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Fernández-Alvarez V, Linares-Sánchez M, Suárez C, López F, Guntinas-Lichius O, Mäkitie AA, Bradley PJ, Ferlito A. Novel Imaging-Based Biomarkers for Identifying Carotid Plaque Vulnerability. Biomolecules 2023; 13:1236. [PMID: 37627301 PMCID: PMC10452902 DOI: 10.3390/biom13081236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/30/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Carotid artery disease has traditionally been assessed based on the degree of luminal narrowing. However, this approach, which solely relies on carotid stenosis, is currently being questioned with regard to modern risk stratification approaches. Recent guidelines have introduced the concept of the "vulnerable plaque," emphasizing specific features such as thin fibrous caps, large lipid cores, intraplaque hemorrhage, plaque rupture, macrophage infiltration, and neovascularization. In this context, imaging-based biomarkers have emerged as valuable tools for identifying higher-risk patients. Non-invasive imaging modalities and intravascular techniques, including ultrasound, computed tomography, magnetic resonance imaging, intravascular ultrasound, optical coherence tomography, and near-infrared spectroscopy, have played pivotal roles in characterizing and detecting unstable carotid plaques. The aim of this review is to provide an overview of the evolving understanding of carotid artery disease and highlight the significance of imaging techniques in assessing plaque vulnerability and informing clinical decision-making.
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Affiliation(s)
- Verónica Fernández-Alvarez
- Department of Vascular and Endovascular Surgery, Hospital Universitario de Cabueñes, 33394 Gijón, Spain;
| | - Miriam Linares-Sánchez
- Department of Vascular and Endovascular Surgery, Hospital Universitario de Cabueñes, 33394 Gijón, Spain;
| | - Carlos Suárez
- Instituto de Investigacion Sanitaria del Principado de Asturias, 33011 Oviedo, Spain; (C.S.); (F.L.)
| | - Fernando López
- Instituto de Investigacion Sanitaria del Principado de Asturias, 33011 Oviedo, Spain; (C.S.); (F.L.)
- Department of Otorhinolaryngology, Hospital Universitario Central de Asturias, Instituto Universitario de Oncologia del Principado de Asturias, University of Oviedo, CIBERONC, 33011 Oviedo, Spain
| | | | - Antti A. Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital, University of Helsinki, P.O. Box 263, 00029 Helsinki, Finland;
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland
- Division of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institute and Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Patrick J. Bradley
- Department of ORLHNS, Queens Medical Centre Campus, Nottingham University Hospitals, Derby Road, Nottingham NG7 2UH, UK;
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35100 Padua, Italy;
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2
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Clezar CN, Flumignan CD, Cassola N, Nakano LC, Trevisani VF, Flumignan RL. Pharmacological interventions for asymptomatic carotid stenosis. Cochrane Database Syst Rev 2023; 8:CD013573. [PMID: 37565307 PMCID: PMC10401652 DOI: 10.1002/14651858.cd013573.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
BACKGROUND Carotid artery stenosis is narrowing of the carotid arteries. Asymptomatic carotid stenosis is when this narrowing occurs in people without a history or symptoms of this disease. It is caused by atherosclerosis; that is, the build-up of fats, cholesterol, and other substances in and on the artery walls. Atherosclerosis is more likely to occur in people with several risk factors, such as diabetes, hypertension, hyperlipidaemia, and smoking. As this damage can develop without symptoms, the first symptom can be a fatal or disabling stroke, known as ischaemic stroke. Carotid stenosis leading to ischaemic stroke is most common in men older than 70 years. Ischaemic stroke is a worldwide public health problem. OBJECTIVES To assess the effects of pharmacological interventions for the treatment of asymptomatic carotid stenosis in preventing neurological impairment, ipsilateral major or disabling stroke, death, major bleeding, and other outcomes. SEARCH METHODS We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, two other databases, and three trials registers from their inception to 9 August 2022. We also checked the reference lists of any relevant systematic reviews identified and contacted specialists in the field for additional references to trials. SELECTION CRITERIA We included all randomised controlled trials (RCTs), irrespective of publication status and language, comparing a pharmacological intervention to placebo, no treatment, or another pharmacological intervention for asymptomatic carotid stenosis. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. Two review authors independently extracted the data and assessed the risk of bias of the trials. A third author resolved disagreements when necessary. We assessed the evidence certainty for key outcomes using GRADE. MAIN RESULTS We included 34 RCTs with 11,571 participants. Data for meta-analysis were available from only 22 studies with 6887 participants. The mean follow-up period was 2.5 years. None of the 34 included studies assessed neurological impairment and quality of life. Antiplatelet agent (acetylsalicylic acid) versus placebo Acetylsalicylic acid (1 study, 372 participants) may result in little to no difference in ipsilateral major or disabling stroke (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.47 to 2.47), stroke-related mortality (RR 1.40, 95% CI 0.54 to 3.59), progression of carotid stenosis (RR 1.16, 95% CI 0.79 to 1.71), and adverse events (RR 0.81, 95% CI 0.41 to 1.59), compared to placebo (all low-certainty evidence). The effect of acetylsalicylic acid on major bleeding is very uncertain (RR 0.98, 95% CI 0.06 to 15.53; very low-certainty evidence). The study did not measure neurological impairment or quality of life. Antihypertensive agents (metoprolol and chlorthalidone) versus placebo The antihypertensive agent, metoprolol, may result in no difference in ipsilateral major or disabling stroke (RR 0.14, 95% CI 0.02 to1.16; 1 study, 793 participants) and stroke-related mortality (RR 0.57, 95% CI 0.17 to 1.94; 1 study, 793 participants) compared to placebo (both low-certainty evidence). However, chlorthalidone may slow the progression of carotid stenosis (RR 0.45, 95% CI 0.23 to 0.91; 1 study, 129 participants; low-certainty evidence) compared to placebo. Neither study measured neurological impairment, major bleeding, adverse events, or quality of life. Anticoagulant agent (warfarin) versus placebo The evidence is very uncertain about the effects of warfarin (1 study, 919 participants) on major bleeding (RR 1.19, 95% CI 0.97 to 1.46; very low-certainty evidence), but it may reduce adverse events (RR 0.89, 95% CI 0.81 to 0.99; low-certainty evidence) compared to placebo. The study did not measure neurological impairment, ipsilateral major or disabling stroke, stroke-related mortality, progression of carotid stenosis, or quality of life. Lipid-lowering agents (atorvastatin, fluvastatin, lovastatin, pravastatin, probucol, and rosuvastatin) versus placebo or no treatment Lipid-lowering agents may result in little to no difference in ipsilateral major or disabling stroke (atorvastatin, lovastatin, pravastatin, and rosuvastatin; RR 0.36, 95% CI 0.09 to 1.53; 5 studies, 2235 participants) stroke-related mortality (lovastatin and pravastatin; RR 0.25, 95% CI 0.03 to 2.29; 2 studies, 1366 participants), and adverse events (fluvastatin, lovastatin, pravastatin, probucol, and rosuvastatin; RR 0.76, 95% CI 0.53 to1.10; 7 studies, 3726 participants) compared to placebo or no treatment (all low-certainty evidence). The studies did not measure neurological impairment, major bleeding, progression of carotid stenosis, or quality of life. AUTHORS' CONCLUSIONS Although there is no high-certainty evidence to support pharmacological intervention, this does not mean that pharmacological treatments are ineffective in preventing ischaemic cerebral events, morbidity, and mortality. High-quality RCTs are needed to better inform the best medical treatment that may reduce the burden of carotid stenosis. In the interim, clinicians will have to use other sources of information.
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Affiliation(s)
- Caroline Nb Clezar
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Carolina Dq Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Nicolle Cassola
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Virginia Fm Trevisani
- Medicina de Urgência and Rheumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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3
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Robson PM, Kaufman A, Pruzan A, Dweck MR, Trivieri MG, Abgral R, Karakatsanis NA, Brunner PM, Guttman E, Fayad ZA, Mani V. Scan-rescan measurement repeatability of 18F-FDG PET/MR imaging of vascular inflammation. J Nucl Cardiol 2022; 29:1660-1670. [PMID: 34046803 DOI: 10.1007/s12350-021-02627-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 03/07/2021] [Indexed: 12/27/2022]
Abstract
Non-invasive positron emission tomography (PET) of vascular inflammation and atherosclerotic plaque by identifying increased uptake of 18F-fluordeoxyglucose (18F-FDG) is a powerful tool for monitoring disease activity, progression, and its response to therapy. 18F-FDG PET/computed tomography (PET/CT) of the aorta and carotid arteries has become widely used to assess changes in inflammation in clinical trials. However, the recent advent of hybrid PET/magnetic resonance (PET/MR) scanners has advantages for vascular imaging due to the reduction in radiation exposure and improved soft tissue contrast of MR compared to CT. Important for research and clinical use is an understanding of the scan-rescan repeatability of the PET measurement. While this has been studied for PET/CT, no data is currently available for vascular PET/MR imaging. In this study, we determined the scan-rescan measurement repeatability of 18F-FDG PET/MR in the aorta and carotid arteries was less than 5%, comparable to similar findings for 18F-FDG PET/CT.
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Affiliation(s)
- Philip M Robson
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Audrey Kaufman
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alison Pruzan
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marc R Dweck
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Maria-Giovanna Trivieri
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ronan Abgral
- Department of Nuclear Medicine, European University of Brittany, EA3878 GETBO, IFR 148, CHRU Brest, Brest, France
| | - Nicolas A Karakatsanis
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patrick M Brunner
- Laboratory for Investigative Dermatology, The Rockefeller University, New York, NY, USA
| | - Emma Guttman
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zahi A Fayad
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Venkatesh Mani
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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4
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Sun B, Ge X, Li X, Zhang J, Zhao Z, Liu X, Zhou Y, Xu J, Zhao H, Sun J. Elevated Hemoglobin A1c Is Associated With Leaky Plaque Neovasculature as Detected by Dynamic Contrast-Enhanced Magnetic Resonance Imaging. Arterioscler Thromb Vasc Biol 2022; 42:504-513. [PMID: 35236109 DOI: 10.1161/atvbaha.121.317190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 02/14/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with diabetes have accelerated atherosclerosis progression, but the underlying mechanisms are not fully understood. Dynamic contrast-enhanced magnetic resonance imaging has allowed in vivo characterization of plaque neovasculature, which plays a critical role in plaque progression. We aimed to evaluate the impact of diabetes on carotid plaque neovasculature as assessed by dynamic contrast-enhanced magnetic resonance imaging. METHODS Patients with recent ischemic stroke and ipsilateral carotid plaque underwent multicontrast magnetic resonance imaging for characterizing plaque morphology and dynamic contrast-enhanced magnetic resonance imaging for pharmacokinetic parameters of plaque neovasculature, including transfer constant (Ktrans, reflecting flow, endothelial surface area, and permeability) and fractional plasma volume (νp). RESULTS Sixty-five patients were enrolled, including 30 patients with diabetes (years since diagnosis: median 5.0 [interquartile range, [3.0-12.0]) and 35 patients without diabetes. Subjects with diabetes had a greater plaque burden and a higher prevalence of high-risk characteristics. Additionally, carotid plaques in the subjects with diabetes showed higher Ktrans than those in the subjects without diabetes (0.100±0.048 min-1 versus 0.067±0.042 min-1, P=0.005) but νp was numerically lower in the subjects with diabetes (5.2±3.7% versus 6.2±4.3%, P=0.31). The association of diabetes with high Ktrans (β=0.033, P=0.005) was independent of patient and plaque characteristics and remained largely intact after adjusting for serum lipids, glucose, or hs-CRP (high-sensitivity C-reactive protein). However, it became nonexistent after adjusting for hemoglobin A1c (β=-0.010, P=0.49). CONCLUSIONS Dynamic contrast-enhanced magnetic resonance imaging of carotid plaques suggested that plaque neovasculature in patients with diabetes is leaky, indicating enhanced capability of bringing blood constituents and facilitating extravasation of inflammatory cells, erythrocytes, and plasma proteins. Leaky plaque neovasculature correlated with hemoglobin A1c and may play a role in accelerated atherosclerosis progression in diabetes.
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Affiliation(s)
- Beibei Sun
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, China (B.S., X.G., X.L., J.Z., Z.Z., X.L., Y.Z., J.X., H.Z.)
| | - Xiaoqian Ge
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, China (B.S., X.G., X.L., J.Z., Z.Z., X.L., Y.Z., J.X., H.Z.)
- Department of Radiology, Shandong Second Provincial General Hospital, Jinan, China (X.G.)
| | - Xiao Li
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, China (B.S., X.G., X.L., J.Z., Z.Z., X.L., Y.Z., J.X., H.Z.)
