1
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Li Y, Chen F, Yang B, Xie S, Wang C, Guo R, Zhang X, Liu Z. Effect of Mid-Basilar Artery Angle and Plaque Characteristics on Pontine Infarction in Patients with Basilar Artery Plaque. J Atheroscler Thromb 2023; 30:182-191. [PMID: 35418542 PMCID: PMC9925201 DOI: 10.5551/jat.63520] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
AIMS The basilar artery (BA) geometry and plaque characteristics may play an important role in the development of atherosclerosis. This study was performed to explore the relationship between the mid-BA angle and plaque characteristics and its effect on pontine infarction using high-resolution magnetic resonance imaging and three-dimensional time-of-flight magnetic resonance angiography. METHODS In total, 77 patients with BA plaques were included in this study. According to the presence of acute pontine infarction on diffusion-weighted imaging, the patients were divided into a pontine infarction group and pontine non-infarction group. The mid-BA angle, plaque burden, stenosis ratio, positive remodeling, and intraplaque hemorrhage were evaluated to investigate their effects on stroke. RESULTS The pontine infarction group had a greater plaque burden, stenosis ratio, positive remodeling, and mid-BA angle than the pontine non-infarction group. The correlation between the plaque burden and mid-BA angle was the highest (r=0.441, P<0.001). Multivariate logistic regression analysis showed that the plaque burden (odds ratio, 1.164; 95% confidence interval, 1.093-1.241; P<0.001) was an independent risk factor for pontine infarction. CONCLUSION The mid-BA angle may increase the incidence of pontine infarction by increasing the plaque burden.
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Affiliation(s)
- Yangchen Li
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China,Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Fengxin Chen
- Department of Hepatology Division 2, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Bo Yang
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Sheng Xie
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China,Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Ce Wang
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Runcai Guo
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Xuebing Zhang
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Zunjing Liu
- Department of Neurology, China-Japan Friendship Hospital, Beijing, China
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2
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Wang X, Li J, Wang X, Gao J, Jing H, Xing Y. Clinical Evaluation of High-Resolution MRI Combined With DWI in Identifying Vulnerable Carotid Plaque. Neurologist 2023; 28:5-10. [PMID: 35348493 DOI: 10.1097/nrl.0000000000000432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND High-resolution magnetic resonance imaging combined with diffusion weighted imaging is used to identify vulnerable plaques (VP) and their characteristic components, and apparent diffusion coefficient (ADC) correlation analysis with serum inflammatory markers to assess plaque vulnerability. METHODS In this study, 60 eligible patients were included, including 29 patients in VP group and 31 patients in non-VP group (N group). The average ADC value, serum inflammatory marker levels (high-sensitivity C-reactive protein, myeloperoxidase, and erythrocyte sedimentation rate) of the 2 groups were measured, and the characteristics of different plaque components and ADC levels of vascular wall in VP group were compared, to evaluate the correlation between serum inflammatory markers and the mean value of plaque ADC. RESULTS The results showed that the ADC mean value of the plaques in the VP group was significantly lower than that in the N group, and the levels of hypersensitive C-reactive protein and myeloperoxidase were correlated with the ADC mean value of the plaques. CONCLUSION The ADC value of plaque measured by high-resolution magnetic resonance imaging combined with diffusion weighted imaging sequence can quantify the identification of VP and its characteristic components, reflect the inflammation of plaque to a certain extent, and thus prevent and treat stroke and other adverse outcomes more effectively.
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Affiliation(s)
- Xinyi Wang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, People's Republic of China
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3
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Li D, Qiao H, Yang X, Li J, Dai W, Chen X, Shen J, Zhao X. Co-existing Hypertension and Hyperhomocysteinemia Increases the Risk of Carotid Vulnerable Plaque and Subsequent Vascular Event: An MR Vessel Wall Imaging Study. Front Cardiovasc Med 2022; 9:858066. [PMID: 35433864 PMCID: PMC9005821 DOI: 10.3389/fcvm.2022.858066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/07/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose This study sought to determine the associations of co-existing hypertension and hyperhomocysteinemia (H-Hcy) with carotid vulnerable plaque features and subsequent vascular events. Methods Symptomatic patients with carotid atherosclerosis were enrolled and underwent carotid magnetic resonance (MR) vessel wall imaging. The patients were divided into the following groups: co-existing hypertension and H-Hcy group; isolated hypertension group; isolated H-Hcy group; and control group. The morphological and compositional characteristics of carotid plaques were assessed on MR images and compared among different groups. Univariate and multivariate cox regressions were used to calculate the hazard ratio (HR) and corresponding 95% confidence interval (CI) of co-existing hypertension and H-Hcy in predicting subsequent vascular events after at least 1-year followed-up. Results In total, 217 patients (mean age, 59.4 ± 11.9 years; 154 males) were recruited. Patients in co-existing hypertension and H-Hcy group had a significantly higher prevalence of carotid lipid-rich necrotic core (LRNC) than isolated H-Hcy and control group (73.2 vs. 43.3 vs. 50%, p = 0.015). During the median follow-up time of 12.2 ± 4.3 months, 61 (39.8%) patients experienced vascular events. After adjusting for baseline confounding factors, co-existing hypertension and H-Hcy (HR, 1.82; 95% CI, 1.01–3.27; p = 0.044), presence of carotid LRNC (HR, 2.25; 95% CI, 1.09–4.65; p = 0.029), and combination of co-existing hypertension and H-Hcy and carotid LRNC (HR, 2.39; 95% CI, 1.26–4.43; p = 0.007) were significantly associated with subsequent vascular events. Conclusions Co-existing hypertension and H-Hcy are associated with carotid vulnerable plaque features, such as LRNC. Combining co-existing hypertension and H-Hcy with carotid vulnerable plaque features has a stronger predictive value for subsequent vascular events than each measurement alone.
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Affiliation(s)
- Dongye Li
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Huiyu Qiao
- Department of Biomedical Engineering, Center for Biomedical Imaging Research, Tsinghua University School of Medicine, Beijing, China
| | - Xieqing Yang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jin Li
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wei Dai
- Department of Neurology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xiaoyi Chen
- Department of Radiology, Beijing Geriatric Hospital, Beijing, China
| | - Jun Shen
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- *Correspondence: Jun Shen
| | - Xihai Zhao
- Department of Biomedical Engineering, Center for Biomedical Imaging Research, Tsinghua University School of Medicine, Beijing, China
- Xihai Zhao
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Chen L, Zhao H, Jiang H, Balu N, Geleri DB, Chu B, Watase H, Zhao X, Li R, Xu J, Hatsukami TS, Xu D, Hwang JN, Yuan C. Domain adaptive and fully automated carotid artery atherosclerotic lesion detection using an artificial intelligence approach (LATTE) on 3D MRI. Magn Reson Med 2021; 86:1662-1673. [PMID: 33885165 DOI: 10.1002/mrm.28794] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/07/2021] [Accepted: 03/18/2021] [Indexed: 01/17/2023]
Abstract
PURPOSE To develop and evaluate a domain adaptive and fully automated review workflow (lesion assessment through tracklet evaluation, LATTE) for assessment of atherosclerotic disease in 3D carotid MR vessel wall imaging (MR VWI). METHODS VWI of 279 subjects with carotid atherosclerosis were used to develop LATTE, mainly convolutional neural network (CNN)-based domain adaptive lesion classification after image quality assessment and artery of interest localization. Heterogeneity in test sets from various sites usually causes inferior CNN performance. With our novel unsupervised domain adaptation (DA), LATTE was designed to accurately classify arteries into normal arteries and early and advanced lesions without additional annotations on new datasets. VWI of 271 subjects from four datasets (eight sites) with slightly different imaging parameters/signal patterns were collected to assess the effectiveness of DA of LATTE using the area under the receiver operating characteristic curve (AUC) on all lesions and advanced lesions before and after DA. RESULTS LATTE had good performance with advanced/all lesion classification, with the AUC of >0.88/0.83, significant improvements from >0.82/0.80 if without DA. CONCLUSIONS LATTE can locate target arteries and distinguish carotid atherosclerotic lesions with consistently improved performance with DA on new datasets. It may be useful for carotid atherosclerosis detection and assessment on various clinical sites.
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Affiliation(s)
- Li Chen
- Department of Electrical and Computer Engineering, University of Washington, Seattle, Washington, USA
| | - Huilin Zhao
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongjian Jiang
- Department of Electrical and Computer Engineering, University of Washington, Seattle, Washington, USA
| | - Niranjan Balu
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | | | - Baocheng Chu
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Hiroko Watase
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Xihai Zhao
- Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
| | - Rui Li
- Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
| | - Jianrong Xu
- Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Thomas S Hatsukami
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Dongxiang Xu
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Jenq-Neng Hwang
- Department of Electrical and Computer Engineering, University of Washington, Seattle, Washington, USA
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, Washington, USA
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5
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Sun Y, Xu L, Jiang Y, Ma M, Wang XY, Xing Y. Significance of high resolution MRI in the identification of carotid plaque. Exp Ther Med 2020; 20:3653-3660. [PMID: 32855717 PMCID: PMC7444342 DOI: 10.3892/etm.2020.9091] [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: 02/04/2020] [Accepted: 07/01/2020] [Indexed: 11/25/2022] Open
Abstract
The stability of carotid artery plaque serves a key role in the occurrence of stroke. The present study was based on the recruitment of patients with acute ischemic cerebrovascular disease. High-resolution magnetic resonance imaging (HR-MRI) was used to identify the nature of carotid artery plaque, and the results were then used to manage the high-risk group of stroke. The patients were divided equally into a symptomatic group (36 cases) and an asymptomatic group (36 cases). According to the degree of carotid artery stenosis, the patients were divided into mild, moderate and severe stenosis groups, each group comprising 12 patients, and HR-MRI was performed. The proportion of patients with vulnerable plaque in the symptomatic group was higher compared with that in the asymptomatic group (P<0.05). The more severe the stenosis, the higher the proportion of vulnerable plaque that was identified (P<0.05). Compared with carotid ultrasound, HR-MRI was indicated to have the capability to both identify and quantify the different components in the plaque, allowing an assessment of its properties. In conclusion, the present study demonstrated that carotid HR-MRI is able to distinguish and quantify the different components of plaque, which may prove to be helpful for the hierarchical management of a population at high risk of stroke.
