Carotid Plaque Calcification Characteristics on Computed Tomography Angiography Are Associated With Symptomatology Beyond Stenosis Severity

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OBJECTIVE: To evaluate quantitative and morphologic calcification characteristics on computed tomography angiography (CTA) and their association with carotid plaque symptomatology. BACKGROUND: Carotid artery disease accounts for approximately 15% of ischemic strokes. Current risk stratification relies primarily on stenosis severity, which incompletely reflects plaque-related risk. Calcification is a key plaque feature with both stabilizing and destabilizing properties, yet its clinical relevance remains incompletely understood. METHODS: In this single-center retrospective cohort study, 1,142 patients undergoing carotid revascularization (2015-2024) were screened, of whom 500 patients (1,000 carotid arteries) met inclusion criteria. Calcifications were quantified using total calcified volume, peak calcium density, and a novel volume‑weighted calcium score, and classified into 6 phenotypes. Associations with symptomatology (ischemic stroke, transient ischemic attack, amaurosis fugax) were assessed using generalized estimating equations adjusted for stenosis severity, vascular risk factors, and medical therapy. RESULTS: Among 1000 carotid arteries, 732 were asymptomatic and 268 symptomatic. Symptomatic plaques had lower calcium scores (567 vs. 599 HU; P=0.039), greater calcified volumes (255 vs. 221 mm³; P=0.044), and the positive rim sign dominated (37.3% vs. 13.4%; P<0.001). After multivariable adjustment, higher calcium score was associated with lower odds of symptomatology (aOR: 0.93 per 100‑HU increase; 95% CI: 0.86-0.99; P=0.047), whereas positive rim sign was associated with higher odds (aOR: 2.33; 95% CI: 1.59-3.41; P<0.001). CONCLUSIONS: CTA-derived quantitative and morphologic calcification characteristics are independently associated with carotid plaque symptomatology beyond stenosis severity, which may refine risk stratification in carotid artery disease.

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