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Purpose: Atherosclerotic plaques on carotid ultrasound are associated with cardiovascular events and may be considered for cardiovascular risk prediction. The sensitivity of carotid ultrasound for detection of atherosclerosis is suboptimal. Contrast enhanced ultrasound (CEUS) provides an accurate delineation of the carotid lumen and may improve detection of atherosclerotic plaques.Methods: Fifty patients from the outpatient clinic, with ≥1 risk factor were included. Bilateral carotid B-Mode ultrasound and CEUS were performed using a Philips iU22 ultrasound system (Bothell, USA), with a L9-3 probe. CEUS was performed by intravenous administration of Sonovue (Bracco, Milan, Italy). The ultrasound clips were digitally stored and reviewed by 2 independent observers. Atherosclerotic plaque was defined as a structure with a thickness >1.5 mm, encroaching the lumen for >0.5 mm or encroaching the lumen for >50% of the intima-media thickness. McNemar testing was used for comparison between groups.Results: Using B-Mode ultrasound the observers detected plaques in 65 (65%) and 69 (69%) carotid arteries respectively. Combining B-Mode ultrasound with CEUS both observers detected plaques in 83 (83%) carotid arteries. Using B-Mode ultrasound observer 1 detected carotid atherosclerosis in 38 patients and with CEUS in 9 (18%) additional patients (p<0.01). Observer 2 detected carotid atherosclerosis in 39 patients using B-Mode ultrasound and in 7 (14%) additional patients with CEUS (p<0.05). The figure shows an atherosclerotic plaque visualized with CEUS (left panel) and was not detected on B-mode ultrasound (right panel).Conclusion: CEUS has a significant incremental value for detection of carotid atherosclerosis, and can be easily incorporated into a standard carotid ultrasound examination.