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Affiliation(s)
- Yong Sun
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Lei Xu
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Yan Jiang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Ming Ma
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Xin-Yi Wang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Ying Xing
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
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6
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Murgia A, Balestrieri A, Francone M, Lucatelli P, Scapin E, Buckler A, Micheletti G, Faa G, Conti M, Suri JS, Guglielmi G, Carriero A, Saba L. Plaque imaging volume analysis: technique and application. Cardiovasc Diagn Ther 2020; 10:1032-1047. [PMID: 32968659 PMCID: PMC7487381 DOI: 10.21037/cdt.2020.03.01] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/15/2020] [Indexed: 12/12/2022]
Abstract
The prevention and management of atherosclerosis poses a tough challenge to public health organizations worldwide. Together with myocardial infarction, stroke represents its main manifestation, with up to 25% of all ischemic strokes being caused by thromboembolism arising from the carotid arteries. Therefore, a vast number of publications have focused on the characterization of the culprit lesion, the atherosclerotic plaque. A paradigm shift appears to be taking place at the current state of research, as the attention is gradually moving from the classically defined degree of stenosis to the identification of features of plaque vulnerability, which appear to be more reliable predictors of recurrent cerebrovascular events. The present review will offer a perspective on the present state of research in the field of carotid atherosclerotic disease, focusing on the imaging modalities currently used in the study of the carotid plaque and the impact that such diagnostic means are having in the clinical setting.
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Affiliation(s)
- Alessandro Murgia
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari – Polo di Monserrato, s.s. 554 Monserrato (Cagliari) 09045, Italy
| | - Antonella Balestrieri
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari – Polo di Monserrato, s.s. 554 Monserrato (Cagliari) 09045, Italy
| | - Marco Francone
- Department of Radiological, Oncological and Anatomopathological Sciences-Radiology, ‘Sapienza’ University of Rome, Rome, Italy
| | - Pierleone Lucatelli
- Department of Radiological, Oncological and Anatomopathological Sciences-Radiology, ‘Sapienza’ University of Rome, Rome, Italy
| | - Elisa Scapin
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari – Polo di Monserrato, s.s. 554 Monserrato (Cagliari) 09045, Italy
| | | | - Giulio Micheletti
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari – Polo di Monserrato, s.s. 554 Monserrato (Cagliari) 09045, Italy
| | - Gavino Faa
- Department of Pathology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari – Polo San Giovanni di Dio, Cagliari (Cagliari) 09045, Italy
| | - Maurizio Conti
- Diagnostic and Monitoring Division, AtheroPoint™ LLC, Roseville, CA, USA
- Department of Electrical Engineering, U of Idaho (Affl.), Idaho, USA
| | - Jasjit S. Suri
- Diagnostic and Monitoring Division, AtheroPoint™ LLC, Roseville, CA, USA
- Department of Electrical Engineering, U of Idaho (Affl.), Idaho, USA
| | | | - Alessandro Carriero
- Department of Radiology, Maggiore della Carità Hospital, Università del Piemonte Orientale, Novara, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari – Polo di Monserrato, s.s. 554 Monserrato (Cagliari) 09045, Italy
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7
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Yang D, Liu Y, Han Y, Li D, Wang W, Li R, Yuan C, Zhao X. Signal of Carotid Intraplaque Hemorrhage on MR T1-Weighted Imaging: Association with Acute Cerebral Infarct. AJNR Am J Neuroradiol 2020; 41:836-843. [PMID: 32273265 DOI: 10.3174/ajnr.a6498] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/29/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Identifying the mere presence of carotid intraplaque hemorrhage would be insufficient to accurately discriminate the presence of acute cerebral infarct. We aimed to investigate the association between signal intensity ratios of carotid intraplaque hemorrhage on T1-weighted MR imaging and acute cerebral infarct in patients with hemorrhagic carotid plaques using MR vessel wall imaging. MATERIALS AND METHODS Symptomatic patients with carotid intraplaque hemorrhage were included. The signal intensity ratios of carotid intraplaque hemorrhage against muscle on T1-weighted, TOF, and MPRAGE images were measured. The acute cerebral infarct was determined on the hemisphere ipsilateral to the carotid intraplaque hemorrhage. The association between signal intensity ratios of carotid intraplaque hemorrhage and acute cerebral infarct was analyzed. RESULTS Of 109 included patients (mean, 66.8 ± 9.9 years of age; 96 men), 40 (36.7%) had acute cerebral infarct. Patients with acute cerebral infarct had significantly higher signal intensity ratios of carotid intraplaque hemorrhage on T1-weighted images than those without (Median, 1.44; 25-75 Percentiles, 1.14-1.82 versus Median, 1.27; 25-75 Percentiles, 1.06-1.55, P = .022). Logistic regression analysis revealed that the signal intensity ratio of carotid intraplaque hemorrhage on T1-weighted images was significantly associated with acute cerebral infarct before (OR, 4.08; 95% CI, 1.34-12.40; P = .013) and after (OR, 3.34; 95% CI, 1.08-10.31; P = .036) adjustment for clinical confounding factors. However, this association was not significant when further adjusted for occlusion of the carotid artery (P = .058) and volumes of intraplaque hemorrhage and lipid-rich necrotic core (P = .458). CONCLUSIONS The signal intensity ratio of carotid intraplaque hemorrhage on T1-weighted images is associated with acute cerebral infarct in symptomatic patients with carotid hemorrhagic plaques. This association is independent of traditional risk factors but not of the size of plaque composition. The possibility of applying T1 signals of carotid intraplaque hemorrhage to predict subsequent cerebrovascular ischemic events needs to be prospectively verified.
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Affiliation(s)
- D Yang
- From the Beijing Institute of Brain Disorders (D.Y., Y.H., D.L.), Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.,Department of Biomedical Engineering (D.Y., Y.H., D.L., R.L., X.Z.), Center for Biomedical Imaging Research, Tsinghua University School of Medicine, Beijing, China
| | - Y Liu
- Department of Radiology (Y.L., W.W.), The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Y Han
- From the Beijing Institute of Brain Disorders (D.Y., Y.H., D.L.), Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.,Department of Biomedical Engineering (D.Y., Y.H., D.L., R.L., X.Z.), Center for Biomedical Imaging Research, Tsinghua University School of Medicine, Beijing, China
| | - D Li
- From the Beijing Institute of Brain Disorders (D.Y., Y.H., D.L.), Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.,Department of Biomedical Engineering (D.Y., Y.H., D.L., R.L., X.Z.), Center for Biomedical Imaging Research, Tsinghua University School of Medicine, Beijing, China
| | - W Wang
- Department of Radiology (Y.L., W.W.), The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - R Li
- Department of Biomedical Engineering (D.Y., Y.H., D.L., R.L., X.Z.), Center for Biomedical Imaging Research, Tsinghua University School of Medicine, Beijing, China
| | - C Yuan
- Department of Radiology (C.Y.), University of Washington, Seattle, Washington
| | - X Zhao
- Department of Biomedical Engineering (D.Y., Y.H., D.L., R.L., X.Z.), Center for Biomedical Imaging Research, Tsinghua University School of Medicine, Beijing, China
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8
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Ziegler M, Good E, Engvall J, Warntjes M, de Muinck E, Dyverfeldt P. Towards Automated Quantification of Vessel Wall Composition Using MRI. J Magn Reson Imaging 2020; 52:710-719. [PMID: 32154973 DOI: 10.1002/jmri.27116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/18/2020] [Accepted: 02/18/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND MRI can be used to generate fat fraction (FF) and R2* data, which have been previously shown to characterize the plaque compositional features lipid-rich necrotic core (LRNC) and intraplaque hemorrhage (IPH) in the carotid arteries (CAs). Previously, these data were extracted from CA plaques using time-consuming manual analyses. PURPOSE To design and demonstrate a method for segmenting the CA and extracting data describing the composition of the vessel wall. STUDY TYPE Prospective. SUBJECTS 31 subjects from the Swedish CArdioPulmonary bioImage Study (SCAPIS). FIELD STRENGTH/SEQUENCES T1 -weighted (T1 W) quadruple inversion recovery, contrast-enhanced MR angiography (CE-MRA), and 4-point Dixon data were acquired at 3T. ASSESSMENT The vessel lumen of the CA was automatically segmented using support vector machines (SVM) with CE-MRA data, and the vessel wall region was subsequently delineated. Automatically generated segmentations were quantitatively measured and three observers visually compared the segmentations to manual segmentations performed on T1 w images. Dixon data were used to generate FF and R2* maps. Both manually and automatically generated segmentations of the CA and vessel wall were used to extract compositional data. STATISTICAL TESTS Two-tailed t-tests were used to examine differences between results generated using manual and automated analyses, and among different configurations of the automated method. Interobserver agreement was assessed with Fleiss' kappa. RESULTS Automated segmentation of the CA using SVM had a Dice score of 0.89 ± 0.02 and true-positive ratio 0.93 ± 0.03 when compared against ground truth, and median qualitative score of 4/5 when assessed visually by multiple observers. Vessel wall regions of 0.5 and 1 mm yielded compositional information similar to that gained from manual analyses. Using the 0.5 mm vessel wall region, the mean difference was 0.1 ± 2.5% considering FF and 1.1 ± 5.7[1/s] for R2*. LEVEL OF EVIDENCE 1. TECHNICAL EFFICACY STAGE 1. J. Magn. Reson. Imaging 2020;52:710-719.
