Magnetic resonance molecular imaging contrast agents and their application in atherosclerosis

Clinical quantitative coronary artery stenosis and coronary atherosclerosis imaging: a Consensus Statement from the Quantitative Cardiovascular Imaging Study Group

The detection and characterization of coronary artery stenosis and atherosclerosis using imaging tools are key for clinical decision-making in patients with known or suspected coronary artery disease. In this regard, imaging-based quantification can be improved by choosing the most appropriate imaging modality for diagnosis, treatment and procedural planning. In this Consensus Statement, we provide clinical consensus recommendations on the optimal use of different imaging techniques in various patient populations and describe the advances in imaging technology. Clinical consensus recommendations on the appropriateness of each imaging technique for direct coronary artery visualization were derived through a three-step, real-time Delphi process that took place before, during and after the Second International Quantitative Cardiovascular Imaging Meeting in September 2022. According to the Delphi survey answers, CT is the method of choice to rule out obstructive stenosis in patients with an intermediate pre-test probability of coronary artery disease and enables quantitative assessment of coronary plaque with respect to dimensions, composition, location and related risk of future cardiovascular events, whereas MRI facilitates the visualization of coronary plaque and can be used in experienced centres as a radiation-free, second-line option for non-invasive coronary angiography. PET has the greatest potential for quantifying inflammation in coronary plaque but SPECT currently has a limited role in clinical coronary artery stenosis and atherosclerosis imaging. Invasive coronary angiography is the reference standard for stenosis assessment but cannot characterize coronary plaques. Finally, intravascular ultrasonography and optical coherence tomography are the most important invasive imaging modalities for the identification of plaques at high risk of rupture. The recommendations made in this Consensus Statement will help clinicians to choose the most appropriate imaging modality on the basis of the specific clinical scenario, individual patient characteristics and the availability of each imaging modality.

Preclinical models of atherosclerosis. The future of Hybrid PET/MR technology for the early detection of vulnerable plaque

Cardiovascular diseases are the leading cause of death in developed countries. The aetiology is currently multifactorial, thus making them very difficult to prevent. Preclinical models of atherothrombotic diseases, including vulnerable plaque-associated complications, are now providing significant insights into pathologies like atherosclerosis, and in combination with the most recent advances in new non-invasive imaging technologies, they have become essential tools to evaluate new therapeutic strategies, with which can forecast and prevent plaque rupture. Positron emission tomography (PET)/computed tomography imaging is currently used for plaque visualisation in clinical and pre-clinical cardiovascular research, albeit with significant limitations. However, the combination of PET and magnetic resonance imaging (MRI) technologies is still the best option available today, as combined PET/MRI scans provide simultaneous data acquisition together with high quality anatomical information, sensitivity and lower radiation exposure for the patient. The coming years may represent a new era for the implementation of PET/MRI in clinical practice, but first, clinically efficient attenuation correction algorithms and research towards multimodal reagents and safety issues should be validated at the preclinical level.

Small animal cardiovascular MR imaging and spectroscopy

The use of MR imaging and spectroscopy for studying cardiovascular disease processes in small animals has increased tremendously over the past decade. This is the result of the remarkable advances in MR technologies and the increased availability of genetically modified mice. MR techniques provide a window on the entire timeline of cardiovascular disease development, ranging from subtle early changes in myocardial metabolism that often mark disease onset to severe myocardial dysfunction associated with end-stage heart failure. MR imaging and spectroscopy techniques play an important role in basic cardiovascular research and in cardiovascular disease diagnosis and therapy follow-up. This is due to the broad range of functional, structural and metabolic parameters that can be quantified by MR under in vivo conditions non-invasively. This review describes the spectrum of MR techniques that are employed in small animal cardiovascular disease research and how the technological challenges resulting from the small dimensions of heart and blood vessels as well as high heart and respiratory rates, particularly in mice, are tackled.