- Department of Radiology, Shandong Second Provincial General Hospital, Jinan, China (X.G.)
| | - Jianjian Zhang
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, China (B.S., X.G., X.L., J.Z., Z.Z., X.L., Y.Z., J.X., H.Z.)
| | - Zizhou Zhao
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, China (B.S., X.G., X.L., J.Z., Z.Z., X.L., Y.Z., J.X., H.Z.)
| | - Xiaosheng Liu
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, China (B.S., X.G., X.L., J.Z., Z.Z., X.L., Y.Z., J.X., H.Z.)
| | - Yan Zhou
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, China (B.S., X.G., X.L., J.Z., Z.Z., X.L., Y.Z., J.X., H.Z.)
| | - Jianrong Xu
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, China (B.S., X.G., X.L., J.Z., Z.Z., X.L., Y.Z., J.X., H.Z.)
| | - Huilin Zhao
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, China (B.S., X.G., X.L., J.Z., Z.Z., X.L., Y.Z., J.X., H.Z.)
| | - Jie Sun
- Department of Radiology, University of Washington, Seattle (J.S.)
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5
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Giannotti N, McNulty J, Foley S, McCabe J, Barry M, Crowe M, Dolan E, Harbison J, Horgan G, Kavanagh E, O'Connell M, Marnane M, Murphy S, Donnell CM, O'Donohoe M, Williams D, Kelly PJ. Association Between 18-FDG Positron Emission Tomography and MRI Biomarkers of Plaque Vulnerability in Patients With Symptomatic Carotid Stenosis. Front Neurol 2022; 12:731744. [PMID: 35002912 PMCID: PMC8732361 DOI: 10.3389/fneur.2021.731744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/25/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose: Pathologic studies suggest that unstable plaque morphology and inflammation are associated with cerebrovascular events. 18F-fluorodeoxyglucose positron emission tomography (18FDG-PET) is a validated technique for non-invasive imaging of inflammation-related plaque metabolism, and MRI can identify morphologic features of plaque instability. The aim of this study was to investigate the association of selected imaging characteristics of plaque vulnerability measured with MRI and PET in patients with symptomatic carotid stenosis. Methods: Patients from the BIOVASC study were selected based on the following inclusion criteria: (1) age ≥ 50 years; (2) recent (<30 days) ischaemic stroke (modified Rankin scale ≤3) or motor/speech/vision TIA; (3) ipsilateral internal carotid artery stenosis (≥5 0% lumen-narrowing); (4) carotid PET/CTA and MRI completed. Semi-automated plaque analysis of MRI images was performed to quantify morphologic features of plaque instability. PET images were co-registered with CTA and inflammation-related metabolism expressed as maximum standardised uptake value (SUVmax). Results: Twenty-five patients met inclusion criteria (72% men, mean age 65 years). MRI-measured plaque volume was greater in men (1,708–1,286 mm3, p = 0.03), patients who qualified with stroke (1,856–1,440 mm3, p = 0.05), and non-statin users (1,325–1,797 mm3, p = 0.03). SUVmax was associated with MRI-measured plaque lipid-rich necrotic core (LRNC) in the corresponding axial slice (rs = 0.64, p < 0.001) and was inversely associated with whole-plaque fibrous cap thickness (rs = −0.4, p = 0.02) and calcium volume (rs = −0.4, p = 0.03). Conclusion: This study demonstrated novel correlations of non-invasive imaging biomarkers of inflammation-related plaque metabolism with morphological MRI markers of plaque instability. If replicated, our findings may support the application of combined MRI and PET to detect vulnerable plaque in future clinical practise and randomised trials.
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Affiliation(s)
| | | | - Shane Foley
- School of Medicine, University College Dublin, Dublin, Ireland
| | - John McCabe
- School of Medicine, University College Dublin, Dublin, Ireland.,Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Marey Barry
- Vascular Surgery, St. Vincent's University Hospital, Dublin, Ireland
| | - Morgan Crowe
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Medicine for the Elderly, St. Vincent's University Hospital, Stroke Service, Dublin, Ireland
| | - Eamon Dolan
- Stroke and Hypertension Unit, Connolly Hospital, Dublin, Ireland
| | - Joseph Harbison
- Acute Stroke Service, St. James Hospital Dublin, Trinity College Dublin, Dublin, Ireland
| | - Gillian Horgan
- Health Research Board (HRB) Stroke Clinical Trials Network Ireland, University College Dublin, Dublin, Ireland
| | - Eoin Kavanagh
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Martin O'Connell
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Marnane
- School of Medicine, University College Dublin, Dublin, Ireland.,Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean Murphy
- Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ciaran Mc Donnell
- Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Martin O'Donohoe
- School of Medicine, University College Dublin, Dublin, Ireland.,Department of Vascular Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - David Williams
- Geriatric Medicine, Beaumont Hospital and Royal College Surgeons Ireland, Dublin, Ireland
| | - Peter J Kelly
- School of Medicine, University College Dublin, Dublin, Ireland.,Neurovascular Unit for Translational and Therapeutics Research, Mater Misericordiae University Hospital, Dublin, Ireland.,Acute Stroke Service, St. James Hospital Dublin, Trinity College Dublin, Dublin, Ireland
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6
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Effect of systemic immune inflammation index on symptom development in patients with moderate to severe carotid stenosis. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1055846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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7
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Sriranjan RS, Tarkin JM, Evans NR, Le EPV, Chowdhury MM, Rudd JHF. Atherosclerosis imaging using PET: Insights and applications. Br J Pharmacol 2021; 178:2186-2203. [PMID: 31517992 DOI: 10.1111/bph.14868] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/02/2019] [Accepted: 08/16/2019] [Indexed: 12/17/2022] Open
Abstract
PET imaging is able to harness biological processes to characterise high-risk features of atherosclerotic plaque prone to rupture. Current radiotracers are able to track inflammation, microcalcification, hypoxia, and neoangiogenesis within vulnerable plaque. 18 F-fluorodeoxyglucose (18 F-FDG) is the most commonly used radiotracer in vascular studies and is employed as a surrogate marker of plaque inflammation. Increasingly, 18 F-FDG and other PET tracers are also being used to provide imaging endpoints in cardiovascular interventional trials. The evolution of novel PET radiotracers, imaging protocols, and hybrid scanners are likely to enable more efficient and accurate characterisation of high-risk plaque. This review explores the role of PET imaging in atherosclerosis with a focus on PET tracers utilised in clinical research and the applications of PET imaging to cardiovascular drug development.
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Affiliation(s)
| | - Jason M Tarkin
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Nicholas R Evans
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Elizabeth P V Le
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | | | - James H F Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
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8
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Sun J, Lepor NE, Cantón G, Contreras L, Hippe DS, Isquith DA, Balu N, Kedan I, Simonini AA, Yuan C, Zhao XQ, Hatsukami TS. Serial magnetic resonance imaging detects a rapid reduction in plaque lipid content under PCSK9 inhibition with alirocumab. Int J Cardiovasc Imaging 2021; 37:1415-1422. [DOI: 10.1007/s10554-020-02115-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/21/2020] [Indexed: 12/29/2022]
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9
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Chung H, Kim BY, Kim HS, Kim HO, Lee JM, Woo JS, Kim JB, Kim WS, Kim KS, Kim W. Long-Term Clinical Effects of Carotid Intraplaque Neovascularization in Patients with Coronary Artery Disease. Korean J Radiol 2020; 21:900-907. [PMID: 32524790 PMCID: PMC7289693 DOI: 10.3348/kjr.2019.0550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/20/2019] [Accepted: 02/09/2020] [Indexed: 12/12/2022] Open
Abstract
Objective To investigate the predictive value of intraplaque neovascularization (IPN) for cardiovascular outcomes. Materials and Methods We evaluated 217 patients with coronary artery disease (CAD) (158 men; mean age, 68 ± 10 years) with a maximal carotid plaque thickness ≥ 1.5 mm for the presence of IPN using contrast-enhanced ultrasonography. We compared patients with (n = 116) and without (n = 101) IPN during the follow-up period and investigated the predictors of major adverse cardiovascular events (MACE), including cardiac death, myocardial infarction, coronary artery revascularization, and transient ischemic accident/stroke. Results During the mean follow-up period of 995 ± 610 days, the MACE rate was 6% (13/217). Patients with IPN had a higher maximal thickness than those without IPN (2.86 ± 1.01 vs. 2.61 ± 0.84 mm, p = 0.046). Common carotid artery-peak systolic velocity, left ventricular mass index (LVMI), and ventricular-vascular coupling index were significantly correlated with MACE. However, on multivariate Cox regression analysis, increased LVMI was independently related to MACE (p < 0.05). The presence of IPN could not predict MACE. Conclusion The presence of IPN was related to a higher plaque thickness but could not predict cardiovascular outcomes better than conventional clinical factors in patients with CAD.
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Affiliation(s)
- Hyemoon Chung
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Bu Yong Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Hyun Soo Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Hyung Oh Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Jung Myung Lee
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Jong Shin Woo
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Jin Bae Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Woo Shik Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Kwon Sam Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Weon Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea.
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10
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Evans NR, Tarkin JM, Le EP, Sriranjan RS, Corovic A, Warburton EA, Rudd JH. Integrated cardiovascular assessment of atherosclerosis using PET/MRI. Br J Radiol 2020; 93:20190921. [PMID: 32238077 DOI: 10.1259/bjr.20190921] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Atherosclerosis is a systemic inflammatory disease typified by the development of lipid-rich atheroma (plaques), the rupture of which are a major cause of myocardial infarction and stroke. Anatomical evaluation of the plaque considering only the degree of luminal stenosis overlooks features associated with vulnerable plaques, such as high-risk morphological features or pathophysiology, and hence risks missing vulnerable or ruptured non-stenotic plaques. Consequently, there has been interest in identifying these markers of vulnerability using either MRI for morphology, or positron emission tomography (PET) for physiological processes involved in atherogenesis. The advent of hybrid PET/MRI scanners offers the potential to combine the strengths of PET and MRI to allow comprehensive assessment of the atherosclerotic plaque. This review will discuss the principles and technical aspects of hybrid PET/MRI assessment of atherosclerosis, and consider how combining the complementary modalities of PET and MRI has already furthered our understanding of atherogenesis, advanced drug development, and how it may hold potential for clinical application.
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Affiliation(s)
- Nicholas R Evans
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Jason M Tarkin
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Elizabeth Pv Le
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Rouchelle S Sriranjan
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Andrej Corovic
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Elizabeth A Warburton
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - James Hf Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, United Kingdom
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Vigne J, Hyafil F. Inflammation imaging to define vulnerable plaque or vulnerable patient. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2020; 64:21-34. [DOI: 10.23736/s1824-4785.20.03231-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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12
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Molecular imaging of carotid artery atherosclerosis with PET: a systematic review. Eur J Nucl Med Mol Imaging 2019; 47:2016-2025. [PMID: 31786626 DOI: 10.1007/s00259-019-04622-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/14/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE To conduct a systematic review of articles on PET imaging of carotid atherosclerosis with emphasis on clinical usefulness and comparison with other imaging modalities. METHODS Research articles reporting carotid artery PET imaging with different radiotracers until 30 November 2018 were systematically searched for in Medline/PubMed, Scopus, Embase, Google Scholar, and Cochrane Library. Duplicates were removed, and editorials, case studies, and investigations on feasibility or reproducibility of PET imaging and of patients with end-stage diseases or immunosuppressive medications were omitted. After quality assessment of included articles using Joanna Briggs Institute checklists, all eligible articles were reviewed. RESULTS Of 1718 primary hits, 53 studies comprising 4472 patients, aged 47-91 years (78.8% males), were included and grouped under the following headlines: diagnostic performance, risk factors, laboratory findings, imaging modalities, and treatment. 18F-fluorodeoxyglucose (FDG) (49/53) and 18F-sodium fluoride (NaF) (5/53) were the most utilized tracers to visualize carotid wall inflammation and microcalcification, respectively. Higher carotid FDG uptake was demonstrated in patients with than without symptomatic carotid atherosclerosis. Normal carotid arteries presented with the lowest FDG uptake. In symptomatic atherosclerosis, carotid arteries ipsilateral to a cerebrovascular event had higher FDG uptake than the contralateral carotid artery. FDG uptake was significantly associated with age, male gender, and body mass index in healthy individuals, and in addition with arterial hypertension, hypercholesterolemia, and diabetes mellitus in patients. Histological assessment indicated a strong correlation between microcalcification and NaF uptake in symptomatic patients. Histological evidence of calcification correlated inversely with FDG uptake, which was associated with increased macrophage and CD68 count, both accounting for increased local inflammatory response. CONCLUSION FDG-PET visualizes the inflammatory part of carotid atherosclerosis enabling risk stratification to a certain degree, whereas NaF-PET seems to indicate long-term consequences of ongoing inflammation by demonstrating microcalcification allowing discrimination of atherosclerotic from normal arteries and suggesting clinically significant carotid atherosclerosis.