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Affiliation(s)
- Magnus Ziegler
- Cardiovascular Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Elin Good
- Cardiovascular Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Department of Cardiology, Linköping University, Linköping, Sweden
| | - Jan Engvall
- Cardiovascular Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Department of Clinical Physiology, Linköping University, Linköping, Sweden
| | - Marcel Warntjes
- Cardiovascular Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Ebo de Muinck
- Cardiovascular Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Department of Cardiology, Linköping University, Linköping, Sweden
| | - Petter Dyverfeldt
- Cardiovascular Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
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9
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Hajhosseiny R, Bahaei TS, Prieto C, Botnar RM. Molecular and Nonmolecular Magnetic Resonance Coronary and Carotid Imaging. Arterioscler Thromb Vasc Biol 2020; 39:569-582. [PMID: 30760017 DOI: 10.1161/atvbaha.118.311754] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atherosclerosis is the leading cause of cardiovascular morbidity and mortality. Over the past 2 decades, increasing research attention is converging on the early detection and monitoring of atherosclerotic plaque. Among several invasive and noninvasive imaging modalities, magnetic resonance imaging (MRI) is emerging as a promising option. Advantages include its versatility, excellent soft tissue contrast for plaque characterization and lack of ionizing radiation. In this review, we will explore the recent advances in multicontrast and multiparametric imaging sequences that are bringing the aspiration of simultaneous arterial lumen, vessel wall, and plaque characterization closer to clinical feasibility. We also discuss the latest advances in molecular magnetic resonance and multimodal atherosclerosis imaging.
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Affiliation(s)
- Reza Hajhosseiny
- From the School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (R.H., T.S.B., C.P., R.M.B.).,National Heart and Lung Institute, Imperial College London, United Kingdom (R.H.)
| | - Tamanna S Bahaei
- From the School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (R.H., T.S.B., C.P., R.M.B.)
| | - Claudia Prieto
- From the School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (R.H., T.S.B., C.P., R.M.B.).,Escuela de Ingeniería, Pontificia Universidad Catolica de Chile, Santiago, Chile (C.P., R.M.B.)
| | - René M Botnar
- From the School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (R.H., T.S.B., C.P., R.M.B.).,Escuela de Ingeniería, Pontificia Universidad Catolica de Chile, Santiago, Chile (C.P., R.M.B.)
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10
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Xu Y, Li D, Yuan C, Zhou Z, He L, Li R, Cui Y, Li Q, Zheng Z, Zhao X. Association of severity between carotid and intracranial artery atherosclerosis. Ann Clin Transl Neurol 2018; 5:843-849. [PMID: 30009201 PMCID: PMC6043773 DOI: 10.1002/acn3.590] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 01/23/2023] Open
Abstract
Objective This study sought to investigate the relationship of atherosclerosis between intracranial and extracranial carotid arteries using three‐dimensional multicontrast magnetic resonance (MR) vessel wall imaging. Methods Patients with recent cerebrovascular symptoms in anterior circulation were recruited and underwent MR vessel wall imaging for intracranial and extracranial carotid arteries. The plaque burden, including maximum wall thickness (Max WT) and stenosis, and presence of intraplaque hemorrhage (IPH) were assessed. The correlation of the plaque characteristics between intracranial and extracranial carotid arteries was determined. Results In total, 107 patients (mean age: 57.0 ± 11.1 years, 69 males) were recruited. In discriminating intracranial severe stenosis (≥50% stenosis), the odds ratio (OR) of Max WT of extracranial carotid arteries was 1.41 (95% confidence interval [CI], 0.94–2.11, P = 0.095) and 1.72 (95% CI, 1.04–2.83, P = 0.034) before and after adjusting for confounding factors, respectively. The OR of stenosis of extracranial carotid arteries with increment of 10% was 1.26 (95% CI, 0.99–1.60, P = 0.054) and 1.37 (95% CI, 1.03–1.82, P = 0.033) before and after adjusting for confounding factors, in discriminating intracranial severe stenosis respectively. Receiver operating characteristic analysis revealed that the area under the curve (AUC) of Max WT, stenosis, and IPH of extracranial carotid artery plaques was 0.641, 0.605, and 0.603 in discriminating intracranial severe stenosis, respectively. After adjusting for confounding factors, the AUC of Max WT, stenosis, and presence of IPH in extracranial carotid artery plaques increased to 0.812, 0.817 and 0.781, respectively. Interpretation Carotid artery plaque burden is significantly associated with severe intracranial artery stenosis, suggesting that extracranial carotid plaque burden might be an independent indicator for severity of intracranial artery atherosclerosis.
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Affiliation(s)
- Yilan Xu
- Department of RadiologyBeijing Tsinghua Changgung HospitalSchool of Clinical MedicineTsinghua UniversityBeijingChina
| | - Dongye Li
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
- Center for Brain Disorders ResearchCapital Medical University and Beijing Institute for Brain DisordersBeijingChina
| | - Chun Yuan
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
- Department of RadiologyUniversity of WashingtonSeattleWashington
| | - Zechen Zhou
- Philips Research North AmericaCambridgeMassachusetts
| | - Le He
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
| | - Rui Li
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
| | - Yuanyuan Cui
- Department of RadiologyPLA General HospitalBeijingChina
| | - Qing Li
- Department of NeurologyPeople's Hospital of Xinjiang Vygur Autonomous RegionUrumqiChina
| | - Zhuozhao Zheng
- Department of RadiologyBeijing Tsinghua Changgung HospitalSchool of Clinical MedicineTsinghua UniversityBeijingChina
| | - Xihai Zhao
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
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11
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Ball S, Rogers S, Kanesalingam K, Taylor R, Katsogridakis E, McCollum C. Carotid plaque volume in patients undergoing carotid endarterectomy. Br J Surg 2018; 105:262-269. [PMID: 29315509 PMCID: PMC5873399 DOI: 10.1002/bjs.10670] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/10/2017] [Accepted: 07/11/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND The main indication for carotid endarterectomy (CEA) is severity of carotid artery stenosis, even though most strokes in carotid disease are embolic. The relationship between carotid plaque volume (CPV) and symptoms of cerebral ischaemia, and the measurement of CPV by minimally invasive tomographic ultrasound imaging, were investigated. METHODS The volume of the endarterectomy specimen was measured using a validated saline suspension technique in patients undergoing CEA. Time from last symptom and severity of stenosis measured by duplex ultrasonography were recorded. Middle cerebral artery emboli were counted using transcranial Doppler imaging (TCD) in a subset of patients. RESULTS Some 339 patients were included, 270 with symptomatic and 69 with asymptomatic carotid stenosis. Mean(s.d.) CPV was higher in symptomatic than in asymptomatic patients (0·97(0·43) versus 0.74(0·41) cm3 ; P < 0·001). CPV did not correlate with severity of carotid stenosis (P = 0·770). Mean CPV was highest at 1·03(0·46) cm3 in the 4 weeks following cerebral symptoms, declining to 0·78(0·36) cm3 beyond 8 weeks. Among 33 patients who had TCD, mean CPV was 1·00(0·48) cm3 in the 27 patients with ipsilateral cerebral emboli compared with 0·67(0·16) cm3 in those without (P = 0·142). There was excellent correlation between CPV measured by tomographic ultrasound imaging and the endarterectomy specimen in 34 patients (r = 0·93, P < 0·001). CONCLUSION CPV correlated with symptoms of cerebral ischaemia, but not carotid stenosis. It could be a potential indicator for CEA.
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Affiliation(s)
- S Ball
- Academic Surgery Unit, Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - S Rogers
- Academic Surgery Unit, Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK.,Independent Vascular Services Ltd, University Hospital of South Manchester, Manchester, UK
| | - K Kanesalingam
- Academic Surgery Unit, Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - R Taylor
- Academic Surgery Unit, Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - E Katsogridakis
- Academic Surgery Unit, Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - C McCollum
- Academic Surgery Unit, Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
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12
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Sun R, Wang L, Guan C, Cao W, Tian B. Carotid Atherosclerotic Plaque Features in Patients with Acute Ischemic Stroke. World Neurosurg 2018; 112:e223-e228. [PMID: 29325936 DOI: 10.1016/j.wneu.2018.01.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 01/02/2018] [Accepted: 01/04/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate the carotid atherosclerotic plaque features in patients with acute ischemic stroke. METHODS A total of 288 patients meeting the included criteria were enrolled and divided into an ulcerated plaque group (n = 139) and a nonulcerated plaque group (n = 149). Patients in the ulcerated plaque group were further subdivided into <50% and ≥50% stenosis groups. Carotid plaque component characteristics including luminal stenosis, carotid plaque volume, hypoechoic plaque volume, and hyperechoic plaque volume were analyzed by color Doppler ultrasound measurement. Associations between ulcerated plaque and carotid plaque features were also evaluated. The relationships among the levels of MMP-9, hs-CRP, and carotid stenosis rate were detected by enzyme-linked immunosorbent assay. RESULTS The plaque volume, hypoechoic plaque volume, and luminal stenosis in the ulcerated plaque group were higher than that of the nonulcerated plaque group (P < 0.05). Ulcerated plaque was positively associated with luminal stenosis, plaque volume, and hypoechoic plaque volume after adjusting for sex and age. The result remained similar after adjusting for age, sex, and carotid luminal stenosis. The levels of MMP-9 and hs-CRP in the ulcerated plaque group were significantly higher than those of the nonulcerated plaque group (P < 0.01). For the ulcerated plaque group, the higher the carotid stenosis rate, the higher the level of MMP-9 and hs-CRP. CONCLUSIONS Higher carotid atherosclerosis plaque volume, hypoechoic plaque volume, and luminal carotid stenosis may be symptoms of ulcerated plaque. Increased MMP-9 and hs-CRP levels could be used as adjunctive therapies of carotid stenosis at the molecular level.
