CEUS as an advanced ultrasound method provides additional characteristics of the atherosclerotic plaque instability and vasa vasorum detection, with positive correlation to the grade of stenosis and histological results and are useful in daily clinical practice for stroke risk awareness. Despite the excellent results described above, some limitation factors, such as extensive calcinosis with important acoustic shadow in carotid atherosclerotic plaque neovascularization diagnostics by CEUS, are still evident. CEUS remains an operator dependent imaging technique and

bidimensional analysis of the plaque enhancement assumes that the longitudinal cross section of the plaque analyzed is representative of the whole carotid plaque. For this reason it could be interesting to apply the emerging technique of 3D and 4D Doppler ultrasonography to CEUS for a global evaluation of the carotid atherosclerotic lesion.