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Diagnosis of spinal lesions using perfusion parameters measured by DCE-MRI and metabolism parameters measured by PET/CT. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:1061-1070. [PMID: 31754820 DOI: 10.1007/s00586-019-06213-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 05/08/2019] [Accepted: 11/07/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE To investigate the correlation of parameters measured by dynamic-contrast-enhanced MRI (DCE-MRI) and 18F-FDG PET/CT in spinal tumors, and their role in differential diagnosis. METHODS A total of 49 patients with pathologically confirmed spinal tumors, including 38 malignant, six benign and five borderline tumors, were analyzed. The MRI and PET/CT were done within 3 days, before biopsy. On MRI, the ROI was manually placed on area showing the strongest enhancement to measure pharmacokinetic parameters Ktrans and kep. On PET, the maximum standardized uptake value SUVmax was measured. The parameters in different histological groups were compared. ROC was performed to differentiate between the two largest subtypes, metastases and plasmacytomas. Spearman rank correlation was performed to compare DCE-MRI and PET/CT parameters. RESULTS The Ktrans, kep and SUVmax were not statistically different among malignant, benign and borderline groups (P = 0.95, 0.50, 0.11). There was no significant correlation between Ktrans and SUVmax (r = - 0.20, P = 0.18), or between kep and SUVmax (r = - 0.16, P = 0.28). The kep was significantly higher in plasmacytoma than in metastasis (0.78 ± 0.17 vs. 0.61 ± 0.18, P = 0.02); in contrast, the SUVmax was significantly lower in plasmacytoma than in metastasis (5.58 ± 2.16 vs. 9.37 ± 4.26, P = 0.03). In differential diagnosis, the AUC of kep and SUVmax was 0.79 and 0.78, respectively. CONCLUSIONS The vascular parameters measured by DCE-MRI and glucose metabolism measured by PET/CT from the most aggressive tumor area did not show a significant correlation. The results suggest they provide complementary information reflecting different aspects of the tumor, which may aid in diagnosis of spinal lesions. These slides can be retrieved under Electronic Supplementary Material.
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Fayad ZA, Swirski FK, Calcagno C, Robbins CS, Mulder W, Kovacic JC. Monocyte and Macrophage Dynamics in the Cardiovascular System: JACC Macrophage in CVD Series (Part 3). J Am Coll Cardiol 2019; 72:2198-2212. [PMID: 30360828 DOI: 10.1016/j.jacc.2018.08.2150] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 07/16/2018] [Accepted: 08/03/2018] [Indexed: 12/12/2022]
Abstract
It has long been recognized that the bone marrow is the primary site of origin for circulating monocytes that may later become macrophages in atherosclerotic lesions. However, only in recent times has the complex relationship among the bone marrow, monocytes/macrophages, and atherosclerotic plaques begun to be understood. Moreover, the systemic nature of these interactions, which also involves additional compartments such as extramedullary hematopoietic sites (i.e., spleen), is only just becoming apparent. In parallel, progressive advances in imaging and cell labeling techniques have opened new opportunities for in vivo imaging of monocyte/macrophage trafficking in atherosclerotic lesions and at the systemic level. In this Part 3 of a 4-part review series covering the macrophage in cardiovascular disease, the authors intersect systemic biology with advanced imaging techniques to explore monocyte and macrophage dynamics in the cardiovascular system, with an emphasis on how events at the systemic level might affect local atherosclerotic plaque biology.
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Affiliation(s)
- Zahi A Fayad
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Filip K Swirski
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Claudia Calcagno
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Clinton S Robbins
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Peter Munk Cardiac Centre, Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada; Departments of Laboratory Medicine and Pathobiology and Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Willem Mulder
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jason C Kovacic
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
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Wallingford MC, Tarui T, Jayaraman N, Huggins GS, Dighe MK. Application of Dynamic Contrast Enhanced Magnetic Resonance Imaging to Evaluate Angiogenic Response and Vascular Permeability. Arterioscler Thromb Vasc Biol 2019; 39:1507-1509. [PMID: 31339781 PMCID: PMC8162837 DOI: 10.1161/atvbaha.119.312972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mary C Wallingford
- From the Mother Infant Research Institute (M.C.W., T.T., N.J.), Tufts Medical Center, Boston, MA
- Molecular Cardiology Research Institute (M.C.W., G.S.H.), Tufts Medical Center, Boston, MA
| | - Tomo Tarui
- From the Mother Infant Research Institute (M.C.W., T.T., N.J.), Tufts Medical Center, Boston, MA
| | - Nirmala Jayaraman
- From the Mother Infant Research Institute (M.C.W., T.T., N.J.), Tufts Medical Center, Boston, MA
| | - Gordon S Huggins
- Molecular Cardiology Research Institute (M.C.W., G.S.H.), Tufts Medical Center, Boston, MA
| | - Manjiri K Dighe
- Department of Radiology, University of Washington, Seattle (M.K.D.)
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Crombag GAJC, Schreuder FHBM, van Hoof RHM, Truijman MTB, Wijnen NJA, Vöö SA, Nelemans PJ, Heeneman S, Nederkoorn PJ, Daemen JWH, Daemen MJAP, Mess WH, Wildberger JE, van Oostenbrugge RJ, Kooi ME. Microvasculature and intraplaque hemorrhage in atherosclerotic carotid lesions: a cardiovascular magnetic resonance imaging study. J Cardiovasc Magn Reson 2019; 21:15. [PMID: 30832656 PMCID: PMC6398220 DOI: 10.1186/s12968-019-0524-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/04/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The presence of intraplaque haemorrhage (IPH) has been related to plaque rupture, is associated with plaque progression, and predicts cerebrovascular events. However, the mechanisms leading to IPH are not fully understood. The dominant view is that IPH is caused by leakage of erythrocytes from immature microvessels. The aim of the present study was to investigate whether there is an association between atherosclerotic plaque microvasculature and presence of IPH in a relatively large prospective cohort study of patients with symptomatic carotid plaque. METHODS One hundred and thirty-two symptomatic patients with ≥2 mm carotid plaque underwent cardiovascular magnetic resonance (CMR) of the symptomatic carotid plaque for detection of IPH and dynamic contrast-enhanced (DCE)-CMR for assessment of plaque microvasculature. Ktrans, an indicator of microvascular flow, density and leakiness, was estimated using pharmacokinetic modelling in the vessel wall and adventitia. Statistical analysis was performed using an independent samples T-test and binary logistic regression, correcting for clinical risk factors. RESULTS A decreased vessel wall Ktrans was found for IPH positive patients (0.051 ± 0.011 min- 1 versus 0.058 ± 0.017 min- 1, p = 0.001). No significant difference in adventitial Ktrans was found in patients with and without IPH (0.057 ± 0.012 min- 1 and 0.057 ± 0.018 min- 1, respectively). Histological analysis in a subgroup of patients that underwent carotid endarterectomy demonstrated no significant difference in relative microvessel density between plaques without IPH (n = 8) and plaques with IPH (n = 15) (0.000333 ± 0.0000707 vs. and 0.000289 ± 0.0000439, p = 0.585). CONCLUSIONS A reduced vessel wall Ktrans is found in the presence of IPH. Thus, we did not find a positive association between plaque microvasculature and IPH several weeks after a cerebrovascular event. Not only leaky plaque microvessels, but additional factors may contribute to IPH development. TRIAL REGISTRATION NCT01208025 . Registration date September 23, 2010. Retrospectively registered (first inclusion September 21, 2010). NCT01709045 , date of registration October 17, 2012. Retrospectively registered (first inclusion August 23, 2011).
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Affiliation(s)
- Geneviève A. J. C. Crombag
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Floris H. B. M. Schreuder
- Department of Neurology & Donders Institute for Brain Cognition & Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Raf H. M. van Hoof
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Martine T. B. Truijman
- Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Nicky J. A. Wijnen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Stefan A. Vöö
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Patty J. Nelemans
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Sylvia Heeneman
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Department of Pathology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Paul J. Nederkoorn
- Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jan-Willem H. Daemen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Mat J. A. P. Daemen
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Werner H. Mess
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Clinical Neurophysiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J. E. Wildberger
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Robert J. van Oostenbrugge
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M. Eline Kooi
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
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Usman A, Yuan J, Patterson AJ, Graves MJ, Varty K, Sadat U, Gillard JH. Neovascularization in Vertebral Artery Atheroma—A Dynamic Contrast-Enhanced Magnetic Resonance Imaging-Based Comparative Study in Patients with Symptomatic and Asymptomatic Carotid Artery Disease. J Stroke Cerebrovasc Dis 2018; 27:2505-2512. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 05/06/2018] [Indexed: 11/16/2022] Open
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Calcagno C, Fayad ZA. Imaging the Permeable Endothelium: Predicting Plaque Rupture in Atherosclerotic Rabbits. Circ Cardiovasc Imaging 2018; 9:CIRCIMAGING.116.005955. [PMID: 27940960 DOI: 10.1161/circimaging.116.005955] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Claudia Calcagno
- From the Translational and Molecular Imaging Institute (C.C., Z.A.F.) and Department of Radiology (C.C., Z.A.F.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Zahi A Fayad
- From the Translational and Molecular Imaging Institute (C.C., Z.A.F.) and Department of Radiology (C.C., Z.A.F.), Icahn School of Medicine at Mount Sinai, New York, NY.
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Saba L, Yuan C, Hatsukami TS, Balu N, Qiao Y, DeMarco JK, Saam T, Moody AR, Li D, Matouk CC, Johnson MH, Jäger HR, Mossa-Basha M, Kooi ME, Fan Z, Saloner D, Wintermark M, Mikulis DJ, Wasserman BA. Carotid Artery Wall Imaging: Perspective and Guidelines from the ASNR Vessel Wall Imaging Study Group and Expert Consensus Recommendations of the American Society of Neuroradiology. AJNR Am J Neuroradiol 2018; 39:E9-E31. [PMID: 29326139 DOI: 10.3174/ajnr.a5488] [Citation(s) in RCA: 176] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Identification of carotid artery atherosclerosis is conventionally based on measurements of luminal stenosis and surface irregularities using in vivo imaging techniques including sonography, CT and MR angiography, and digital subtraction angiography. However, histopathologic studies demonstrate considerable differences between plaques with identical degrees of stenosis and indicate that certain plaque features are associated with increased risk for ischemic events. The ability to look beyond the lumen using highly developed vessel wall imaging methods to identify plaque vulnerable to disruption has prompted an active debate as to whether a paradigm shift is needed to move away from relying on measurements of luminal stenosis for gauging the risk of ischemic injury. Further evaluation in randomized clinical trials will help to better define the exact role of plaque imaging in clinical decision-making. However, current carotid vessel wall imaging techniques can be informative. The goal of this article is to present the perspective of the ASNR Vessel Wall Imaging Study Group as it relates to the current status of arterial wall imaging in carotid artery disease.