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Affiliation(s)
- Runming Sun
- Department of Neurology, People's Hospital of Linzi District, Affiliated to Binzhou Medical College, Zibo, China.
| | - Lixia Wang
- Department of Endocrinology, People's Hospital of Linzi District, Affiliated to Binzhou Medical College, Zibo, China
| | - Cuiling Guan
- Department of Neurology, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
| | - Wenyuan Cao
- Department of Neurology, People's Hospital of Linzi District, Affiliated to Binzhou Medical College, Zibo, China
| | - Bing Tian
- Department of Ultrasonography, People's Hospital of Linzi District, Affiliated to Binzhou Medical College, Zibo, China
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13
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Cai Y, He L, Yuan C, Chen H, Zhang Q, Li R, Li C, Zhao X. Atherosclerotic plaque features and distribution in bilateral carotid arteries of asymptomatic elderly population: A 3D multicontrast MR vessel wall imaging study. Eur J Radiol 2017; 96:6-11. [DOI: 10.1016/j.ejrad.2017.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 07/28/2017] [Accepted: 09/08/2017] [Indexed: 11/27/2022]
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14
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Kerwin WS, Miller Z, Yuan C. Imaging of the high-risk carotid plaque: magnetic resonance imaging. Semin Vasc Surg 2017; 30:54-61. [PMID: 28818259 DOI: 10.1053/j.semvascsurg.2017.04.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The emergence of the concept of high-risk atherosclerotic plaque has led to considerable interest in noninvasive imaging techniques to identify high-risk features before clinical sequelae. For plaques in the carotid arteries, magnetic resonance imaging has undergone considerable histologic validation to link imaging features to indicators of plaque instability, including plaque burden, intraplaque hemorrhage, fibrous cap disruption, lipid rich necrotic core, and calcification. Recently introduced imaging technologies, especially those focused on three-dimensional imaging sequences, are now poised for integration into the clinical workup of patients with suspected carotid atherosclerosis. The purpose of this article is to review the carotid plaque magnetic resonance imaging techniques that are most ready for integration into the clinic.
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Affiliation(s)
- William S Kerwin
- University of Washington Vascular Imaging Lab, Department of Radiology, 850 Republican Street, Seattle, WA 98109
| | - Zach Miller
- University of Washington Vascular Imaging Lab, Department of Radiology, 850 Republican Street, Seattle, WA 98109
| | - Chun Yuan
- University of Washington Vascular Imaging Lab, Department of Radiology, 850 Republican Street, Seattle, WA 98109.
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15
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Chițu M, Benedek T, Rat N, Hodas R, Mester A, Benedek A, Bordi L, Benedek I. Low-Density Carotid Plaques and the Risk of Stroke. JOURNAL OF INTERDISCIPLINARY MEDICINE 2017. [DOI: 10.1515/jim-2017-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractIschemic stroke is the second cause of death worldwide, and at least a quarter of all ischemic strokes are associated with carotid atherosclerotic disease, the diagnosis of which relies primarily on imaging methods. Traditional risk assessment in carotid atherosclerotic disease has long been based on the measurement of stenosis severity, but there is strong evidence that only stenosis grading falls short in predicting near-future events. Moreover, numerous histopathologic studies gathered increasing evidence that plaque vulnerability depends on its composition and morphology, therefore, the new concept of “vulnerable plaque” analysis is necessary, independent of the carotid narrowing. Follow-up studies concluded that the presence of a large-lipid necrotic core and thin fibrous cap are significantly more likely to result in future ischemic events and thereby are hallmarks for unstable lesions. Under these conditions, magnetic resonance imaging (MRI) and multi-detector computed tomography (MDCT) characterization of specific plaque properties can provide additional information on ischemic stroke risk that are not provided by the simple measurement of luminal stenosis. Therefore, besides the stenosis degree, plaque morphology assessment using noninvasive methods could be useful to identify rupture-prone plaques and may be a suitable prognosis tool that will help improve risk stratification and the effectiveness of therapeutic strategies.
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16
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Zhao X, Li R, Hippe DS, Hatsukami TS, Yuan C. Chinese Atherosclerosis Risk Evaluation (CARE II) study: a novel cross-sectional, multicentre study of the prevalence of high-risk atherosclerotic carotid plaque in Chinese patients with ischaemic cerebrovascular events-design and rationale. Stroke Vasc Neurol 2017; 2:15-20. [PMID: 28959486 PMCID: PMC5435211 DOI: 10.1136/svn-2016-000053] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 11/30/2016] [Indexed: 12/11/2022] Open
Abstract
Background Carotid atherosclerotic plaque is identified as one of the main sources of ischaemic stroke. However, the prevalence of carotid high-risk atherosclerotic plaque in Chinese patients with ischaemic cerebrovascular events has been inconsistently reported and needs to be investigated in a large population. Objectives The primary objective of CARE II study was to determine the prevalence and characteristics of high-risk features of atherosclerotic plaques in the carotid arteries in Chinese patients with recent ischaemic stroke or transient ischaemia attack (TIA). The relationship between carotid plaque features and cerebral infarcts, the differences of carotid plaque patterns among different regions of China and the gender specific characteristics of carotid plaque will be also determined. Study design The CARE II study will enrol 1000 patients with recent ischaemic stroke or TIA and carotid plaque from 13 hospitals and medical centres across China. In this cross-sectional, non-randomised, observational, multicentre study, all patients will undergo carotid artery MRI of bilateral carotid arteries and routine brain MRI with standardised protocols. The MRI will be interpreted at core reading centres to evaluate the characteristics of morphology and compositions of carotid plaque. Conclusions This is a cross-sectional, multicentre study to investigate the prevalence and characteristics of high-risk atherosclerotic carotid plaque in Chinese patients with stroke and TIA by using high-resolution MRI of vessel wall. This trial is sufficiently powered to demonstrate the prevalence of carotid high-risk plaque and to explore regional differences in Chinese patients who suffered stroke. Trial registration number NCT02017756.
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Affiliation(s)
- Xihai Zhao
- Department of Biomedical Engineering, Center for Biomedical Imaging Research, Tsinghua University School of Medicine, Beijing, China
| | - Rui Li
- Department of Biomedical Engineering, Center for Biomedical Imaging Research, Tsinghua University School of Medicine, Beijing, China
| | - Daniel S Hippe
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Thomas S Hatsukami
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Chun Yuan
- Department of Biomedical Engineering, Center for Biomedical Imaging Research, Tsinghua University School of Medicine, Beijing, China.,Department of Radiology, University of Washington, Seattle, Washington, USA
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17
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Alagoz AN, Acar BA, Acar T, Karacan A, Demiryürek BE. Relationship Between Carotid Stenosis and Infarct Volume in Ischemic Stroke Patients. Med Sci Monit 2016; 22:4954-4959. [PMID: 27984560 PMCID: PMC5189723 DOI: 10.12659/msm.898112] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Stroke is a serious health problem all over the world. Ischemia causes 85% of strokes and 75% of these ischemic strokes occur within the area supplied by the internal carotid artery (ICA). Material/Methods This study included 47 acute stroke patients who were in the large-artery atherosclerosis group according to Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification and who had an infarct in the area supplied by the internal carotid artery. We sought to determine whether there was a significant correlation between the infarct volume of the patients as measured by diffusion-weighted magnetic resonance imaging (DW MRI), their National Institutes of Health Stroke Scale (NIHSS), and degree of carotid stenosis as identified by carotid computed tomography angiography (CTA). Results A significant correlation was observed between the percentage of carotid artery stenosis and infarct volume (p<0.001). In addition, there was a significant positive correlation between the NIHSS and infarct volume; the correlation was of moderate strength (r=0.366, p=0.001). Conclusions Our findings indicate that the percentage of carotid artery stenosis could be useful in predicting the infarct volume of the stroke.
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Affiliation(s)
| | | | - Türkan Acar
- Department of Neurology, Sakarya University, Faculty of Medicine, Sakarya, Turkey
| | - Alper Karacan
- Department of Radiology, Sakarya University, Faculty of Medicine, Sakarya, Turkey
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18
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Sun J, Hatsukami TS. Plaque Imaging to Decide on Optimal Treatment: Medical Versus Carotid Endarterectomy Versus Carotid Artery Stenting. Neuroimaging Clin N Am 2016; 26:165-73. [PMID: 26610667 DOI: 10.1016/j.nic.2015.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Many of the current guidelines for the management of carotid atherosclerosis are based on clinical trial findings published more than 2 decades ago. The lack of plaque information in clinical decision making represents a major shortcoming and highlights the need for contemporary trials based on characteristics of the atherosclerotic lesion itself, rather than luminal stenosis alone. This article summarizes the major dilemmas clinicians face in current practice, and discusses the rationale and evidence that plaque imaging may help to address these challenges and optimize the clinical management of carotid artery disease in the future.
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Affiliation(s)
- Jie Sun
- Department of Radiology, University of Washington, 850 Republican Street, Seattle, WA 98109, USA
| | - Thomas S Hatsukami
- Department of Surgery, University of Washington, 850 Republican Street, Seattle, WA 98109, USA.
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19
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Koppal S, Warntjes M, Swann J, Dyverfeldt P, Kihlberg J, Moreno R, Magee D, Roberts N, Zachrisson H, Forssell C, Länne T, Treanor D, de Muinck ED. Quantitative fat and R2* mapping in vivo to measure lipid-rich necrotic core and intraplaque hemorrhage in carotid atherosclerosis. Magn Reson Med 2016; 78:285-296. [PMID: 27510300 DOI: 10.1002/mrm.26359] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 06/29/2016] [Accepted: 07/07/2016] [Indexed: 11/08/2022]
Abstract
PURPOSE The aim of this work was to quantify the extent of lipid-rich necrotic core (LRNC) and intraplaque hemorrhage (IPH) in atherosclerotic plaques. METHODS Patients scheduled for carotid endarterectomy underwent four-point Dixon and T1-weighted magnetic resonance imaging (MRI) at 3 Tesla. Fat and R2* maps were generated from the Dixon sequence at the acquired spatial resolution of 0.60 × 0.60 × 0.70 mm voxel size. MRI and three-dimensional (3D) histology volumes of plaques were registered. The registration matrix was applied to segmentations denoting LRNC and IPH in 3D histology to split plaque volumes in regions with and without LRNC and IPH. RESULTS Five patients were included. Regarding volumes of LRNC identified by 3D histology, the average fat fraction by MRI was significantly higher inside LRNC than outside: 12.64 ± 0.2737% versus 9.294 ± 0.1762% (mean ± standard error of the mean [SEM]; P < 0.001). The same was true for IPH identified by 3D histology, R2* inside versus outside IPH was: 71.81 ± 1.276 s-1 versus 56.94 ± 0.9095 s-1 (mean ± SEM; P < 0.001). There was a strong correlation between the cumulative fat and the volume of LRNC from 3D histology (R2 = 0.92) as well as between cumulative R2* and IPH (R2 = 0.94). CONCLUSION Quantitative mapping of fat and R2* from Dixon MRI reliably quantifies the extent of LRNC and IPH. Magn Reson Med 78:285-296, 2017. © 2016 International Society for Magnetic Resonance in Medicine.
