Carotid hypoechoic plaques generally contain a large amount of lipid material fibrous, fatty plaques that appear hypoechoic. Such plaques are slightly less echogenic than the surrounding sternocleidomastoid muscle, and in some cases the fibrous fatty plaques are so hypoechoic that they cannot be distinguished from anechoic by ultrasound. This can then be determined indirectly by localized blood flow filling defects using color flow imaging. Hypoechoic plaques contain fewer cells than more echogenic plaques and tend to have a high risk of hypointense lipoproteinemia, plaque, ulceration, and cerebral ischemia. Based on plaque echogenicity characteristics the entire plaque is anechoic or the majority of the plaque is hypoechoic, i.e. greater than 50% hypoechoic. The risk of developing clinical symptoms is high, but the overall assessment should be combined with clinical, especially stroke risk factors, like hypertension, hyperlipidemia, diabetes, smoking, atrial fibrillation and obesity, lack of exercise, presence of three or more of them as high risk of stroke need to be evaluated comprehensively. Treatment should be directed at high risk factors for stroke and regular TCC neck ultrasound should be performed.