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Affiliation(s)
- L Saba
- From the Department of Medical Imaging (L.S.), University of Cagliari, Cagliari, Italy
| | - C Yuan
- Departments of Radiology (C.Y., N.B., M.M.-B.)
| | - T S Hatsukami
- Surgery (T.S.H.), University of Washington, Seattle, Washington
| | - N Balu
- Departments of Radiology (C.Y., N.B., M.M.-B.)
| | - Y Qiao
- The Russell H. Morgan Department of Radiology and Radiological Sciences (Y.Q., B.A.W.), Johns Hopkins Hospital, Baltimore, Maryland
| | - J K DeMarco
- Department of Radiology (J.K.D.), Walter Reed National Military Medical Center, Bethesda, Maryland
| | - T Saam
- Department of Radiology (T.S.), Ludwig-Maximilian University Hospital, Munich, Germany
| | - A R Moody
- Department of Medical Imaging (A.R.M.), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - D Li
- Biomedical Imaging Research Institute (D.L., Z.F.), Cedars-Sinai Medical Center, Los Angeles, California
| | - C C Matouk
- Departments of Neurosurgery, Neurovascular and Stroke Programs (C.C.M., M.H.J.).,Radiology and Biomedical Imaging (C.C.M., M.H.J.)
| | - M H Johnson
- Departments of Neurosurgery, Neurovascular and Stroke Programs (C.C.M., M.H.J.).,Radiology and Biomedical Imaging (C.C.M., M.H.J.).,Surgery (M.H.J.), Yale University School of Medicine, New Haven, Connecticut
| | - H R Jäger
- Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair and Rehabilitation, University College London Institute of Neurology, London, UK
| | | | - M E Kooi
- Department of Radiology (M.E.K.), CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Z Fan
- Biomedical Imaging Research Institute (D.L., Z.F.), Cedars-Sinai Medical Center, Los Angeles, California
| | - D Saloner
- Department of Radiology and Biomedical Imaging (D.S.), University of California, San Francisco, California
| | - M Wintermark
- Department of Radiology (M.W.), Neuroradiology Division, Stanford University, Stanford, California
| | - D J Mikulis
- Division of Neuroradiology (D.J.M.), Department of Medical Imaging, University Health Network
| | - B A Wasserman
- The Russell H. Morgan Department of Radiology and Radiological Sciences (Y.Q., B.A.W.), Johns Hopkins Hospital, Baltimore, Maryland
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Robson PM, Dey D, Newby DE, Berman D, Li D, Fayad ZA, Dweck MR. MR/PET Imaging of the Cardiovascular System. JACC Cardiovasc Imaging 2017; 10:1165-1179. [PMID: 28982570 PMCID: PMC6415529 DOI: 10.1016/j.jcmg.2017.07.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/26/2017] [Accepted: 07/27/2017] [Indexed: 12/11/2022]
Abstract
Cardiovascular imaging has largely focused on identifying structural, functional, and metabolic changes in the heart. The ability to reliably assess disease activity would have major potential clinical advantages, including the identification of early disease, differentiating active from stable conditions, and monitoring disease progression or response to therapy. Positron emission tomography (PET) imaging now allows such assessments of disease activity to be acquired in the heart, whereas magnetic resonance (MR) scanning provides detailed anatomic imaging and tissue characterization. Hybrid MR/PET scanners therefore combine the strengths of 2 already powerful imaging modalities. Simultaneous acquisition of the 2 scans also provides added benefits, including improved scanning efficiency, motion correction, and partial volume correction. Radiation exposure is lower than with hybrid PET/computed tomography scanning, which might be particularly beneficial in younger patients who may need repeated scans. The present review discusses the expanding clinical literature investigating MR/PET imaging, highlights its advantages and limitations, and explores future potential applications.
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Affiliation(s)
- Philip M Robson
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Damini Dey
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Daniel Berman
- Departments of Imaging and Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Debiao Li
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Zahi A Fayad
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
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Coolen BF, Calcagno C, van Ooij P, Fayad ZA, Strijkers GJ, Nederveen AJ. Vessel wall characterization using quantitative MRI: what's in a number? MAGNETIC RESONANCE MATERIALS IN PHYSICS BIOLOGY AND MEDICINE 2017; 31:201-222. [PMID: 28808823 PMCID: PMC5813061 DOI: 10.1007/s10334-017-0644-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/04/2017] [Accepted: 07/18/2017] [Indexed: 12/15/2022]
Abstract
The past decade has witnessed the rapid development of new MRI technology for vessel wall imaging. Today, with advances in MRI hardware and pulse sequences, quantitative MRI of the vessel wall represents a real alternative to conventional qualitative imaging, which is hindered by significant intra- and inter-observer variability. Quantitative MRI can measure several important morphological and functional characteristics of the vessel wall. This review provides a detailed introduction to novel quantitative MRI methods for measuring vessel wall dimensions, plaque composition and permeability, endothelial shear stress and wall stiffness. Together, these methods show the versatility of non-invasive quantitative MRI for probing vascular disease at several stages. These quantitative MRI biomarkers can play an important role in the context of both treatment response monitoring and risk prediction. Given the rapid developments in scan acceleration techniques and novel image reconstruction, we foresee the possibility of integrating the acquisition of multiple quantitative vessel wall parameters within a single scan session.
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Affiliation(s)
- Bram F Coolen
- Department of Biomedical Engineering and Physics, Academic Medical Center, PO BOX 22660, 1100 DD, Amsterdam, The Netherlands. .,Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands.
| | - Claudia Calcagno
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Pim van Ooij
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Zahi A Fayad
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gustav J Strijkers
- Department of Biomedical Engineering and Physics, Academic Medical Center, PO BOX 22660, 1100 DD, Amsterdam, The Netherlands
| | - Aart J Nederveen
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
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Plaque microvascularization and permeability: Key players in atherogenesis and plaque rupture. Atherosclerosis 2017; 263:320-321. [PMID: 28673479 DOI: 10.1016/j.atherosclerosis.2017.06.915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 06/20/2017] [Indexed: 12/29/2022]
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Abstract
Objective To investigate the effect of a heart rate (HR) lowering agent (Ivabradine) on features of atherosclerotic plaque vulnerability with magnetic resonance imaging (MRI), ultrasound imaging, and histology. Approach and results Atherosclerosis was induced in the abdominal aorta of 19 rabbits. Nine rabbits were treated with Ivabradine (17 mg/kg/day) during the entire study period. At week 14, imaging was performed. Plaque size was quantified on contrast-enhanced T1-weighted MR images. Microvascular flow, density, and permeability was studied with dynamic contrast-enhanced MRI. Plaque biomechanics was studied by measuring the aortic distension with ultrasound. After, animals were sacrificed and histology was performed. HR was reduced by 16% (p = 0.026) in Ivabradine-treated animals. No differences in absolute and relative vessel wall beat-to-beat distension were found, but due to the reduction in HR, the frequency of the biomechanical load on the plaque was reduced. Plaque size (MR and histology) was similar between groups. Although microvessel density (histology) was similar between groups, AUC and Ktrans, indicative for plaque microvasculature flow, density, and permeability, were decreased by 24% (p = 0.029) and 32% (p = 0.037), respectively. Macrophage content (relative RAM11 positive area) was reduced by 44% (p<0.001) on histology in Ivabradine-treated animals. Conclusions HR lowering treatment with Ivabradine in an atherosclerotic rabbit model is associated with a reduction in vulnerable plaque features. The current study suggests that HR reduction may be beneficial for inducing or maintaining a more stable plaque phenotype.
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Demeure F, Bouzin C, Roelants V, Bol A, Verhelst R, Astarci P, Gerber BL, Pouleur AC, Pasquet A, de Meester C, Vanoverschelde JLJ, Vancraeynest D. Head-to-Head Comparison of Inflammation and Neovascularization in Human Carotid Plaques: Implications for the Imaging of Vulnerable Plaques. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.005846. [PMID: 28487317 DOI: 10.1161/circimaging.116.005846] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/28/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inflammation and intraplaque neovascularization are acknowledged to be 2 features of plaque vulnerability, although their temporal expression and their respective value in predicting clinical events are poorly understood. To determine their respective temporal associations, we conducted a comprehensive assessment of inflammation and intraplaque neovascularization in the carotid plaque of symptomatic and asymptomatic patients. METHODS AND RESULTS Thirty patients with severe carotid stenosis underwent 18F-fluorodeoxyglucose-positron emission tomography/computed tomographic imaging. Plaque 18F-fluorodeoxyglucose-uptake, indicative of inflammation, was measured by calculating the target:background ratio. The presence of intraplaque neovascularization during contrast-enhanced ultrasound was judged semiquantitatively; low-grade contrast enhancement (CE) suggested its absence, and high-grade CE, the presence of neovascularization. Carotid surgery was performed 1.6±1.8 days after completing both imaging modalities in all patients, and the presence of macrophages and neovessels was quantified by immunohistochemistry. We identified a significant correlation between the target:background ratio and macrophage quantification (R=0.78; P<0.001). The number of vessels was also significantly higher in carotid plaque with high-CE (P<0.001). Surprisingly, immunohistochemistry showed that high-CE and vessel number were neither associated with an elevated target:background ratio (P=0.28 and P=0.60, respectively) nor macrophage infiltration (P=0.59 and P=0.40, respectively). Finally, macrophage infiltration and target:background ratio were higher in the carotid plaque of symptomatic patients (P=0.021 and P=0.05, respectively), whereas CE grade and the presence of neovessels were not. CONCLUSIONS Inflammation and intraplaque neovascularization are not systematically associated in carotid plaques, suggesting a temporal separation between the 2 processes. Inflammation seems more pronounced when symptoms are present. These data highlight the challenges that face any imaging strategy designed to assess plaque vulnerability.
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Affiliation(s)
- Fabian Demeure
- From the Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); IREC Imaging Platform, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (C.B.); Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (V.R., A.B.); and Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (V.R., A.B.)
| | - Caroline Bouzin
- From the Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); IREC Imaging Platform, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (C.B.); Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (V.R., A.B.); and Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (V.R., A.B.)
| | - Véronique Roelants
- From the Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); IREC Imaging Platform, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (C.B.); Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (V.R., A.B.); and Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (V.R., A.B.)
| | - Anne Bol
- From the Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); IREC Imaging Platform, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (C.B.); Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (V.R., A.B.); and Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (V.R., A.B.)
| | - Robert Verhelst
- From the Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); IREC Imaging Platform, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (C.B.); Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (V.R., A.B.); and Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (V.R., A.B.)
| | - Parla Astarci
- From the Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); IREC Imaging Platform, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (C.B.); Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (V.R., A.B.); and Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (V.R., A.B.)
| | - Bernhard L Gerber
- From the Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); IREC Imaging Platform, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (C.B.); Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (V.R., A.B.); and Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (V.R., A.B.)
| | - Anne-Catherine Pouleur
- From the Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); IREC Imaging Platform, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (C.B.); Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (V.R., A.B.); and Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (V.R., A.B.)
| | - Agnès Pasquet
- From the Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); IREC Imaging Platform, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (C.B.); Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (V.R., A.B.); and Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (V.R., A.B.)
| | - Christophe de Meester
- From the Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); IREC Imaging Platform, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (C.B.); Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (V.R., A.B.); and Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (V.R., A.B.)
| | - Jean-Louis J Vanoverschelde
- From the Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); IREC Imaging Platform, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (C.B.); Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (V.R., A.B.); and Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (V.R., A.B.)
| | - David Vancraeynest
- From the Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium (F.D., R.V., P.A., B.L.G., A.-C.P., A.P., C.d.M., J.-L.J.V., D.V.); IREC Imaging Platform, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (C.B.); Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium (V.R., A.B.); and Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium (V.R., A.B.).
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26
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van Hoof RHM, Vöö SA, Sluimer JC, Wijnen NJA, Hermeling E, Schreuder FHBM, Truijman MTB, Cleutjens JPM, Daemen MJAP, Daemen JWH, van Oostenbrugge RJ, Mess WH, Wildberger JE, Heeneman S, Kooi ME. Vessel wall and adventitial DCE-MRI parameters demonstrate similar correlations with carotid plaque microvasculature on histology. J Magn Reson Imaging 2017; 46:1053-1059. [PMID: 28152245 DOI: 10.1002/jmri.25648] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/11/2017] [Accepted: 01/11/2017] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To assess parameter agreement of volume transfer coefficient (Ktrans ) between two vascular regions and to study the correlation with microvessel density on histology. The dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parameter Ktrans is frequently used to study atherosclerotic plaque microvasculature. Ktrans has been reported using different descriptive statistics (mean, median, 75th percentile) either for the whole vessel wall or the adventitia in previous studies. MATERIALS AND METHODS DCE-MRI parameter agreement was analyzed in 110 symptomatic patients with ≥2 mm carotid plaque that underwent a 3T carotid DCE-MRI examination. Ktrans was estimated in the entire vessel wall and adventitia. Twenty-three patients underwent carotid endarterectomy and were used for comparison with histological quantification of microvessel density of the plaque using CD31 immunohistochemistry. DCE-MRI parameters in the vessel wall regions were compared using Pearson's correlation coefficient, Bland-Altman analysis, and a two-sided paired samples t-test. Correlation of the DCE-MRI parameters with histology was studied using the Pearson's correlation coefficient. RESULTS Median adventitial Ktrans was 5% higher (P = 0.003) than entire vessel wall Ktrans , with no differences for other descriptive statistics. Vessel wall and adventitial Ktrans showed similar moderately strong correlations with plaque microvessel density on histology (Pearson's ρ: 0.59-0.65 [P < 0.003] and 0.52-0.64 [P < 0.011], respectively). CONCLUSION The similar moderately strong correlations for vessel wall and adventitial Ktrans with microvessel density on histology suggested that both regions reflected plaque microvessel density. Care should to be taken when comparing absolute values between studies. Future studies incorporating thresholds for risk stratification need to agree upon standardization of DCE-MRI parameters. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;46:1053-1059.