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Affiliation(s)
- Sandeep Koppal
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Marcel Warntjes
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,SyntheticMR AB, Linköping, Sweden
| | - Jeremy Swann
- School of Computing, University of Leeds, Leeds, United Kingdom
| | - Petter Dyverfeldt
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Johan Kihlberg
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Department of Radiology, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Rodrigo Moreno
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,KTH, Royal Institute of Technology, Stockholm, Sweden
| | - Derek Magee
- School of Computing, University of Leeds, Leeds, United Kingdom
| | - Nicholas Roberts
- Division of Brain Sciences, Department of Medicine, Institute of Neurology, Imperial College, London, United Kingdom
| | - Helene Zachrisson
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Claes Forssell
- Department of Thoracic and Vascular Surgery, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Toste Länne
- Department of Thoracic and Vascular Surgery, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Darren Treanor
- Department of Pathology and Tumor Biology, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, United Kingdom.,Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Ebo D de Muinck
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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21
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Huang C, Pan X, He Q, Huang M, Huang L, Zhao X, Yuan C, Bai J, Luo J. Ultrasound-Based Carotid Elastography for Detection of Vulnerable Atherosclerotic Plaques Validated by Magnetic Resonance Imaging. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:365-377. [PMID: 26553205 DOI: 10.1016/j.ultrasmedbio.2015.09.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 08/27/2015] [Accepted: 09/23/2015] [Indexed: 06/05/2023]
Abstract
Ultrasound-based carotid elastography has been developed to estimate the mechanical properties of atherosclerotic plaques. The objective of this study was to evaluate the in vivo capability of carotid elastography in vulnerable plaque detection using high-resolution magnetic resonance imaging as reference. Ultrasound radiofrequency data of 46 carotid plaques from 29 patients (74 ± 5 y old) were acquired and inter-frame axial strain was estimated with an optical flow method. The maximum value of absolute strain rate for each plaque was derived as an indicator for plaque classification. Magnetic resonance imaging of carotid arteries was performed on the same patients to classify the plaques into stable and vulnerable groups for carotid elastography validation. The maximum value of absolute strain rate was found to be significantly higher in vulnerable plaques (2.15 ± 0.79 s(-1), n = 27) than in stable plaques (1.21 ± 0.37 s(-1), n = 19) (p < 0.0001). Receiver operating characteristic curve analysis was performed, and the area under the curve was 0.848. Therefore, the in vivo capability of carotid elastography to detect vulnerable plaques, validated by magnetic resonance imaging, was proven, revealing the potential of carotid elastography as an important tool in atherosclerosis assessment and stroke prevention.
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Affiliation(s)
- Chengwu Huang
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China; Center for Biomedical Imaging Research, Tsinghua University, Beijing, China
| | - Xiaochang Pan
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China; Center for Biomedical Imaging Research, Tsinghua University, Beijing, China
| | - Qiong He
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China; Center for Biomedical Imaging Research, Tsinghua University, Beijing, China
| | - Manwei Huang
- Department of Sonography, China Meitan General Hospital, Beijing, China
| | - Lingyun Huang
- Clinical Sites Research Program, Philips Research China, Shanghai, China
| | - Xihai Zhao
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China; Center for Biomedical Imaging Research, Tsinghua University, Beijing, China.
| | - Chun Yuan
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China; Center for Biomedical Imaging Research, Tsinghua University, Beijing, China; Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Jing Bai
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Jianwen Luo
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China; Center for Biomedical Imaging Research, Tsinghua University, Beijing, China.
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22
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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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Clinical factors associated with high-risk carotid plaque features as assessed by magnetic resonance imaging in patients with established vascular disease (from the AIM-HIGH Study). Am J Cardiol 2014; 114:1412-9. [PMID: 25245415 DOI: 10.1016/j.amjcard.2014.08.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 08/01/2014] [Accepted: 08/01/2014] [Indexed: 11/23/2022]
Abstract
Association between clinical factors and high-risk plaque features, such as, thin or ruptured cap, intraplaque hemorrhage, presence of lipid-rich necrotic core (LRNC), and increased LRNC volume as assessed by magnetic resonance imaging (MRI), was examined in patients with established vascular disease in the Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides (AIM-HIGH) trial. A total of 214 subjects underwent carotid MRI and had acceptable image quality for assessment of plaque burden, tissue contents, and MRI-modified American Heart Association lesion type by a core laboratory. We found that 77% of subjects had carotid plaques, 52% had lipid-containing plaques, and 11% had advanced American Heart Association type-VI lesions with possible surface defect, intraplaque hemorrhage, or mural thrombus. Type-VI lesions were associated with older age (odds ratio [OR] = 2.6 per 5 years increase, p <0.001). After adjusting for age, these lesions were associated with history of cerebrovascular disease (OR = 4.1, p = 0.01), higher levels of lipoprotein(a) (OR = 2.0 per 1 SD increase, p = 0.02), and larger percent wall volume (PWV [OR = 4.6 per 1 SD increase, p <0.001]) but, were negatively associated with metabolic syndrome (OR = 0.2, p = 0.02). Presence of LRNC was associated with the male gender (OR = 3.2, p = 0.02) and PWV (OR = 3.8 per 1 SD, p <0.001); however, it was negatively associated with diabetes (OR = 0.4, p = 0.02) and high-density lipoprotein cholesterol levels (OR = 0.7 per 1 SD, p = 0.02). Increased percent LRNC was associated with PWV (regression coefficient = 0.36, p <0.001) and negatively associated with ApoA1 levels (regression coefficient = -0.20, p = 0.03). In conclusion, older age, male gender, history of cerebrovascular disease, larger plaque burden, higher lipoprotein(a), and lower high-density lipoprotein cholesterol or ApoA1 level have statistically significant associations with high-risk plaque features. Metabolic syndrome and diabetes showed negative associations in this population.
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Du R, Cai J, Zhao XQ, Wang QJ, Liu DQ, Leng WX, Gao P, Wu HM, Ma L, Ye P. Early decrease in carotid plaque lipid content as assessed by magnetic resonance imaging during treatment of rosuvastatin. BMC Cardiovasc Disord 2014; 14:83. [PMID: 25022285 PMCID: PMC4107586 DOI: 10.1186/1471-2261-14-83] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 06/26/2014] [Indexed: 12/05/2022] Open
Abstract
Background Statin therapy has shown to deplete atherosclerotic plaque lipid content and induce plaque regression. However, how early the plaque lipid depletion can occur with low-density lipoprotein cholesterol (LDL-C) lowering in humans in vivo has not been fully described. Methods We enrolled 43 lipid treatment naïve subjects with asymptomatic carotid atherosclerosis and LDL-C ≥ 100 and ≤ 250 mg/dl. Rosuvastatin 5–20 mg/day was used to lower LDL-C levels to < 80 mg/dl. Lipid profile and carotid MRI scans were obtained at baseline, 3, 12, and 24 months. Carotid plaque lipid-rich necrotic core (LRNC) and plaque burden were measured and compared between baseline and during treatment. Results Among the 32 subjects who completed the study, at 3 months, an average dose of rosuvastatin of 11 mg/day lowered LDL-C levels by 47% (125.2 ± 24.4 mg/dl vs. 66.7 ± 17.3 mg/dl, p < 0.001). There were no statistically significant changes in total wall volume, percent wall volume or lumen volume. However, LRNC volume was significantly decreased by 7.9 mm3, a reduction of 7.3% (111.5 ± 104.2 mm3 vs. 103.6 ± 95.8 mm3, p = 0.044). Similarly, % LRNC was also significantly decreased from 18.9 ± 11.9% to 17.9 ± 11.5% (p = 0.02) at 3 months. Both LRNC volume and % LRNC continued to decrease moderately at 12 and 24 months, although this trend was not significant. Conclusions Among a small number of lipid treatment naïve subjects, rosuvastatin therapy may induce a rapid and lasting decrease in carotid plaque lipid content as assessed by MRI. Trial registration ClinicalTrials.Gov numbers NCT00885872
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Affiliation(s)
| | | | | | | | | | | | | | | | - Lin Ma
- Department of Geriatric Cardiology, Chinese PLA General Hospital, No, 28, Fuxing Road, Beijing 100853, China.
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Xu D, Hippe DS, Underhill HR, Oikawa-Wakayama M, Dong L, Yamada K, Yuan C, Hatsukami TS. Prediction of high-risk plaque development and plaque progression with the carotid atherosclerosis score. JACC Cardiovasc Imaging 2014; 7:366-73. [PMID: 24631510 DOI: 10.1016/j.jcmg.2013.09.022] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 09/13/2013] [Accepted: 09/19/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The goal of this prospective study was to evaluate the carotid atherosclerosis score (CAS) for predicting the development of high-risk plaque features and plaque burden progression. BACKGROUND Previous studies have shown that carotid intraplaque hemorrhage (IPH) and a disrupted luminal surface (DLS), as identified by using magnetic resonance imaging, are associated with greater risk for cerebrovascular events. On the basis of data from a large cross-sectional study, a scoring system was developed to determine which plaque features are associated with the presence of IPH and DLS. However, the predictive value of CAS has not been previously tested in a prospective, longitudinal study. METHODS A total of 120 asymptomatic subjects with 50% to 79% carotid stenosis underwent carotid magnetic resonance imaging scans at baseline and 3 years thereafter. Presence of IPH and DLS, wall volume, maximum wall thickness, and maximum percent lipid-rich necrotic core area were measured at both time-points. Baseline CAS values were calculated on the basis of previously published criteria. RESULTS Of the 73 subjects without IPH or DLS at baseline, 9 (12%) developed 1 or both of these features during follow-up. There was a significant increasing trend between CAS and the development of new DLS (p < 0.001) and with plaque burden progression (p = 0.03) but not with the development of new IPH (p = 0.3). Percent carotid stenosis was not significantly associated with new DLS (p = 0.2), new IPH (p = 0.1), or plaque progression (p = 0.6). CONCLUSIONS CAS was found to have a significant increasing relationship with incident DLS and plaque progression in this prospective study. CAS can potentially provide improved risk stratification beyond luminal stenosis.
