-axis. What you can see is that in those patients with mild to moderate carotid stenosis and a plaque rat score that was low, less than three, they did much, much better compared to patients with a high plaque rat score, three or greater. And this difference was statistically significant. Now let's turn to recurrent stroke and the survival curve for recurrent stroke. And so similarly, patients with mild to moderate carotid stenosis, they were much more likely to be free of recurrent stroke compared to patients with severe carotid stenosis. Again, the differences were statistically significant. And then if we look at this patient population and look at their recurrence of stroke divided by plaque rats score of less than three, these patients did really well. They didn't really have recurrent stroke over time compared to those with a mild to moderate carotid stenosis and a plaque rat score of three or more. And again, this was statistically significant. Now let's look at the percentage of stroke occurring in patients divided by their degree of carotid stenosis. And as you can see, patients with mild to moderate carotid stenosis, only 4% of those patients ended up having ischemic stroke compared to patients with severe carotid stenosis. Wow, 75% of these patients had ischemic stroke. Now let's add carotid stenosis with plaque rats. And we're gonna ignore the middle panel in the interest of time, but we'll look at the combination of carotid stenosis and plaque rats. So those patients with mild to moderate carotid stenosis and a low plaque rat score, only 0.8% of patients had an ischemic stroke. Compared to patients with severe carotid stenosis and a high plaque rat score, 75% of patients had an ischemic stroke. Now the interesting group are those patients with mild to moderate carotid stenosis and a plaque rat score of greater than or equal to three, and 32% of those patients had an ischemic stroke, much higher than those with a low plaque rat score. Turning to patients with recurrent ischemic stroke, looking at carotid stenosis, patients with mild to moderate stenosis, only 15% had recurrent stroke compared to patients with severe carotid stenosis. 80% of those patients had repeat stroke over time. And then adding plaque rats to the equation, similar to just initial carotid stenosis, just initial ischemic stroke, patients with mild to moderate carotid stenosis and a low plaque rat score, only about 7% of patients had recurrent stroke. In contrast, patients with severe carotid stenosis and a plaque rat score of three or more, 80% had recurrent ischemic stroke. And the patients with mild to moderate carotid stenosis and a high plaque rat score, three or greater, well, almost 60% of these patients ended up having recurrent stroke. And I think you could actually put our patient case into this category too. So we're getting to the end of our talk. I'll summarize here. Plaque rats is a four point plaque vulnerability score for reporting carotid plaque morphology. It evaluates carotid artery disease beyond carotid stenosis, and it helps us predict the risk of cerebrovascular event. So this helps us to understand for patients what plaque may mean clinically. And it's a common language between stenographers, CT and MRI specialists, radiologists, treating providers, as well as research scientists. There are advantages to plaque rats. It can be applied across multiple imaging modalities, including ultrasound, CTA, and MRI. It incorporates current research findings, and it has the potential to be applied in future clinical trials. And while it's limited because it has yet to be validated in larger cohorts, as I reviewed with you, there is one retrospective study in which plaque rats significantly improve stroke risk stratification over carotid stenosis alone, especially in those patients with mild to moderate carotid stenosis. And so I'm curious to hear from the audience what you think of plaque rats. I encourage you to give it a try. Here's a suggested method for incorporating plaque rats into a carotid duplex study. So in addition to what we already do, side of the carotid, the degree of stenosis, any ancillary features such as progression of plaque, any modifiers such as history of carotid and arterectomy, or a carotid stent, I encourage you to give plaque rat score a try. I think it's gonna take some learning and getting used to, but I think a good place to start is even just measuring the maximal wall thickness. So I wanna thank you all for your attention. I especially wanna give a shout out to Lenny Carr who actually started this conversation in Seattle, Washington with our group. I wanna thank my colleagues at Swedish Medical Center and Pacific Vascular, especially the hardworking technologists. They make my life so much easier and I really appreciate everything they do to make great quality studies. And I'm just so proud to have them, being a team member with them. And if you have any questions, please feel free to contact me. This is my email and I think I'll stop here and take any questions. Thank you, Dr. Ho. Thank you for using the SpongeBob references. It makes it much more palatable. Yeah, it is entertaining. So we do have a couple of questions. One of them is who's doing this analysis currently in your practice? Is it the technologist taking the measurements or are you using some sort of post-processing software? Yeah, I think there, I saw a poster. I didn't present the poster because it wasn't published data, but there is software I think that can calculate plaque reds. I don't remember the name of it. Like that automatically will measure it for you? Like you just, you know, you- I think so, yeah. Yeah, we're still traditional old school making manual measurements. So, and I think this will be something to be discussed. I don't know if the technologists would feel comfortable making, coming up with a calculation ourselves, but we would have to discuss it with our providers to talk about who would be making the final call. I've actually been doing it sort of like on the slide. Like I don't put it in my report.

carotid plaque

plaque RAD scoring

ischemic strokes

neurology care

imaging modalities

stroke risk

Dr. Emily Ho

cerebrovascular events