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Affiliation(s)
- Raf H M van Hoof
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Stefan A Vöö
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Judith C Sluimer
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Nicky J A Wijnen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Evelien Hermeling
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Floris H B M Schreuder
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Clinical Neurophysiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martine T B Truijman
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Clinical Neurophysiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jack P M Cleutjens
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mat J A P Daemen
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jan-Willem H Daemen
- Department of General Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Werner H Mess
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Clinical Neurophysiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Joachim E Wildberger
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Sylvia Heeneman
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - M Eline Kooi
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
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27
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Evans NR, Tarkin JM, Chowdhury MM, Warburton EA, Rudd JHF. PET Imaging of Atherosclerotic Disease: Advancing Plaque Assessment from Anatomy to Pathophysiology. Curr Atheroscler Rep 2016; 18:30. [PMID: 27108163 PMCID: PMC4842219 DOI: 10.1007/s11883-016-0584-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Atherosclerosis is a leading cause of morbidity and mortality. It is now widely recognized that the disease is more than simply a flow-limiting process and that the atheromatous plaque represents a nidus for inflammation with a consequent risk of plaque rupture and atherothrombosis, leading to myocardial infarction or stroke. However, widely used conventional clinical imaging techniques remain anatomically focused, assessing only the degree of arterial stenosis caused by plaques. Positron emission tomography (PET) has allowed the metabolic processes within the plaque to be detected and quantified directly. The increasing armory of radiotracers has facilitated the imaging of distinct metabolic aspects of atherogenesis and plaque destabilization, including macrophage-mediated inflammatory change, hypoxia, and microcalcification. This imaging modality has not only furthered our understanding of the disease process in vivo with new insights into mechanisms but has also been utilized as a non-invasive endpoint measure in the development of novel treatments for atherosclerotic disease. This review provides grounding in the principles of PET imaging of atherosclerosis, the radioligands in use and in development, its research and clinical applications, and future developments for the field.
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Affiliation(s)
- Nicholas R Evans
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Jason M Tarkin
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Mohammed M Chowdhury
- Division of Vascular and Endovascular Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Elizabeth A Warburton
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - James H F Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
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28
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van Hoof RHM, Heeneman S, Wildberger JE, Kooi ME. Dynamic Contrast-Enhanced MRI to Study Atherosclerotic Plaque Microvasculature. Curr Atheroscler Rep 2016; 18:33. [PMID: 27115144 PMCID: PMC4846686 DOI: 10.1007/s11883-016-0583-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Rupture of a vulnerable atherosclerotic plaque of the carotid artery is an important underlying cause of clinical ischemic events, such as stroke. Abundant microvasculature has been identified as an important aspect contributing to plaque vulnerability. Plaque microvasculature can be studied non-invasively with dynamic contrast-enhanced (DCE-)MRI in animals and patients. In recent years, several DCE-MRI studies have been published evaluating the association between microvasculature and other key features of plaque vulnerability (e.g., inflammation and intraplaque hemorrhage), as well as the effects of novel therapeutic interventions. The present paper reviews this literature, focusing on DCE-MRI methods of acquisition and analysis of atherosclerotic plaques, the current state and future potential of DCE-MRI in the evaluation of plaque microvasculature in clinical and preclinical settings.
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Affiliation(s)
- Raf H. M. van Hoof
- />Department of Radiology, Maastricht University Medical Center (MUMC), P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- />CARIM School for Cardiovascular Diseases, Maastricht University, P.O. Box 616, Maastricht, 6200 MD The Netherlands
| | - Sylvia Heeneman
- />CARIM School for Cardiovascular Diseases, Maastricht University, P.O. Box 616, Maastricht, 6200 MD The Netherlands
- />Department of Pathology, Maastricht University Medical Center (MUMC), P.O. Box 5800, Maastricht, 6202 AZ The Netherlands
| | - Joachim E. Wildberger
- />Department of Radiology, Maastricht University Medical Center (MUMC), P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- />CARIM School for Cardiovascular Diseases, Maastricht University, P.O. Box 616, Maastricht, 6200 MD The Netherlands
| | - M. Eline Kooi
- />Department of Radiology, Maastricht University Medical Center (MUMC), P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- />CARIM School for Cardiovascular Diseases, Maastricht University, P.O. Box 616, Maastricht, 6200 MD The Netherlands
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29
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Tang D, Yang C, Huang S, Mani V, Zheng J, Woodard PK, Robson P, Teng Z, Dweck M, Fayad ZA. Cap inflammation leads to higher plaque cap strain and lower cap stress: An MRI-PET/CT-based FSI modeling approach. J Biomech 2016; 50:121-129. [PMID: 27847118 DOI: 10.1016/j.jbiomech.2016.11.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Abstract
Plaque rupture may be triggered by extreme stress/strain conditions. Inflammation is also implicated and can be imaged using novel imaging techniques. The impact of cap inflammation on plaque stress/strain and flow shear stress were investigated. A patient-specific MRI-PET/CT-based modeling approach was used to develop 3D fluid-structure interaction models and investigate the impact of inflammation on plaque stress/strain conditions for better plaque assessment. 18FDG-PET/CT and MRI data were acquired from 4 male patients (average age: 66) to assess plaque characteristics and inflammation. Material stiffness for the fibrous cap was adjusted lower to reflect cap weakening causing by inflammation. Setting stiffness ratio (SR) to be 1.0 (fibrous tissue) for baseline, results for SR=0.5, 0.25, and 0.1 were obtained. Thin cap and hypertension were also considered. Combining results from the 4 patients, mean cap stress from 729 cap nodes was lowered by 25.2% as SR went from 1.0 to 0.1. Mean cap strain value for SR=0.1 was 0.313, 114% higher than that from SR=1.0 model. The thin cap SR=0.1 model had 40% mean cap stress decrease and 81% cap strain increase compared with SR=1.0 model. The hypertension SR=0.1 model had 19.5% cap stress decrease and 98.6% cap strain increase compared with SR=1.0 model. Differences of flow shear stress with 4 different SR values were limited (<10%). Cap inflammation may lead to large cap strain conditions when combined with thin cap and hypertension. Inflammation also led to lower cap stress. This shows the influence of inflammation on stress/strain calculations which are closely related to plaque assessment.
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Affiliation(s)
- Dalin Tang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing, China; Mathematical Sciences Department, WPI, Worcester, MA 01609, USA.
| | - Chun Yang
- Mathematical Sciences Department, WPI, Worcester, MA 01609, USA; Network Technology Research Institute, China United Network Comm. Co., Ltd., Beijing, China
| | - Sarayu Huang
- Department of Radiology, Translational and molecular imaging institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Venkatesh Mani
- Department of Radiology, Translational and molecular imaging institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jie Zheng
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO 63110, USA
| | - Pamela K Woodard
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO 63110, USA
| | - Philip Robson
- Department of Radiology, Translational and molecular imaging institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Zhongzhao Teng
- Department of Radiology, University of Cambridge, CB2 0QQ, United Kingdom
| | - Marc Dweck
- Department of Radiology, Translational and molecular imaging institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Zahi A Fayad
- Department of Radiology, Translational and molecular imaging institute, Icahn School of Medicine at Mount Sinai, New York, USA
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Determination of the Input Function at the Entry of the Tissue of Interest and Its Impact on PET Kinetic Modeling Parameters. Mol Imaging Biol 2016; 17:748-56. [PMID: 26395903 DOI: 10.1007/s11307-015-0895-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Quantitative positron emission tomography (PET) imaging is employed with several measurement protocols all relying on the a priori determination of the input function (IF). The standard technique to determine IF is by blood sampling. However, a unique IF determined in a subject for a given PET study, either defined by sampling or in the images, and commonly utilized for all analyzed tissues in that study equally at rest and during interventions, is expected to provoke biases in the rate constants and in tissue blood volume. The determination of a specific IF at the site of the tissue to be analyzed enhances PET accuracy and renders PET imaging less invasive.
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Brinjikji W, Huston J, Rabinstein AA, Kim GM, Lerman A, Lanzino G. Contemporary carotid imaging: from degree of stenosis to plaque vulnerability. J Neurosurg 2016. [DOI: 10.3171/2015.1.jns142452.test] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | | | | | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Amsallem M, Saito T, Tada Y, Dash R, McConnell MV. Magnetic Resonance Imaging and Positron Emission Tomography Approaches to Imaging Vascular and Cardiac Inflammation. Circ J 2016; 80:1269-77. [DOI: 10.1253/circj.cj-16-0224] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford University School of Medicine
| | - Toshinobu Saito
- Division of Cardiovascular Medicine, Stanford University School of Medicine
| | - Yuko Tada
- Division of Cardiovascular Medicine, Stanford University School of Medicine
| | - Rajesh Dash
- Division of Cardiovascular Medicine, Stanford University School of Medicine
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Abstract
Plaque imaging by MR imaging provides a wealth of information on the characteristics of individual plaque that may reveal vulnerability to rupture, likelihood of progression, or optimal treatment strategy. T1-weighted and T2-weighted images among other options reveal plaque morphology and composition. Dynamic contrast-enhanced-MR imaging reveals plaque activity. To extract this information, image processing tools are needed. Numerous approaches for analyzing such images have been developed, validated against histologic gold standards, and used in clinical studies. These efforts are summarized in this article.
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Affiliation(s)
- Huijun Chen
- Department of Biomedical Engineering, Center for Biomedical Imaging Research, School of Medicine, Tsinghua University, Room No. 109, Haidian District, Beijing, China
| | - Qiang Zhang
- Department of Biomedical Engineering, Center for Biomedical Imaging Research, School of Medicine, Tsinghua University, Room No. 120, Haidian District, Beijing, China
| | - William Kerwin
- Department of Radiology, School of Medicine, University of Washington, 850 Republican Street, Seattle, WA 98109, USA.
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Calcagno C, Lobatto ME, Dyvorne H, Robson PM, Millon A, Senders ML, Lairez O, Ramachandran S, Coolen BF, Black A, Mulder WJM, Fayad ZA. Three-dimensional dynamic contrast-enhanced MRI for the accurate, extensive quantification of microvascular permeability in atherosclerotic plaques. NMR IN BIOMEDICINE 2015; 28:1304-14. [PMID: 26332103 PMCID: PMC4573915 DOI: 10.1002/nbm.3369] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 06/19/2015] [Accepted: 07/06/2015] [Indexed: 05/28/2023]
Abstract
Atherosclerotic plaques that cause stroke and myocardial infarction are characterized by increased microvascular permeability and inflammation. Dynamic contrast-enhanced MRI (DCE-MRI) has been proposed as a method to quantify vessel wall microvascular permeability in vivo. Until now, most DCE-MRI studies of atherosclerosis have been limited to two-dimensional (2D) multi-slice imaging. Although providing the high spatial resolution required to image the arterial vessel wall, these approaches do not allow the quantification of plaque permeability with extensive anatomical coverage, an essential feature when imaging heterogeneous diseases, such as atherosclerosis. To our knowledge, we present the first systematic evaluation of three-dimensional (3D), high-resolution, DCE-MRI for the extensive quantification of plaque permeability along an entire vascular bed, with validation in atherosclerotic rabbits. We compare two acquisitions: 3D turbo field echo (TFE) with motion-sensitized-driven equilibrium (MSDE) preparation and 3D turbo spin echo (TSE). We find 3D TFE DCE-MRI to be superior to 3D TSE DCE-MRI in terms of temporal stability metrics. Both sequences show good intra- and inter-observer reliability, and significant correlation with ex vivo permeability measurements by Evans Blue near-infrared fluorescence (NIRF). In addition, we explore the feasibility of using compressed sensing to accelerate 3D DCE-MRI of atherosclerosis, to improve its temporal resolution and therefore the accuracy of permeability quantification. Using retrospective under-sampling and reconstructions, we show that compressed sensing alone may allow the acceleration of 3D DCE-MRI by up to four-fold. We anticipate that the development of high-spatial-resolution 3D DCE-MRI with prospective compressed sensing acceleration may allow for the more accurate and extensive quantification of atherosclerotic plaque permeability along an entire vascular bed. We foresee that this approach may allow for the comprehensive and accurate evaluation of plaque permeability in patients, and may be a useful tool to assess the therapeutic response to approved and novel drugs for cardiovascular disease.