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Affiliation(s)
- Dongxiang Xu
- Department of Radiology, University of Washington, Seattle, Washington
| | - Daniel S Hippe
- Department of Radiology, University of Washington, Seattle, Washington
| | - Hunter R Underhill
- Departments of Neurological Surgery and Medicine, University of Washington, Seattle, Washington
| | | | - Li Dong
- Department of Radiology, Anzhen Hospital, Beijing, China
| | - Kiyofumi Yamada
- Department of Radiology, University of Washington, Seattle, Washington
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, Washington
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Zhao H, Zhao X, Liu X, Cao Y, Hippe DS, Sun J, Li F, Xu J, Yuan C. Association of carotid atherosclerotic plaque features with acute ischemic stroke: a magnetic resonance imaging study. Eur J Radiol 2013; 82:e465-70. [PMID: 23680156 DOI: 10.1016/j.ejrad.2013.04.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 04/15/2013] [Accepted: 04/17/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE It remains unclear whether direct vessel wall imaging can identify carotid high-risk lesions in symptomatic subjects and whether carotid plaque characteristics are more effective indicators for cerebral infarct severity than stenosis. This study sought to determine the associations of carotid plaque characteristics by MR imaging with stenosis and acute cerebral infarct (ACI) sizes on diffusion weighted imaging (DWI). MATERIALS AND METHODS One hundred and fourteen symptomatic patients underwent carotid and brain MRI. ACI volume was determined from symptomatic internal carotid artery territory on DWI images. Ipsilateral carotid plaque morphological and compositional characteristics, and stenosis were also determined. The relationships between carotid plaque characteristics, stenosis and ACIs size were then evaluated. RESULTS In carotid arteries with 30-49% stenosis, 86.7% and 26.7% were found to have lipid-rich necrotic core (LRNC) and intraplaque hemorrhage, respectively. Furthermore, 45.8% of carotid arteries with 0-29% stenosis developed LRNCs. Carotid morphological measurements, such as % wall volume, and the LRNC size were significantly associated with ipsilateral ACIs volume before and after adjustment for significant demographic factors (age and LDL) or stenosis in patients with carotid plaque (all p<0.05). CONCLUSIONS A substantial number of high-risk plaques characterized by vessel wall imaging exist in carotid arteries with lower grade stenosis. In addition, carotid plaque characteristics, particularly the % wall volume and LRNC size, are independently associated with cerebral infarction as measured by DWI lesions. Our findings indicate that characterizing atherosclerotic plaque by MR vessel wall imaging might be useful for stratification of plaque risk and infarction severity.
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Affiliation(s)
- Huilin Zhao
- Department of Radiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
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Abstract
OBJECTIVE Although MRI is widely used to observe atherosclerosis impacts on the vessel lumen, MRI also depicts the size of the plaque itself, its composition, and plaque inflammation, providing information beyond simple stenosis. This article summarizes the state of evidence for a clinical role for MRI of carotid atherosclerosis. CONCLUSION MRI of carotid atherosclerosis has a proven role in pharmaceutical trials and may improve patient management once large-scale clinical trials have been completed.
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Sun J, Underhill HR, Hippe DS, Xue Y, Yuan C, Hatsukami TS. Sustained acceleration in carotid atherosclerotic plaque progression with intraplaque hemorrhage: a long-term time course study. JACC Cardiovasc Imaging 2013; 5:798-804. [PMID: 22897993 DOI: 10.1016/j.jcmg.2012.03.014] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 03/08/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study sought to determine the immediate and long-term effects of intraplaque hemorrhage (IPH) on plaque progression in the carotid artery. BACKGROUND Previous studies have associated IPH in the carotid artery with more rapid plaque progression. However, the time course and long-term effect remain unknown. Carotid magnetic resonance imaging is a noninvasive imaging technique that has been validated with histology for the accurate in vivo detection of IPH and measurement of plaque burden. METHODS Asymptomatic subjects with 50% to 79% carotid stenosis underwent carotid magnetic resonance imaging at baseline and then serially every 18 months for a total of 54 months. Subjects with IPH present in at least 1 carotid artery at 54 months were selected. Subsequently, presence/absence of IPH and wall volume were determined independently in all time points for both sides. A piece-wise progression curve was fit by using a linear mixed model to compare progression rates described as annualized changes in wall volume between periods defined by their relationship to IPH development. RESULTS From 14 subjects who exhibited IPH at 54 months, 12 arteries were found to have developed IPH during the study period. The progression rates were -20.5 ± 13.1, 20.5 ± 13.6, and 16.5 ± 10.8 mm(3)/year before, during, and after IPH development, respectively. The progression rate during IPH development tended to be higher than the period before (p = 0.080) but comparable to the period after (p = 0.845). The progression rate in the combined period during/after IPH development was 18.3 ± 6.5 mm(3)/year, which indicated significant progression (p = 0.008 compared with a slope of 0) and was higher than the period before IPH development (p = 0.018). No coincident ischemic events were noted for new IPH. CONCLUSIONS The development of IPH posed an immediate and long-term promoting effect on plaque progression. IPH seems to alter the biology and natural history of carotid atherosclerosis. Early identification of patients with IPH may prove invaluable in optimizing management to minimize future sequelae.
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Affiliation(s)
- Jie Sun
- Department of Radiology, University of Washington, Seattle, WA, USA
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Yamada K, Song Y, Hippe DS, Sun J, Dong L, Xu D, Ferguson MS, Chu B, Hatsukami TS, Chen M, Zhou C, Yuan C. Quantitative evaluation of high intensity signal on MIP images of carotid atherosclerotic plaques from routine TOF-MRA reveals elevated volumes of intraplaque hemorrhage and lipid rich necrotic core. J Cardiovasc Magn Reson 2012; 14:81. [PMID: 23194180 PMCID: PMC3552725 DOI: 10.1186/1532-429x-14-81] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 11/16/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Carotid intraplaque hemorrhage (IPH) and lipid rich necrotic core (LRNC) have been associated with accelerated plaque growth, luminal narrowing, future surface disruption and development of symptomatic events. The aim of this study was to evaluate the quantitative relationships between high intensity signals (HIS) in the plaque on TOF-MRA and IPH or LRNC volumes as measured by multicontrast weighted CMR. METHODS Seventy six patients with a suspected carotid artery stenosis or carotid plaque by ultrasonography underwent multicontrast carotid CMR. HIS presence and volume were measured from TOF-MRA MIP images while IPH and LRNC volumes were separately measured from multicontrast CMR. RESULTS For detecting IPH, HIS on MIP images overall had high specificity (100.0%, 95% CI: 93.0 - 100.0%) but relatively low sensitivity (32%, 95% CI: 20.8 - 47.9%). However, the sensitivity had a significant increasing relationship with underlying IPH volume (p = 0.033) and degree of stenosis (p = 0.022). Mean IPH volume was 2.7 times larger in those with presence of HIS than in those without (142.8 ± 97.7 mm(3) vs. 53.4 ± 56.3 mm(3), p = 0.014). Similarly, mean LRNC volume was 3.4 times larger in those with HIS present (379.8 ± 203.4 mm(3) vs. 111.3 ± 122.7 mm(3), p = 0.001). There was a strong correlation between the volume of the HIS region and the IPH volume measured from multicontrast CMR (r = 0.96, p < 0.001). CONCLUSION MIP images are easily reformatted from three minute, routine, clinical TOF sequences. High intensity signals in carotid plaque on TOF-MRA MIP images are associated with increased intraplaque hemorrhage and lipid-rich necrotic core volumes. The technique is most sensitive in patients with moderate to severe stenosis.
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Affiliation(s)
- Kiyofumi Yamada
- Department of Radiology, University of Washington, 815 Mercer St, Seattle, WA 98109-4325, USA
| | - Yan Song
- Department of Radiology, Beijing Hospital, Beijing, China
| | - Daniel S Hippe
- Department of Radiology, University of Washington, 815 Mercer St, Seattle, WA 98109-4325, USA
| | - Jie Sun
- Department of Radiology, University of Washington, 815 Mercer St, Seattle, WA 98109-4325, USA
| | - Li Dong
- Department of Radiology, University of Washington, 815 Mercer St, Seattle, WA 98109-4325, USA
| | - Dongxiang Xu
- Department of Radiology, University of Washington, 815 Mercer St, Seattle, WA 98109-4325, USA
| | - Marina S Ferguson
- Department of Radiology, University of Washington, 815 Mercer St, Seattle, WA 98109-4325, USA
| | - Baocheng Chu
- Department of Radiology, University of Washington, 815 Mercer St, Seattle, WA 98109-4325, USA
| | | | - Min Chen
- Department of Radiology, Beijing Hospital, Beijing, China
| | - Cheng Zhou
- Department of Radiology, Beijing Hospital, Beijing, China
| | - Chun Yuan
- Department of Radiology, University of Washington, 815 Mercer St, Seattle, WA 98109-4325, USA
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Kerwin WS. Carotid artery disease and stroke: assessing risk with vessel wall MRI. ISRN CARDIOLOGY 2012; 2012:180710. [PMID: 23209940 PMCID: PMC3504380 DOI: 10.5402/2012/180710] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 10/03/2012] [Indexed: 11/23/2022]
Abstract
Although MRI is widely used to diagnose stenotic carotid arteries, it also detects characteristics of the atherosclerotic plaque itself, including its size, composition, and activity. These features are emerging as additional risk factors for stroke that can be feasibly acquired clinically. This paper summarizes the state of evidence for a clinical role for MRI of carotid atherosclerosis.
