Despite advances in cardiovascular imaging, risk stratification of atherosclerotic patients remains to be guided by the degree of luminal stenosis [1]. Yet, plaque composition—particularly intraplaque haemorrhage (IPH), thrombus, and lipid-rich necrotic core—plays a central role in rupture risk and the occurrence of myocardial infarction and stroke [2,3]. In this proof-of-concept study, Shami et al. [4] provide in vivo evidence that photon-counting computed tomography (PCCT) can detect rupture-prone plaque features in patients with symptomatic carotid disease non-invasively.

Indeed, by matching PCCT scans with histological sections from ten carotid endarterectomy specimens, encompassing over 1100 regions of interest, Shami and colleagues demonstrated that PCCT reliably differentiated calcium, IPH, thrombus, fibrosis, necrosis, and lipid core based on their spectral attenuation patterns. Notably, thrombus and IPH were distinguishable from other features across most energy levels, highlighting the technique’s potential to overcome the limitations of conventional CT angiography, which is largely restricted to calcification and stenosis assessment.

These findings mark an important milestone: PCCT enables non-invasive, high-resolution tissue characterization of atherosclerotic plaques under clinical routine acquisition settings. By moving beyond luminal narrowing, this modality could refine risk stratification, identify patients at highest risk of events, and potentially guide individualized therapy of rupture-prone plaques. However, several limitations should be acknowledged. The study cohort was small, restricted to male patients with severe symptomatic carotid stenosis, limiting generalisability. Comparisons with other imaging modalities (e.g. MRI, standard CT angiography) were lacking, and performance in coronary disease—a more common clinical scenario—remains unexplored.

Nevertheless, PCCT represents a promising step towards precision imaging in atherosclerosis. As larger studies validate its diagnostic accuracy, reproducibility, and prognostic value, the focus may shift from “can PCCT detect vulnerable plaques?” to “how can PCCT be integrated into clinical decision-making and prevention strategies?” This technological advance has the potential to transform cardiovascular imaging from anatomical assessment to biological risk profiling to guide the personalized management of the future patient burdened by atherosclerotic cardiovascular disease.