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Affiliation(s)
- Claudia Calcagno
- Department of Radiology, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mark E Lobatto
- Department of Radiology, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Radiology, Academisch Medisch Centrum, Amsterdam, the Netherlands
| | - Hadrien Dyvorne
- Department of Radiology, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Philip M Robson
- Department of Radiology, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Antoine Millon
- Department of Vascular Surgery, University Hospital of Lyon, Lyon, France
| | - Max L Senders
- Department of Radiology, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Olivier Lairez
- Department of Radiology, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Cardiac Imaging Center, University Hospital of Rangueil, Toulouse, France
| | - Sarayu Ramachandran
- Department of Radiology, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bram F Coolen
- Department of Radiology, Academisch Medisch Centrum, Amsterdam, the Netherlands
| | - Alexandra Black
- Department of Radiology, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Willem J M Mulder
- Department of Radiology, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Radiology, Academisch Medisch Centrum, Amsterdam, the Netherlands
| | - Zahi A Fayad
- Department of Radiology, Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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van Hinsbergh VWM, Eringa EC, Daemen MJAP. Neovascularization of the atherosclerotic plaque: interplay between atherosclerotic lesion, adventitia-derived microvessels and perivascular fat. Curr Opin Lipidol 2015; 26:405-11. [PMID: 26241102 DOI: 10.1097/mol.0000000000000210] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Neovascularization is a prominent feature in advanced human atherosclerotic plaques. This review surveys recent evidence for and remaining uncertainties regarding a role of neovascularization in atherosclerotic plaque progression. Specific emphasis is given to hypoxia, angiogenesis inhibition, and perivascular adipose tissue (PVAT). RECENT FINDINGS Immunohistochemical and imaging studies showed a strong association between hypoxia, inflammation and neovascularization, and the progression of the atherosclerotic plaque both in humans and mice. Whereas in humans, a profound invasion of microvessels from the adventitia into the plaque occurs, neovascularization in mice is found mainly (peri)adventitially. Influencing neovascularization in mice affected plaque progression, possibly by improving vessel perfusion, but supportive clinical data are not available. Whereas plaque neovascularization contributes to monocyte/macrophage accumulation in the plaque, lymphangiogenesis may facilitate egress of cells and waste products. A specific role for PVAT and its secreted factors is anticipated and wait further clinical evaluation. SUMMARY Hypoxia, inflammation, and plaque neovascularization are associated with plaque progression as underpinned by recent imaging data in humans. Recent studies provide new insights into modulation of adventitia-associated angiogenesis, PVAT, and plaque development in mice, but there is still a need for detailed information on modulating human plaque vascularization in patients.
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Affiliation(s)
- Victor W M van Hinsbergh
- aLaboratory for Physiology, Institute for Cardiovascular Research, VU University Medical Center bDepartment of Pathology, Academic Medical Center, Amsterdam, The Netherlands
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Singh N, Moody AR, Roifman I, Bluemke DA, Zavodni AEH. Advanced MRI for carotid plaque imaging. Int J Cardiovasc Imaging 2015; 32:83-9. [PMID: 26293362 PMCID: PMC4706840 DOI: 10.1007/s10554-015-0743-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/13/2015] [Indexed: 10/28/2022]
Abstract
Atherosclerosis is the ubiquitous underling pathological process that manifests in heart attack and stroke, cumulating in the death of one in three North American adults. High-resolution magnetic resonance imaging (MRI) is able to delineate atherosclerotic plaque components and total plaque burden within the carotid arteries. Using dedicated hardware, high resolution images can be obtained. Combining pre- and post-contrast T1, T2, proton-density, and magnetization-prepared rapid acquisition gradient echo weighted fat-saturation imaging, plaque components can be defined. Post-processing software allows for semi- and fully automated quantitative analysis. Imaging correlation with surgical specimens suggests that this technique accurately differentiates plaque features. Total plaque burden and specific plaque components such as a thin fibrous cap, large fatty or necrotic core and intraplaque hemorrhage are accepted markers of neuroischemic events. Given the systemic nature of atherosclerosis, emerging science suggests that the presence of carotid plaque is also an indicator of coronary artery plaque burden, although the preliminary data primarily involves patients with stable coronary disease. While the availability and cost-effectiveness of MRI will ultimately be important determinants of whether carotid MRI is adopted clinically in cardiovascular risk assessment, the high accuracy and reliability of this technique suggests that it has potential as an imaging biomarker of future risk.
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Affiliation(s)
- Navneet Singh
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room AG56b, Toronto, ON, M4N 3M5, Canada
| | - Alan R Moody
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room AG56b, Toronto, ON, M4N 3M5, Canada
| | - Idan Roifman
- Division of Cardiology, Department of Internal Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - David A Bluemke
- Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Anna E H Zavodni
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room AG56b, Toronto, ON, M4N 3M5, Canada.
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Brinjikji W, Huston J, Rabinstein AA, Kim GM, Lerman A, Lanzino G. Contemporary carotid imaging: from degree of stenosis to plaque vulnerability. J Neurosurg 2015; 124:27-42. [PMID: 26230478 DOI: 10.3171/2015.1.jns142452] [Citation(s) in RCA: 209] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Carotid artery stenosis is a well-established risk factor of ischemic stroke, contributing to up to 10%-20% of strokes or transient ischemic attacks. Many clinical trials over the last 20 years have used measurements of carotid artery stenosis as a means to risk stratify patients. However, with improvements in vascular imaging techniques such as CT angiography and MR angiography, ultrasonography, and PET/CT, it is now possible to risk stratify patients, not just on the degree of carotid artery stenosis but also on how vulnerable the plaque is to rupture, resulting in ischemic stroke. These imaging techniques are ushering in an emerging paradigm shift that allows for risk stratifications based on the presence of imaging features such as intraplaque hemorrhage (IPH), plaque ulceration, plaque neovascularity, fibrous cap thickness, and presence of a lipid-rich necrotic core (LRNC). It is important for the neurosurgeon to be aware of these new imaging techniques that allow for improved patient risk stratification and outcomes. For example, a patient with a low-grade stenosis but an ulcerated plaque may benefit more from a revascularization procedure than a patient with a stable 70% asymptomatic stenosis with a thick fibrous cap. This review summarizes the current state-of-the-art advances in carotid plaque imaging. Currently, MRI is the gold standard in carotid plaque imaging, with its high resolution and high sensitivity for identifying IPH, ulceration, LRNC, and inflammation. However, MRI is limited due to time constraints. CT also allows for high-resolution imaging and can accurately detect ulceration and calcification, but cannot reliably differentiate LRNC from IPH. PET/CT is an effective technique to identify active inflammation within the plaque, but it does not allow for assessment of anatomy, ulceration, IPH, or LRNC. Ultrasonography, with the aid of contrast enhancement, is a cost-effective technique to assess plaque morphology and characteristics, but it is limited in sensitivity and specificity for detecting LRNC, plaque hemorrhage, and ulceration compared with MRI. Also summarized is how these advanced imaging techniques are being used in clinical practice to risk stratify patients with low- and high-grade carotid artery stenosis. For example, identification of IPH on MRI in patients with low-grade carotid artery stenosis is a risk factor for failure of medical therapy, and studies have shown that such patients may fair better with carotid endarterectomy (CEA). MR plaque imaging has also been found to be useful in identifying revascularization candidates who would be better candidates for CEA than carotid artery stenting (CAS), as high intraplaque signal on time of flight imaging is associated with vulnerable plaque and increased rates of adverse events in patients undergoing CAS but not CEA.
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Affiliation(s)
| | | | | | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Eldib M, Bini J, Lairez O, Faul DD, Oesingmann N, Fayad ZA, Mani V. Feasibility of (18)F-Fluorodeoxyglucose radiotracer dose reduction in simultaneous carotid PET/MR imaging. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2015; 5:401-407. [PMID: 26269777 PMCID: PMC4529593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 04/20/2015] [Indexed: 06/04/2023]
Abstract
The purpose of this study was to develop and validate low dose (18)F-FDG-PET acquisition protocols for detection of inflamed carotid plaques specifically for simultaneous PET/MR imaging. The hypothesis was that increasing the duration of the PET acquisition to match that of the MR acquisition might allow for the use of lower levels of the radiotracer, while preserving quantification and image quality. Seven subjects were scanned twice at least one week apart on a simultaneous PET/MR scanner using either the standard clinical dose of (18)F-FDG (373 ± 63 MBq) for 8 minutes or a low dose (93 ± 17 MBq) for 75 minutes. A maximum absolute percent difference of only 4.17% and 7.49% in the left and right carotid TBR was found between the standard dose and four time points of the low dose acquisitions (8, 24, 45, 75 minutes). Only the 8-minute low dose PET data was significantly different in terms of SNR (P = 0.009; % difference = -51%) and qualitative image quality evaluation (P = 0.0005; % difference = -45%). Our preliminary findings indicate that up to 75% reduction of the clinical standard (18)F-FDG dose could be achieved using the proposed acquisition scheme while maintaining accurate quantification and SNR.
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Affiliation(s)
- Mootaz Eldib
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount SinaiNew York, New York
- Department of Biomedical Engineering, The City College of New YorkNew York
| | - Jason Bini
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount SinaiNew York, New York
- Department of Biomedical Engineering, The City College of New YorkNew York
| | - Olivier Lairez
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount SinaiNew York, New York
| | | | | | - Zahi A Fayad
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount SinaiNew York, New York
- Department of Radiology, Icahn School of Medicine at Mount SinaiNew York, New York
- Department of Cardiology, Zena and Michael A. Weiner Cardiovascular Institute and Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at Mount SinaiNew York, New York
| | - Venkatesh Mani
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount SinaiNew York, New York
- Department of Radiology, Icahn School of Medicine at Mount SinaiNew York, New York
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Gholami S, Salavati A, Houshmand S, Werner TJ, Alavi A. Assessment of atherosclerosis in large vessel walls: A comprehensive review of FDG-PET/CT image acquisition protocols and methods for uptake quantification. J Nucl Cardiol 2015; 22:468-79. [PMID: 25827619 DOI: 10.1007/s12350-015-0069-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 01/05/2015] [Indexed: 01/02/2023]
Abstract
There is growing evidence showing the importance of fluorodeoxyglucose positron emission tomography (FDG-PET) in the evaluation of vessel wall inflammation and atherosclerosis. Although this imaging modality has been increasingly used, there are various methods for image acquisition and evaluating FDG uptake activity in the vessel walls and atherosclerotic lesions, including qualitative visual scaling, semi-quantitative, and quantitative evaluations. Using each of these image acquisition protocols and measurement methods may result in different findings. In this review, we are going to describe the various image acquisition methods and common measurement strategies reflected in the literature and discuss their advantages and flaws.
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Affiliation(s)
- Saeid Gholami
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA,
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Kratochvíla J, Jiřík R, Bartoš M, Standara M, Starčuk Z, Taxt T. Distributed capillary adiabatic tissue homogeneity model in parametric multi-channel blind AIF estimation using DCE-MRI. Magn Reson Med 2015; 75:1355-65. [PMID: 25865576 DOI: 10.1002/mrm.25619] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 12/01/2014] [Accepted: 12/24/2014] [Indexed: 12/21/2022]
Abstract
PURPOSE One of the main challenges in quantitative dynamic contrast-enhanced (DCE) MRI is estimation of the arterial input function (AIF). Usually, the signal from a single artery (ignoring contrast dispersion, partial volume effects and flow artifacts) or a population average of such signals (also ignoring variability between patients) is used. METHODS Multi-channel blind deconvolution is an alternative approach avoiding most of these problems. The AIF is estimated directly from the measured tracer concentration curves in several tissues. This contribution extends the published methods of multi-channel blind deconvolution by applying a more realistic model of the impulse residue function, the distributed capillary adiabatic tissue homogeneity model (DCATH). In addition, an alternative AIF model is used and several AIF-scaling methods are tested. RESULTS The proposed method is evaluated on synthetic data with respect to the number of tissue regions and to the signal-to-noise ratio. Evaluation on clinical data (renal cell carcinoma patients before and after the beginning of the treatment) gave consistent results. An initial evaluation on clinical data indicates more reliable and less noise sensitive perfusion parameter estimates. CONCLUSION Blind multi-channel deconvolution using the DCATH model might be a method of choice for AIF estimation in a clinical setup.