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Affiliation(s)
- William S Kerwin
- Department of Radiology, University of Washington, Seattle, WA 98109, USA ; VPDiagnostics Incorporation, Seattle, WA 98101, USA
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Fei W, Tong T, Yifeng P, Jingli T, Weizhong G, Guangyu T, Daoying G, Yingsheng C. A modified rabbit model of carotid atherosclerotic plaque suitable for the stroke study and MRI evaluation. Int J Neurosci 2011; 121:662-9. [PMID: 21793783 DOI: 10.3109/00207454.2011.608138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In order to induce a modified rabbit model of carotid atherosclerotic plaque suitable for the stroke study and to evaluate the lesion with magnetic resonance imaging (MRI). Eight rabbits of group A were fed with high-fat diet only. Atherosclerosis at the right common carotid artery was induced in rabbits of group B (n = 12) by high-fat diet and balloon catheter injury to the endothelium 4 weeks later. The rabbits were examined in vivo with a 1.5-T MRI. After 4 weeks on the high-fat diet, the serum lipid levels were markedly increased, which became significantly higher than the baseline levels. The lesions on both MRI and histology were remarkable. One week after balloon injury, the signal of injured right common carotid was higher on all the contrast-weighted images than the left side. The extent of abnormal signal was reduced 9 weeks after balloon injury. Hemorrhage was detected on all the contrast-weighted images. In conclusion, the rabbit model established by the authors is such a feasible one to the study of stroke caused by carotid atherosclerosis.
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Affiliation(s)
- Wang Fei
- Department of Radiology, Tenth People's Hospital, Tongji University, Shanghai, China.
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Cheung HMC, Moody AR, Singh N, Bitar R, Zhan J, Leung G. Late stage complicated atheroma in low-grade stenotic carotid disease: MR imaging depiction--prevalence and risk factors. Radiology 2011; 260:841-7. [PMID: 21734157 DOI: 10.1148/radiol.11101652] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine if complicated plaque can be found by using magnetic resonance (MR) imaging-depicted intraplaque hemorrhage (IPH), even among symptomatic patients with low-grade (≤50%) carotid stenosis. MATERIALS AND METHODS The institutional ethics review board approved this retrospective study and waived requirements for written informed consent. Symptomatic patients with bilateral 0%-50% carotid stenosis referred for carotid MR imaging were considered. Risk factors (age, sex, hypertension, diabetes, hyperlipidemia, myocardial infarction, atrial fibrillation, smoking, coronary artery disease, and cerebrovascular disease), medications (antihypertensive drugs, diabetes drugs, statins, and aspirin), and the brain side causing symptoms were recorded. MR-depicted IPH prevalence in the carotid arteries ipsilateral and contralateral to the symptomatic side was compared by using the Fisher exact test. Multivariable regression was used to compare the MR-depicted IPH prevalence, while adjusting for risk factors and medications. RESULTS A total of 217 patients (434 carotid arteries) were included. MR-depicted IPH was found in 13% (31 of 233) of carotid arteries ipsilateral and 7% (14 of 201) of arteries contralateral to symptoms (P < .05). Male sex (P < .05) and increasing age (P < .05) were associated with MR-depicted IPH after controlling for risk factors and medications. CONCLUSION Complicated carotid atheroma can be found among symptomatic patients with low-grade (≤50%) stenosis, and this is associated with male sex and increasing age. MR-depicted IPH may be useful to stratify risk for patients with low-grade carotid stenosis.
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Affiliation(s)
- Helen M C Cheung
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, Canada
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What Will Noninvasive Carotid Atherosclerosis Imaging Show Us About High-Risk Coronary Plaques? J Am Coll Cardiol 2011; 58:423-5. [DOI: 10.1016/j.jacc.2011.02.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 02/22/2011] [Indexed: 11/24/2022]
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Underhill HR, Yuan C. Carotid MRI: a tool for monitoring individual response to cardiovascular therapy? Expert Rev Cardiovasc Ther 2011; 9:63-80. [PMID: 21166529 DOI: 10.1586/erc.10.172] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Stroke remains a leading cause of morbidity and mortality. While stroke-related mortality has declined over the past four decades, data indicate that the mortality rate has begun to plateau. This change in trend may be attributable to variation in individual response to therapies that were derived from population-based studies. Further reductions in stroke mortality may require individualized care governed by directly monitoring the effects of cardiovascular therapy. In this article, carotid MRI is considered as a tool for monitoring in vivo carotid atherosclerotic disease, a principal etiology of stroke. Carotid MRI has been previously utilized to identify specific plaque features beyond luminal stenosis that are predictive of transient ischemic attack and stroke. To gain perspective on the possibility of monitoring plaque change within the individual, clinical trials and natural history studies that have used serial carotid MRI are considered. Data from these studies indicate that patients with a lipid-rich necrotic core with or without intraplaque hemorrhage may represent the desired phenotype for monitoring treatment effects in the individual. Advances in tissue-specific sequences, acquisition resolution, scan time, and techniques for monitoring inflammation and mechanical forces are expected to enable earlier detection of response to therapy. In so doing, cost-effective multicenter studies can be conducted to confirm the anticipated positive effects on outcomes of using carotid MRI for individualized care in patients with carotid atherosclerosis. In accordance, carotid MRI is poised to emerge as a powerful clinical tool for individualized management of carotid atherosclerotic disease to prevent stroke.
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Affiliation(s)
- Hunter R Underhill
- Department of Medicine, Division of Medical Genetics, University of Washington, 1705 NE Pacific Street, K253, Box 357720, Seattle, WA 98195, USA.
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Zhao X, Underhill HR, Zhao Q, Cai J, Li F, Oikawa M, Dong L, Ota H, Hatsukami TS, Chu B, Yuan C. Discriminating carotid atherosclerotic lesion severity by luminal stenosis and plaque burden: a comparison utilizing high-resolution magnetic resonance imaging at 3.0 Tesla. Stroke 2010; 42:347-53. [PMID: 21183749 DOI: 10.1161/strokeaha.110.597328] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To determine associations between stenosis, measures of plaque burden, and compositional features of carotid atherosclerosis, including high-risk features of intraplaque hemorrhage (IPH) and surface disruption. METHODS Institutional Review Board approval and informed consent for all participants were obtained before study initiation. Patients with either carotid stenosis >50% by duplex ultrasound or suspected coronary artery disease underwent multi-contrast carotid MRI at 3.0 T. For each artery, stenosis, percent wall volume (PWV=100%×wall volume/total vessel volume), and mean wall thickness (MWT) were measured. Presence or absence of a lipid-rich necrotic core, calcification, IPH, and surface disruption were recorded. RESULTS One hundred eighty-one patients were included in the final analysis. The area under the curve (AUC) calculated from receiver-operating-characteristics analysis found the presence of IPH was similarly classified by stenosis (AUC=0.82), PWV (AUC=0.88), and MWT (AUC=0.88). Notably, IPH was present in the lowest category of each parameter. Prevalence of IPH in arteries with 0% stenosis was 4.4%. In arteries with PWV <40%, prevalence was 3.2%; in arteries with MWT <1.0 mm, prevalence was 2.3%. Strength of classification for surface disruption was similarly classified by stenosis (AUC=0.87), PWV (AUC=0.93), and MWT (AUC=0.94). CONCLUSIONS Measures of plaque burden do not substantially improve disease assessment compared to stenosis. The finding of IPH in all categories of stenosis and plaque burden suggests that direct characterization of plaque composition and surface status is necessary to fully discriminate disease severity.
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Affiliation(s)
- Xihai Zhao
- Department of Radiology, University of Washington, Seattle, WA 98109, USA
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Abstract
Vessel wall imaging of large vessels has the potential to identify culprit atherosclerotic plaques that lead to cardiovascular events. Comprehensive assessment of atherosclerotic plaque size, composition, and biological activity is possible with magnetic resonance imaging (MRI). Magnetic resonance imaging of the atherosclerotic plaque has demonstrated high accuracy and measurement reproducibility for plaque size. The accuracy of in vivo multicontrast MRI for identification of plaque composition has been validated against histological findings. Magnetic resonance imaging markers of plaque biological activity such as neovasculature and inflammation have been demonstrated. In contrast to other plaque imaging modalities, MRI can be used to study multiple vascular beds noninvasively over time. In this review, we compare the status of in vivo plaque imaging by MRI to competing imaging modalities. Recent MR technological improvements allow fast, accurate, and reproducible plaque imaging. An overview of current MRI techniques required for carotid plaque imaging including hardware, specialized pulse sequences, and processing algorithms are presented. In addition, the application of these techniques to coronary, aortic, and peripheral vascular beds is reviewed.
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Abstract
Cardiovascular disease (CVD) is a leading cause of morbidity and mortality worldwide. Current clinical techniques that rely on stenosis measurement alone appear to be insufficient for risk prediction in atherosclerosis patients. Many novel imaging methods have been developed to study atherosclerosis progression and to identify new features that can predict future clinical risk. MRI of atherosclerotic vessel walls is one such method. It has the ability to noninvasively evaluate multiple biomarkers of the disease such as luminal stenosis, plaque burden, tissue composition and plaque activity. In addition, the accuracy of in vivo MRI has been validated against histology with high reproducibility, thus paving the way for application to epidemiological studies of disease pathogenesis and, by serial MRI, in monitoring the efficacy of therapeutic intervention. In this review, we describe the various MR techniques used to evaluate aspects of plaque progression, discuss imaging-based measurements (imaging biomarkers), and also detail their validation. The application of plaque MRI in clinical trials as well as emerging imaging techniques used to evaluate plaque compositional features and biological activities are also discussed.