Superparamagnetic iron oxide based nanoprobes for imaging and theranostics

The need to target, deliver and subsequently evaluate the efficacy of therapeutics in the treatment of a disease has provided added impetus in developing novel and highly efficient contrast agents. Superparamagnetic iron oxide nanoparticles (SPIONs) have offered tremendous potential in designing advanced magnetic resonance imaging (MRI) diagnostic agents, due to their unique physicochemical properties. There has been tremendous effort devoted in the recent past in developing synthetic methodologies through which their size, hydrodynamic radii, chemical composition and morphologies could be tailored at the nanoscale. This enables one to fine tune their magnetic behavior, and thus their MRI response. While novel synthetic strategies are being assembled for directing SPIONs to the diseased site as well as imparting them stealth and biocompatibility, it is also essential to evaluate their biological toxicological profiles. This review highlights recent advances that have been made in the synthesis of SPIONs, subsequent functionalization with desired entities, and a discussion on their use as MRI contrast agents in cardiovascular research.

Self-gated CINE MRI for combined contrast-enhanced imaging and wall-stiffness measurements of murine aortic atherosclerotic lesions

Background

High-resolution contrast-enhanced imaging of the murine atherosclerotic vessel wall is difficult due to unpredictable flow artifacts, motion of the thin artery wall and problems with flow suppression in the presence of a circulating contrast agent.

Methods and Results

We applied a 2D-FLASH retrospective-gated CINE MRI method at 9.4T to characterize atherosclerotic plaques and vessel wall distensibility in the aortic arch of aged ApoE^−/− mice after injection of a contrast agent. The method enabled detection of contrast enhancement in atherosclerotic plaques in the aortic arch after I.V. injection of micelles and iron oxides resulting in reproducible plaque enhancement. Both contrast agents were taken up in the plaque, which was confirmed by histology. Additionally, the retrospective-gated CINE method provided images of the aortic wall throughout the cardiac cycle, from which the vessel wall distensibility could be calculated. Reduction in plaque size by statin treatment resulted in lower contrast enhancement and reduced wall stiffness.

Conclusions

The retrospective-gated CINE MRI provides a robust and simple way to detect and quantify contrast enhancement in atherosclerotic plaques in the aortic wall of ApoE^−/− mice. From the same scan, plaque-related changes in stiffness of the aortic wall can be determined. In this mouse model, a correlation between vessel wall stiffness and atherosclerotic lesions was found.

Past, current and future concepts in atherosclerotic biobanking

Knowledge on the pathogenesis of atherosclerotic disease mainly originates from observations made by pathologists who systemically collected vascular tissue. Biobanking of human tissues has become a professionalized joint effort, including the expertise of epidemiologists, pathologists and biologists. Mostly, biobanks are used for cross-sectional studies and the obtained specimens often represent later stages of disease. Technical improvements in high-throughput genetic and proteomic screening lead to important new insights into pathophysiological processes. Atherosclerotic disease progression is a major killer in the Western society. Pathological biobanking studies revealed insights in plaque progression and destabilization. However, atherosclerotic disease is a typical example where insights into progression of the disease may be hampered by the cross-sectional design of the biobanks. This article will focus on the accomplishments that have been made through biobanking of atherosclerotic tissues in the past and the present. In addition, future potentials of atherosclerotic plaque biobanks will be discussed.

MRI-determined carotid artery flow velocities and wall shear stress in a mouse model of vulnerable and stable atherosclerotic plaque

OBJECTIVES

We report here on the pre-clinical MRI characterization of an apoE-/- mouse model of stable and vulnerable carotid artery atherosclerotic plaques, which were induced by a tapered restriction (cast) around the artery. Specific focus was on the quantification of the wall shear stress, which is considered a key player in the development of the plaque phenotype.

MATERIALS AND METHODS

In vivo MRI was performed at 9.4 T. The protocol consisted of time-of-flight angiography, high-resolution T1- and T2-weighted black-blood imaging and phase-contrast flow velocity imaging as function of time in the cardiac cycle. Wall shear stress was determined by fitting the flow profile to a quadratic polynomial.

RESULTS

Time-of-flight angiography confirmed preservation of blood flow through the carotid arteries in all cases. T1- and T2-weighted MRI resulted in high-resolution images in which the position of the cast, luminal narrowing introduced by cast and plaque, as well as the arterial wall could be well identified. Laminar flow with low wall shear stress (11.2+/- 5.2 Pa) was measured upstream to the cast at the position of the vulnerable plaque. Downstream to the cast at the position of the stable plaque, the apparent velocities were low, which is consistent with vortices and an oscillatory nature of the flow.

CONCLUSIONS

Flow velocities and wall shear stress were successfully measured in this mouse model of stable and unstable plaque. The presented tools can be used to provide valuable insights in the pathogenesis of atherosclerosis.

