A surprise behind the dark

Standard ultrasound has a poor accuracy in the detection of carotid plaque surface irregularities and ulcers, which are features of vulnerable lesions. Sonographic contrast agents can improve vessel wall lumen definition, thus potentially overcoming this limitation. Recent studies also suggest that contrast ultrasound can be used to study intraplaque neovascularizaion, a potential marker of high-risk lesions. This case represents a striking example of the added value of contrast ultrasound to improve diagnostic accuracy of vascular studies, particularly in the detection of plaque surface irregularities and plaque neovascularization.