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Affiliation(s)
- Jinnan Wang
- Clinical Sites Research Program, Philips Research North America, Briarcliff Manor, NY, 10510
- Department of Radiology, University of Washington, Seattle, WA, 98109
| | - Niranjan Balu
- Department of Radiology, University of Washington, Seattle, WA, 98109
| | - Gador Canton
- Department of Radiology, University of Washington, Seattle, WA, 98109
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, WA, 98109
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Hatsukami TS, Yuan C. MRI in the early identification and classification of high-risk atherosclerotic carotid plaques. IMAGING IN MEDICINE 2010; 2:63-75. [PMID: 20953294 PMCID: PMC2953811 DOI: 10.2217/iim.09.33] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Stroke is a leading cause of mortality and long-term morbidity. As a means for stroke prevention, an estimated 99,000 carotid endarterectomy procedures were performed in the USA in 2006. Traditionally, the degree of luminal stenosis has been used as a marker of the stage of atherosclerosis and as an indication for surgical intervention. However, prospective clinical trials have shown that the majority of patients with a history of recent transient ischemic attack or stroke have mild-to-moderate carotid stenosis. Using stenosis criteria, many of these symptomatic individuals would be considered to have early-stage carotid atherosclerosis. It is evident that improved criteria are needed for identifying the high-risk carotid plaque across a range of stenoses. Histological studies have led to the hypothesis that plaques with larger lipid-rich necrotic cores, thin fibrous cap rupture, intraplaque hemorrhage, plaque neovasculature and vessel wall inflammation are characteristics of the high-risk, 'vulnerable plaque'. Despite the widespread consensus on the importance of these plaque features, testing the vulnerable plaque hypothesis in prospective clinical studies has been hindered by the lack of reliable imaging tools for in vivo plaque characterization. MRI has been shown to accurately identify key carotid plaque features, including the fibrous cap, lipid-rich necrotic core, intraplaque hemorrhage, neovasculature and vascular wall inflammation. Thus, MRI is a histologically validated technique that will permit prospective testing of the vulnerable plaque hypothesis. This article will provide a summary of the histological validation of carotid MRI, and highlight its application in prospective clinical studies aimed at early identification of the high-risk atherosclerotic carotid plaque.
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Affiliation(s)
- Thomas S Hatsukami
- Department of Surgery, Vascular Imaging Lab, University of Washington, 815 Mercer Street, Box 358050, Seattle, WA 98109, USA, Tel.: +1 206 543 3061, ,
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Underhill HR, Hatsukami TS, Fayad ZA, Fuster V, Yuan C. MRI of carotid atherosclerosis: clinical implications and future directions. Nat Rev Cardiol 2010; 7:165-73. [PMID: 20101259 DOI: 10.1038/nrcardio.2009.246] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Atherosclerosis is now widely recognized as a multifactorial disease with outcomes that arise from complex factors such as plaque components, blood flow, and inflammation. Despite recent advances in understanding of plaque biology, diagnosis, and treatment, atherosclerosis remains a leading cause of morbidity and mortality. Further research into the development and validation of reliable indicators of the high-risk individual is greatly needed. Carotid MRI is a histologically validated, noninvasive imaging method that can track disease progression and regression, and quantitatively evaluate a spectrum of parameters associated with in vivo plaque morphology and composition. Intraplaque hemorrhage and the lipid-rich necrotic core are the best indicators of lesion severity currently visualized by carotid MRI. However, MRI methods capable of imaging other important aspects of carotid atherosclerotic disease in vivo-including inflammation, neovascularization, and mechanical forces-are emerging and may aid in advancing our understanding of the pathophysiology of this multifactorial disease.
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Affiliation(s)
- Hunter R Underhill
- Department of Radiology, University of Washington, 815 Mercer Street, Box 358050, Seattle, WA 98109, USA.
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Underhill HR, Hatsukami TS, Cai J, Yu W, DeMarco JK, Polissar NL, Ota H, Zhao X, Dong L, Oikawa M, Yuan C. A noninvasive imaging approach to assess plaque severity: the carotid atherosclerosis score. AJNR Am J Neuroradiol 2010; 31:1068-75. [PMID: 20093315 DOI: 10.3174/ajnr.a2007] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The presence of IPH and/or FCR in the carotid atherosclerotic plaque indicates a high-risk lesion. The aim of this multicenter cross-sectional study was to establish the characteristics of lesions that may precede IPH and/or FCR. We further sought to construct a CAS that stratifies carotid disease severity. MATERIALS AND METHODS Three hundred forty-four individuals from 4 imaging centers with 16%-99% carotid stenosis by duplex sonography underwent carotid MR imaging. In approximately 60% of the study sample (training group), multivariate analysis was used to determine factors associated with IPH and FCR. Statistically significant parameters identified during multivariate analysis were used to construct CAS. CAS was then applied to the remaining arteries (40%, test group), and the accuracy of classification for determining the presence versus absence of IPH or, separately, FCR was determined by ROC analysis and calculation of the AUC. RESULTS The maximum proportion of the arterial wall occupied by the LRNC was the strongest predictor of IPH (P < .001) and FCR (P < .001) during multivariate analysis of the training group. The subsequently derived CAS applied to the test group was an accurate classifier of IPH (AUC = 0.91) and FCR (AUC = 0.93). Compared with MRA stenosis, CAS was a stronger classifier of both IPH and FCR. CONCLUSIONS LRNC quantification may be an effective complementary strategy to stenosis for classifying carotid atherosclerotic disease severity. CAS forms the foundation for a simple imaging-based risk-stratification system in the carotid artery to classify severity of atherosclerotic disease.
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Affiliation(s)
- H R Underhill
- Department of Radiology, Vascular Imaging Lab, University of Washington, 815 Mercer Street, Seattle, WA 98109, USA.
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Dong L, Kerwin WS, Ferguson MS, Li R, Wang J, Chen H, Canton G, Hatsukami TS, Yuan C. Cardiovascular magnetic resonance in carotid atherosclerotic disease. J Cardiovasc Magn Reson 2009; 11:53. [PMID: 20003520 PMCID: PMC2806867 DOI: 10.1186/1532-429x-11-53] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Accepted: 12/15/2009] [Indexed: 11/13/2022] Open
Abstract
Atherosclerosis is a chronic, progressive, inflammatory disease affecting many vascular beds. Disease progression leads to acute cardiovascular events such as myocardial infarction, stroke and death. The diseased carotid alone is responsible for one third of the 700,000 new or recurrent strokes occurring yearly in the United States. Imaging plays an important role in the management of atherosclerosis, and cardiovascular magnetic resonance (CMR) of the carotid vessel wall is one promising modality in the evaluation of patients with carotid atherosclerotic disease. Advances in carotid vessel wall CMR allow comprehensive assessment of morphology inside the wall, contributing substantial disease-specific information beyond luminal stenosis. Although carotid vessel wall CMR has not been widely used to screen for carotid atherosclerotic disease, many trials support its potential for this indication. This review summarizes the current state of knowledge regarding carotid vessel wall CMR and its potential clinical application for management of carotid atherosclerotic disease.
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Affiliation(s)
- Li Dong
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - William S Kerwin
- Department of Radiology, University of Washington, Seattle, WA, USA
| | | | - Rui Li
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Jinnan Wang
- Clinical Sites Research Program, Philips Research North America, Briarcliff Manor, NY, USA
| | - Huijun Chen
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Gador Canton
- Department of Radiology, University of Washington, Seattle, WA, USA
| | | | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, WA, USA
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Yu W, Underhill HR, Ferguson MS, Hippe DS, Hatsukami TS, Yuan C, Chu B. The added value of longitudinal black-blood cardiovascular magnetic resonance angiography in the cross sectional identification of carotid atherosclerotic ulceration. J Cardiovasc Magn Reson 2009; 11:31. [PMID: 19689816 PMCID: PMC2737539 DOI: 10.1186/1532-429x-11-31] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Accepted: 08/18/2009] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Carotid atherosclerotic ulceration is a significant source of stroke. This study evaluates the efficacy of adding longitudinal black-blood (BB) cardiovascular magnetic resonance (CMR) angiography to cross-sectional CMR images in the identification of carotid atherosclerotic ulceration. METHODS Thirty-two subjects (30 males and two females with ages between 48 and 83 years) scheduled for carotid endarterectomy were imaged on a 1.5T GE Signa scanner using multisequence [3D time-of-flight, T1, proton density, T2, contrast enhanced T1], cross-sectional CMR images and longitudinal BB CMR angiography (0.625 x 0.625 mm/pixel). Two rounds of review (round 1: cross-sectional CMR images alone and round 2: cross-sectional CMR images plus longitudinal BB CMR angiography) were conducted for the presence and volume measurements of ulceration. Ulceration was defined as a distinct depression into the plaque containing blood flow signal on cross-sectional CMR and longitudinal BB CMR angiography. RESULTS Of the 32 plaques examined by histology, 17 contained 21 ulcers. Using the longitudinal BB CMR angiography sequence in addition to the cross-sectional CMR images in round 2, the sensitivity improved to 80% for ulcers of at least 6 mm3 in volume by histology and 52.4% for all ulcers, compared to 30% and 23.8% in round 1, respectively. There was a slight decline in specificity from 88.2% to 82.3%, though both the positive and negative predictive values increased modestly from 71.4% to 78.6% and from 48.4% to 58.3%, respectively. CONCLUSION The addition of longitudinal BB CMR angiography to multisequence cross-sectional CMR images increases accuracy in the identification of carotid atherosclerotic ulceration.
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Affiliation(s)
- Wei Yu
- Department of Radiology, University of Washington, Seattle, WA, USA
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, PR China
| | | | | | - Daniel S Hippe
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Thomas S Hatsukami
- Department of Surgery, Vascular Surgery Division, University of Washington, Seattle, WA, USA
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Baocheng Chu
- Department of Radiology, University of Washington, Seattle, WA, USA
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