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Affiliation(s)
- Jiří Kratochvíla
- Department of Biomedical Engineering, Brno University of Technology, Brno, Czech Republic.,Institute of Scientific Instruments of the Academy of Sciences of the Czech Republic, Brno, Czech Republic
| | - Radovan Jiřík
- Institute of Scientific Instruments of the Academy of Sciences of the Czech Republic, Brno, Czech Republic
| | - Michal Bartoš
- Department of Biomedical Engineering, Brno University of Technology, Brno, Czech Republic.,Institute of Information Technology and Automation of the Academy of Sciences of the Czech Republic, Praha, Czech Republic
| | | | - Zenon Starčuk
- Institute of Scientific Instruments of the Academy of Sciences of the Czech Republic, Brno, Czech Republic
| | - Torfinn Taxt
- Department of Biomedicine, University of Bergen, Bergen, Norway
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Huet P, Burg S, Le Guludec D, Hyafil F, Buvat I. Variability and uncertainty of 18F-FDG PET imaging protocols for assessing inflammation in atherosclerosis: suggestions for improvement. J Nucl Med 2015; 56:552-9. [PMID: 25722452 DOI: 10.2967/jnumed.114.142596] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 01/13/2015] [Indexed: 12/26/2022] Open
Abstract
UNLABELLED PET with (18)F-FDG shows promise for the evaluation of metabolic activities in atherosclerotic plaques. Although recommendations regarding the acquisition and measurement protocols to be used for (18)F-FDG PET imaging of atherosclerosis inflammation have been published, there is no consensus regarding the most appropriate protocols, and the image reconstruction approach has been especially overlooked. Given the small size of the targeted lesions, the reconstruction and measurement methods might strongly affect the results. We determined the differences in results due to the protocol variability and identified means of increasing the measurement reliability. METHODS An extensive literature search was performed to characterize the variability in atherosclerosis imaging and quantification protocols. Highly realistic simulations of atherosclerotic carotid lesions based on real patient data were designed to determine how the acquisition and processing protocol parameters affected the measured values. RESULTS In 49 articles, we identified 53 different acquisition protocols, 51 reconstruction protocols, and 46 quantification methods to characterize atherosclerotic lesions from (18)F-FDG PET images. The most important parameters affecting the measurement accuracy were the number of iterations used for reconstruction and the postfiltering applied to the reconstructed images, which could together make the measured standardized uptake values (SUVs) vary by a factor greater than 3. Image sampling, acquisition duration, and metrics used for the measurements also affected the results to a lesser extent (SUV varying by a factor of 1.3 at most). For an acceptable SUV variability, the lowest bias in SUV was observed using an 8-min acquisition per bed position; ordered-subset expectation maximization reconstruction with at least 120 maximum likelihood expectation maximization equivalent iterations, including a point spread function model using a 1 mm(3) voxel size; and no postfiltering. Because of the partial-volume effect, measurement bias remained greater than 60%. The use and limitations of the target-to-blood activity ratio metrics are also presented and discussed. CONCLUSION (18)F-FDG PET protocol harmonization is needed in atherosclerosis imaging. Optimized protocols can significantly reduce the measurement errors in wall activity estimates, but PET systems with higher spatial resolution and advanced partial-volume corrections will be required to accurately assess plaque inflammation from (18)F-FDG PET.
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Affiliation(s)
- Pauline Huet
- U1023 Inserm/CEA/Paris Sud University-ERL 9218 CNRS, CEA-SHFJ, Orsay, France IMNC UMR 8165 CNRS, Paris Sud University, Orsay, France; and
| | - Samuel Burg
- Department of Nuclear Medicine, Bichat University Hospital, Assistance Publique-Hôpitaux de Paris, UMR 1148, Inserm and Paris Diderot-Paris 7 University, Département Hospitalo-Universitaire Fire, Paris, France
| | - Dominique Le Guludec
- Department of Nuclear Medicine, Bichat University Hospital, Assistance Publique-Hôpitaux de Paris, UMR 1148, Inserm and Paris Diderot-Paris 7 University, Département Hospitalo-Universitaire Fire, Paris, France
| | - Fabien Hyafil
- Department of Nuclear Medicine, Bichat University Hospital, Assistance Publique-Hôpitaux de Paris, UMR 1148, Inserm and Paris Diderot-Paris 7 University, Département Hospitalo-Universitaire Fire, Paris, France
| | - Irène Buvat
- U1023 Inserm/CEA/Paris Sud University-ERL 9218 CNRS, CEA-SHFJ, Orsay, France
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Correlation of perfusion MRI and 18F-FDG PET imaging biomarkers for monitoring regorafenib therapy in experimental colon carcinomas with immunohistochemical validation. PLoS One 2015; 10:e0115543. [PMID: 25668193 PMCID: PMC4323201 DOI: 10.1371/journal.pone.0115543] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 11/25/2014] [Indexed: 12/15/2022] Open
Abstract
Objectives To investigate a multimodal, multiparametric perfusion MRI / 18F-fluoro-deoxyglucose-(18F-FDG)-PET imaging protocol for monitoring regorafenib therapy effects on experimental colorectal adenocarcinomas in rats with immunohistochemical validation. Materials and Methods Human colorectal adenocarcinoma xenografts (HT-29) were implanted subcutaneously in n = 17 (n = 10 therapy group; n = 7 control group) female athymic nude rats (Hsd:RH-Foxn1rnu). Animals were imaged at baseline and after a one-week daily treatment protocol with regorafenib (10 mg/kg bodyweight) using a multimodal, multiparametric perfusion MRI/18F-FDG-PET imaging protocol. In perfusion MRI, quantitative parameters of plasma flow (PF, mL/100 mL/min), plasma volume (PV, %) and endothelial permeability-surface area product (PS, mL/100 mL/min) were calculated. In 18F-FDG-PET, tumor-to-background-ratio (TTB) was calculated. Perfusion MRI parameters were correlated with TTB and immunohistochemical assessments of tumor microvascular density (CD-31) and cell proliferation (Ki-67). Results Regorafenib significantly (p<0.01) suppressed PF (81.1±7.5 to 50.6±16.0 mL/100mL/min), PV (12.1±3.6 to 7.5±1.6%) and PS (13.6±3.2 to 7.9±2.3 mL/100mL/min) as well as TTB (3.4±0.6 to 1.9±1.1) between baseline and day 7. Immunohistochemistry revealed significantly (p<0.03) lower tumor microvascular density (CD-31, 7.0±2.4 vs. 16.1±5.9) and tumor cell proliferation (Ki-67, 434.0 ± 62.9 vs. 663.0 ± 98.3) in the therapy group. Perfusion MRI parameters ΔPF, ΔPV and ΔPS showed strong and significant (r = 0.67-0.78; p<0.01) correlations to the PET parameter ΔTTB and significant correlations (r = 0.57-0.67; p<0.03) to immunohistochemical Ki-67 as well as to CD-31-stainings (r = 0.49-0.55; p<0.05). Conclusions A multimodal, multiparametric perfusion MRI/PET imaging protocol allowed for non-invasive monitoring of regorafenib therapy effects on experimental colorectal adenocarcinomas in vivo with significant correlations between perfusion MRI parameters and 18F-FDG-PET validated by immunohistochemistry.
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Imaging atherosclerosis with hybrid positron emission tomography/magnetic resonance imaging. BIOMED RESEARCH INTERNATIONAL 2015; 2015:914516. [PMID: 25695091 PMCID: PMC4324479 DOI: 10.1155/2015/914516] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 09/16/2014] [Indexed: 01/31/2023]
Abstract
Noninvasive imaging of atherosclerosis could potentially move patient management towards individualized triage, treatment, and followup. The newly introduced combined positron emission tomography (PET) and magnetic resonance imaging (MRI) system could emerge as a key player in this context. Both PET and MRI have previously been used for imaging plaque morphology and function: however, the combination of the two methods may offer new synergistic opportunities. Here, we will give a short summary of current relevant clinical applications of PET and MRI in the setting of atherosclerosis. Additionally, our initial experiences with simultaneous PET/MRI for atherosclerosis imaging are presented. Finally, future potential vascular applications exploiting the unique combination of PET and MRI will be discussed.
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Alie N, Eldib M, Fayad ZA, Mani V. Inflammation, Atherosclerosis, and Coronary Artery Disease: PET/CT for the Evaluation of Atherosclerosis and Inflammation. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2015; 8:13-21. [PMID: 25674025 PMCID: PMC4294600 DOI: 10.4137/cmc.s17063] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 11/16/2014] [Accepted: 11/20/2014] [Indexed: 12/16/2022]
Abstract
Atherosclerosis is a prevalent cardiovascular disease marked by inflammation and the formation of plaque within arterial walls. As the disease progresses, there is an increased risk of major cardiovascular events. Owing to the nature of atherosclerosis, it is imperative to develop methods to further understand the physiological implications and progression of the disease. The combination of positron emission tomography (PET)/computed tomography (CT) has proven to be promising for the evaluation of atherosclerotic plaques and inflammation within the vessel walls. The utilization of the radiopharmaceutical tracer, 18F-fluorodeoxyglucose (18F-FDG), with PET/CT is invaluable in understanding the pathophysiological state involved in atherosclerosis. In this review, we will discuss the use of 18F-FDG-PET/CT imaging for the evaluation of atherosclerosis and inflammation both in preclinical and clinical studies. The potential of more specific novel tracers will be discussed. Finally, we will touch on the potential benefits of using the newly introduced combined PET/magnetic resonance imaging (MRI) for non-invasive imaging of atherosclerosis.
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Affiliation(s)
- Nadia Alie
- Translational and Molecular Imaging Institute, Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mootaz Eldib
- Translational and Molecular Imaging Institute, Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zahi A Fayad
- Translational and Molecular Imaging Institute, Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Venkatesh Mani
- Translational and Molecular Imaging Institute, Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Sadat U, Jaffer FA, van Zandvoort MAMJ, Nicholls SJ, Ribatti D, Gillard JH. Inflammation and neovascularization intertwined in atherosclerosis: imaging of structural and molecular imaging targets. Circulation 2014; 130:786-94. [PMID: 25156914 DOI: 10.1161/circulationaha.114.010369] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Umar Sadat
- From the Cambridge Vascular Unit (U.S.) and University Department of Radiology (U.S., J.H.G.), Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom; Cardiovascular Research Center, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, MA (F.A.J.); Advanced Microscopy Unit, Department of Genetics and Cell Biology-Molecular Cell Biology, Maastricht University, Maastricht, The Netherlands (M.A.M.J.v.Z.); Institute for Molecular Cardiovascular Research, Aachen University, Aachen, Germany (M.A.M.J.v.Z.); South Australian Health and Medical Research Institute and Heart Foundation Heart Health, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia (S.J.N.); Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari Medical School, Bari, Italy (D.R.); and National Cancer Institute "Giovanni Paolo II," Bari, Italy (D.R.).
| | - Farouc A Jaffer
- From the Cambridge Vascular Unit (U.S.) and University Department of Radiology (U.S., J.H.G.), Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom; Cardiovascular Research Center, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, MA (F.A.J.); Advanced Microscopy Unit, Department of Genetics and Cell Biology-Molecular Cell Biology, Maastricht University, Maastricht, The Netherlands (M.A.M.J.v.Z.); Institute for Molecular Cardiovascular Research, Aachen University, Aachen, Germany (M.A.M.J.v.Z.); South Australian Health and Medical Research Institute and Heart Foundation Heart Health, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia (S.J.N.); Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari Medical School, Bari, Italy (D.R.); and National Cancer Institute "Giovanni Paolo II," Bari, Italy (D.R.)
| | - Marc A M J van Zandvoort
- From the Cambridge Vascular Unit (U.S.) and University Department of Radiology (U.S., J.H.G.), Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom; Cardiovascular Research Center, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, MA (F.A.J.); Advanced Microscopy Unit, Department of Genetics and Cell Biology-Molecular Cell Biology, Maastricht University, Maastricht, The Netherlands (M.A.M.J.v.Z.); Institute for Molecular Cardiovascular Research, Aachen University, Aachen, Germany (M.A.M.J.v.Z.); South Australian Health and Medical Research Institute and Heart Foundation Heart Health, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia (S.J.N.); Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari Medical School, Bari, Italy (D.R.); and National Cancer Institute "Giovanni Paolo II," Bari, Italy (D.R.)
| | - Stephen J Nicholls
- From the Cambridge Vascular Unit (U.S.) and University Department of Radiology (U.S., J.H.G.), Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom; Cardiovascular Research Center, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, MA (F.A.J.); Advanced Microscopy Unit, Department of Genetics and Cell Biology-Molecular Cell Biology, Maastricht University, Maastricht, The Netherlands (M.A.M.J.v.Z.); Institute for Molecular Cardiovascular Research, Aachen University, Aachen, Germany (M.A.M.J.v.Z.); South Australian Health and Medical Research Institute and Heart Foundation Heart Health, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia (S.J.N.); Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari Medical School, Bari, Italy (D.R.); and National Cancer Institute "Giovanni Paolo II," Bari, Italy (D.R.)
| | - Domenico Ribatti
- From the Cambridge Vascular Unit (U.S.) and University Department of Radiology (U.S., J.H.G.), Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom; Cardiovascular Research Center, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, MA (F.A.J.); Advanced Microscopy Unit, Department of Genetics and Cell Biology-Molecular Cell Biology, Maastricht University, Maastricht, The Netherlands (M.A.M.J.v.Z.); Institute for Molecular Cardiovascular Research, Aachen University, Aachen, Germany (M.A.M.J.v.Z.); South Australian Health and Medical Research Institute and Heart Foundation Heart Health, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia (S.J.N.); Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari Medical School, Bari, Italy (D.R.); and National Cancer Institute "Giovanni Paolo II," Bari, Italy (D.R.)
| | - Jonathan H Gillard
- From the Cambridge Vascular Unit (U.S.) and University Department of Radiology (U.S., J.H.G.), Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom; Cardiovascular Research Center, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, MA (F.A.J.); Advanced Microscopy Unit, Department of Genetics and Cell Biology-Molecular Cell Biology, Maastricht University, Maastricht, The Netherlands (M.A.M.J.v.Z.); Institute for Molecular Cardiovascular Research, Aachen University, Aachen, Germany (M.A.M.J.v.Z.); South Australian Health and Medical Research Institute and Heart Foundation Heart Health, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia (S.J.N.); Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari Medical School, Bari, Italy (D.R.); and National Cancer Institute "Giovanni Paolo II," Bari, Italy (D.R.)