Advanced techniques for MRI of atherosclerotic plaque

This review examines the state of the art in vessel wall imaging by magnetic resonance imaging (MRI) with an emphasis on the biomechanical assessment of atherosclerotic plaque. Three areas of advanced techniques are discussed. First, alternative contrast mechanisms, including susceptibility, magnetization transfer, diffusion, and perfusion, are presented as to how they facilitate accurate determination of plaque constituents underlying biomechanics. Second, imaging technologies including hardware and sequences, are reviewed as to how they provide the resolution and signal-to-noise ratio necessary for determining plaque structure. Finally, techniques for combining MRI data into an overall assessment of plaque biomechanical properties, including wall shear stress and internal plaque strain, are presented. The paper closes with a discussion of the extent to which these techniques have been applied to different arteries commonly targeted by vessel wall MRI.

Cellular compartmentalization of internalized paramagnetic liposomes strongly influences both T1 and T2 relaxivity

In recent years, numerous Gd(3+)-based contrast agents have been developed to enable target-specific MR imaging of in vivo processes at the molecular level. The combination of powerful contrast agents and amplification strategies, aimed at increasing the contrast agent dose at the target site, is an often-used strategy to improve the sensitivity of biomarker detection. One such amplification mechanism is to target a disease-specific cell membrane receptor that can undergo multiple rounds of internalization following ligand binding and thus shuttle a sizeable amount of contrast agent into the target cell. An example of such a membrane receptor is the alpha(nu)beta(3) integrin. The goal of this study was to investigate the consequences of this amplification approach for the T(1)- and T(2)-shortening efficacy of a paramagnetic contrast agent. Cultured endothelial cells were incubated with paramagnetic liposomes that were conjugated with a cyclic RGD-peptide to enable internalization by means of the alpha(nu)beta(3) integrin receptor. Non-targeted liposomes served as a control. This study showed that alpha(nu)beta(3) targeting dramatically increased the uptake of paramagnetic liposomes. This targeting strategy, however, strongly influenced both the longitudinal and transverse relaxivity of the internalized paramagnetic liposomes.

Quantitative segmentation of principal carotid atherosclerotic lesion components by feature space analysis based on multicontrast MRI at 1.5 T

The purpose of this paper is to evaluate the capability of feature space analysis (FSA) for quantifying the relative volumes of principal components (thrombus, calcification, fibrous, normal intima, and lipid) of atherosclerotic plaque tissue in multicontrast magnetic resonance images (mc-MRI) acquired in a setup resembling clinical conditions ex vivo. Utilizing endogenous contrast, proton density, T1-weighted, and T2-weighted images were acquired for 13 carotid endarterectomy (CEA) tissues under near-clinical conditions (human 1.5 T GE Excite scanner with sequence parameters comparable to an in vivo acquisition). An FSA algorithm was utilized to segment and quantify the principal components of atherosclerotic plaques. Pilot in vivo mc-MRI images were analyzed in the same way as the ex vivo images for exploring the possible adaptation of this technique to in vivo imaging. Relative abundance of principal plaque components in CEA tissues as determined by mc-MRI/FSA were compared to those measured by histology. Mean differences +/- standard deviations were 5.8 +/- 4.1% for thrombus, 1.5 +/-1.4 % for calcification, 4.0 +/-2.8% for fibrous, 8.2 +/- 10% for normal intima, and 2.4 +/- 2.2% for lipid. Reasonable quantitative agreement between the classification results obtained with FSA and histological data was obtained for near-clinical imaging conditions. Combination of mc-MRI and FSA may have an application for determining atherosclerotic lesion composition and monitoring treatment in vivo.

In vivo molecular imaging of vascular stress

Noninvasive in vivo imaging is an emerging specialty in experimental radiology aiming at developing hardware and appropriate contrast agents to visualize the molecular basis and pathophysiological processes of many pathological conditions, including atherosclerosis. The list of potentially useful tracers and targets for in vivo molecular imaging in the cascade of early atherosclerotic events has been narrowed down to some very promising endothelial factors, i.e., cell adhesion molecules, macrophages, apoptosis, lipoproteins, heat shock proteins, and others. In this review, we will update on the progress of recent developments in the field of noninvasive molecular imaging in experimental atherosclerosis.