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Taqueti VR, Di Carli MF, Jerosch-Herold M, Sukhova GK, Murthy VL, Folco EJ, Kwong RY, Ozaki CK, Belkin M, Nahrendorf M, Weissleder R, Libby P. Increased microvascularization and vessel permeability associate with active inflammation in human atheromata. Circ Cardiovasc Imaging 2014; 7:920-9. [PMID: 25170063 DOI: 10.1161/circimaging.114.002113] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Studies have shown the feasibility of imaging plaques with 2-deoxy-2-[(18)F]fluoroglucose (FDG) positron emission tomography and dynamic contrast-enhanced magnetic resonance imaging with inconsistent results. We sought to investigate the relationship between markers of inflammatory activation, plaque microvascularization, and vessel wall permeability in subjects with carotid plaques using a multimodality approach combining FDG positron emission tomography, dynamic contrast-enhanced magnetic resonance imaging, and histopathology. METHODS AND RESULTS Thirty-two subjects with carotid stenoses underwent noninvasive imaging with FDG positron emission tomography and dynamic contrast-enhanced magnetic resonance imaging, 46.9% (n=15) before carotid endarterectomy. We measured FDG uptake (target:background ratio [TBR]) by positron emission tomography and K(trans) (reflecting microvascular permeability and perfusion) by magnetic resonance imaging and correlated imaging with immunohistochemical markers of macrophage content (CD68), activated inflammatory cells (major histocompatibility complex class II), and microvessels (CD31) in plaque and control regions. TBR and K(trans) correlated significantly with tertiles of CD68(+) (P=0.009 and P=0.008, respectively), major histocompatibility complex class II(+) (P=0.003 and P<0.001, respectively), and CD31(+) (P=0.004 and P=0.008, respectively). Regions of plaques were associated with increased CD68(+) (P=0.002), major histocompatibility complex class II(+) (P=0.002), CD31(+) (P=0.02), TBR (P<0.0001), and K(trans) (P<0.0001), as compared with those without plaques. Microvascularization correlated with macrophage content (rs=0.52; P=0.007) and inflammatory activity (rs=0.68; P=0.0001) and TBR correlated with K(trans) (rs=0.53; P<0.0001). In multivariable mixed linear regression modeling, TBR remained independently associated with K(trans) (β[SE], 2.68[0.47]; P<0.0001). CONCLUSIONS Plaque regions with active inflammation, as determined by macrophage content and major histocompatibility complex class II expression, showed increased FDG uptake, which correlated with increased K(trans) and microvascularization. The correlation between K(trans) and TBR was moderate, direct, highly significant, and independent of clinical symptoms and plaque luminal severity.
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Affiliation(s)
- Viviany R Taqueti
- From the Heart and Vascular Institute (V.R.T., M.F.D.C., G.K.S., E.J.F., R.Y.K., C.K.O., M.B., P.L.), Noninvasive Cardiovascular Imaging Program, Nuclear Medicine and Molecular Imaging Division, Department of Radiology (V.R.T., M.F.D.C., M.J.-H., R.Y.K.), Brigham and Women's Hospital, and Center for Systems Biology, Massachusetts General Hospital (M.N., R.W.), Harvard Medical School, Boston, MA; and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Marcelo F Di Carli
- From the Heart and Vascular Institute (V.R.T., M.F.D.C., G.K.S., E.J.F., R.Y.K., C.K.O., M.B., P.L.), Noninvasive Cardiovascular Imaging Program, Nuclear Medicine and Molecular Imaging Division, Department of Radiology (V.R.T., M.F.D.C., M.J.-H., R.Y.K.), Brigham and Women's Hospital, and Center for Systems Biology, Massachusetts General Hospital (M.N., R.W.), Harvard Medical School, Boston, MA; and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Michael Jerosch-Herold
- From the Heart and Vascular Institute (V.R.T., M.F.D.C., G.K.S., E.J.F., R.Y.K., C.K.O., M.B., P.L.), Noninvasive Cardiovascular Imaging Program, Nuclear Medicine and Molecular Imaging Division, Department of Radiology (V.R.T., M.F.D.C., M.J.-H., R.Y.K.), Brigham and Women's Hospital, and Center for Systems Biology, Massachusetts General Hospital (M.N., R.W.), Harvard Medical School, Boston, MA; and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Galina K Sukhova
- From the Heart and Vascular Institute (V.R.T., M.F.D.C., G.K.S., E.J.F., R.Y.K., C.K.O., M.B., P.L.), Noninvasive Cardiovascular Imaging Program, Nuclear Medicine and Molecular Imaging Division, Department of Radiology (V.R.T., M.F.D.C., M.J.-H., R.Y.K.), Brigham and Women's Hospital, and Center for Systems Biology, Massachusetts General Hospital (M.N., R.W.), Harvard Medical School, Boston, MA; and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Venkatesh L Murthy
- From the Heart and Vascular Institute (V.R.T., M.F.D.C., G.K.S., E.J.F., R.Y.K., C.K.O., M.B., P.L.), Noninvasive Cardiovascular Imaging Program, Nuclear Medicine and Molecular Imaging Division, Department of Radiology (V.R.T., M.F.D.C., M.J.-H., R.Y.K.), Brigham and Women's Hospital, and Center for Systems Biology, Massachusetts General Hospital (M.N., R.W.), Harvard Medical School, Boston, MA; and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Eduardo J Folco
- From the Heart and Vascular Institute (V.R.T., M.F.D.C., G.K.S., E.J.F., R.Y.K., C.K.O., M.B., P.L.), Noninvasive Cardiovascular Imaging Program, Nuclear Medicine and Molecular Imaging Division, Department of Radiology (V.R.T., M.F.D.C., M.J.-H., R.Y.K.), Brigham and Women's Hospital, and Center for Systems Biology, Massachusetts General Hospital (M.N., R.W.), Harvard Medical School, Boston, MA; and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Raymond Y Kwong
- From the Heart and Vascular Institute (V.R.T., M.F.D.C., G.K.S., E.J.F., R.Y.K., C.K.O., M.B., P.L.), Noninvasive Cardiovascular Imaging Program, Nuclear Medicine and Molecular Imaging Division, Department of Radiology (V.R.T., M.F.D.C., M.J.-H., R.Y.K.), Brigham and Women's Hospital, and Center for Systems Biology, Massachusetts General Hospital (M.N., R.W.), Harvard Medical School, Boston, MA; and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - C Keith Ozaki
- From the Heart and Vascular Institute (V.R.T., M.F.D.C., G.K.S., E.J.F., R.Y.K., C.K.O., M.B., P.L.), Noninvasive Cardiovascular Imaging Program, Nuclear Medicine and Molecular Imaging Division, Department of Radiology (V.R.T., M.F.D.C., M.J.-H., R.Y.K.), Brigham and Women's Hospital, and Center for Systems Biology, Massachusetts General Hospital (M.N., R.W.), Harvard Medical School, Boston, MA; and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Michael Belkin
- From the Heart and Vascular Institute (V.R.T., M.F.D.C., G.K.S., E.J.F., R.Y.K., C.K.O., M.B., P.L.), Noninvasive Cardiovascular Imaging Program, Nuclear Medicine and Molecular Imaging Division, Department of Radiology (V.R.T., M.F.D.C., M.J.-H., R.Y.K.), Brigham and Women's Hospital, and Center for Systems Biology, Massachusetts General Hospital (M.N., R.W.), Harvard Medical School, Boston, MA; and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Matthias Nahrendorf
- From the Heart and Vascular Institute (V.R.T., M.F.D.C., G.K.S., E.J.F., R.Y.K., C.K.O., M.B., P.L.), Noninvasive Cardiovascular Imaging Program, Nuclear Medicine and Molecular Imaging Division, Department of Radiology (V.R.T., M.F.D.C., M.J.-H., R.Y.K.), Brigham and Women's Hospital, and Center for Systems Biology, Massachusetts General Hospital (M.N., R.W.), Harvard Medical School, Boston, MA; and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Ralph Weissleder
- From the Heart and Vascular Institute (V.R.T., M.F.D.C., G.K.S., E.J.F., R.Y.K., C.K.O., M.B., P.L.), Noninvasive Cardiovascular Imaging Program, Nuclear Medicine and Molecular Imaging Division, Department of Radiology (V.R.T., M.F.D.C., M.J.-H., R.Y.K.), Brigham and Women's Hospital, and Center for Systems Biology, Massachusetts General Hospital (M.N., R.W.), Harvard Medical School, Boston, MA; and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.)
| | - Peter Libby
- From the Heart and Vascular Institute (V.R.T., M.F.D.C., G.K.S., E.J.F., R.Y.K., C.K.O., M.B., P.L.), Noninvasive Cardiovascular Imaging Program, Nuclear Medicine and Molecular Imaging Division, Department of Radiology (V.R.T., M.F.D.C., M.J.-H., R.Y.K.), Brigham and Women's Hospital, and Center for Systems Biology, Massachusetts General Hospital (M.N., R.W.), Harvard Medical School, Boston, MA; and Divisions of Nuclear Medicine, Cardiothoracic Imaging, and Cardiovascular Medicine, Departments of Medicine and Radiology, University of Michigan, Ann Arbor (V.L.M.).
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Wong SK, Mobolaji-Iawal M, Arama L, Cambe J, Biso S, Alie N, Fayad ZA, Mani V. Atherosclerosis imaging using 3D black blood TSE SPACE vs 2D TSE. World J Radiol 2014; 6:192-202. [PMID: 24876923 PMCID: PMC4037545 DOI: 10.4329/wjr.v6.i5.192] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 01/30/2014] [Accepted: 04/19/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare 3D Black Blood turbo spin echo (TSE) sampling perfection with application-optimized contrast using different flip angle evolution (SPACE) vs 2D TSE in evaluating atherosclerotic plaques in multiple vascular territories.
METHODS: The carotid, aortic, and femoral arterial walls of 16 patients at risk for cardiovascular or atherosclerotic disease were studied using both 3D black blood magnetic resonance imaging SPACE and conventional 2D multi-contrast TSE sequences using a consolidated imaging approach in the same imaging session. Qualitative and quantitative analyses were performed on the images. Agreement of morphometric measurements between the two imaging sequences was assessed using a two-sample t-test, calculation of the intra-class correlation coefficient and by the method of linear regression and Bland-Altman analyses.
RESULTS: No statistically significant qualitative differences were found between the 3D SPACE and 2D TSE techniques for images of the carotids and aorta. For images of the femoral arteries, however, there were statistically significant differences in all four qualitative scores between the two techniques. Using the current approach, 3D SPACE is suboptimal for femoral imaging. However, this may be due to coils not being optimized for femoral imaging. Quantitatively, in our study, higher mean total vessel area measurements for the 3D SPACE technique across all three vascular beds were observed. No significant differences in lumen area for both the right and left carotids were observed between the two techniques. Overall, a significant-correlation existed between measures obtained between the two approaches.
CONCLUSION: Qualitative and quantitative measurements between 3D SPACE and 2D TSE techniques are comparable. 3D-SPACE may be a feasible approach in the evaluation of cardiovascular patients.
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Chen H, Wu T, Kerwin WS, Yuan C. Atherosclerotic plaque inflammation quantification using dynamic contrast-enhanced (DCE) MRI. Quant Imaging Med Surg 2014; 3:298-301. [PMID: 24404443 DOI: 10.3978/j.issn.2223-4292.2013.12.01] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 12/05/2013] [Indexed: 01/12/2023]
Abstract
Inflammation plays an important role in atherosclerosis. Given the increasing interest in using in-vivo imaging methods to study the physiology and treatment effects in atherosclerosis, noninvasive intraplaque inflammation quantitative method is needed. Dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) has been proposed and validated to quantitatively characterize atherosclerotic plaque inflammation. Recent studies have optimized the imaging protocol, pharmacokinetic modeling techniques. All of these technical advances further promoted DCE-MRI to clinical investigations in plaque risk assessment and therapeutic response monitor. Although larger clinical studies are still needed, DCE-MRI has been proven to be a promising tool to reveal more about intraplaque inflammation by in vivo quantitative inflammation imaging.
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Affiliation(s)
- Huijun Chen
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University, Beijing 100084, China
| | - Tingting Wu
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University, Beijing 100084, China
| | - William S Kerwin
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Chun Yuan
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University, Beijing 100084, China; ; Department of Radiology, University of Washington, Seattle, Washington, USA
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