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Pisu F, Williamson BJ, Nardi V, Paraskevas KI, Puig J, Vagal A, de Rubeis G, Porcu M, Cau R, Benson JC, Balestrieri A, Lanzino G, Suri JS, Mahammedi A, Saba L. Machine Learning Detects Symptomatic Plaques in Patients With Carotid Atherosclerosis on CT Angiography. Circ Cardiovasc Imaging 2024; 17:e016274. [PMID: 38889214 PMCID: PMC11186714 DOI: 10.1161/circimaging.123.016274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 05/03/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND This study aimed to develop and validate a computed tomography angiography based machine learning model that uses plaque composition data and degree of carotid stenosis to detect symptomatic carotid plaques in patients with carotid atherosclerosis. METHODS The machine learning based model was trained using degree of stenosis and the volumes of 13 computed tomography angiography derived intracarotid plaque subcomponents (eg, lipid, intraplaque hemorrhage, calcium) to identify plaques associated with cerebrovascular events. The model was internally validated through repeated 10-fold cross-validation and tested on a dedicated testing cohort according to discrimination and calibration. RESULTS This retrospective, single-center study evaluated computed tomography angiography scans of 268 patients with both symptomatic and asymptomatic carotid atherosclerosis (163 for the derivation set and 106 for the testing set) performed between March 2013 and October 2019. The area-under-receiver-operating characteristics curve by machine learning on the testing cohort (0.89) was significantly higher than the areas under the curve of traditional logit analysis based on the degree of stenosis (0.51, P<0.001), presence of intraplaque hemorrhage (0.69, P<0.001), and plaque composition (0.78, P<0.001), respectively. Comparable performance was obtained on internal validation. The identified plaque components and associated cutoff values that were significantly associated with a higher likelihood of symptomatic status after adjustment were the ratio of intraplaque hemorrhage to lipid volume (≥50%, 38.5 [10.1-205.1]; odds ratio, 95% CI) and percentage of intraplaque hemorrhage volume (≥10%, 18.5 [5.7-69.4]; odds ratio, 95% CI). CONCLUSIONS This study presented an interpretable machine learning model that accurately identifies symptomatic carotid plaques using computed tomography angiography derived plaque composition features, aiding clinical decision-making.
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Affiliation(s)
- Francesco Pisu
- Department of Radiology, Azienda Ospedaliero-Universitaria, Monserrato (Cagliari), Italy (F.P., M.P., R.C., A.B., L.S.)
| | - Brady J. Williamson
- Department of Radiology, University of Cincinnati, Cincinnati, OH (B.J.W., A.V., A.M.)
| | - Valentina Nardi
- Department of Radiology, Mayo Clinic, Rochester, MN (V.N., J.C.B., G.L.)
| | - Kosmas I. Paraskevas
- Department of Vascular Surgery, Central Clinic of Athens, Athens, Greece (K.I.P.)
| | - Josep Puig
- Department of Radiology (IDI), Hospital Universitari de Girona, Girona, Spain (J.P.)
| | - Achala Vagal
- Department of Radiology, University of Cincinnati, Cincinnati, OH (B.J.W., A.V., A.M.)
| | - Gianluca de Rubeis
- UOC Neuroradiology Diagnostic and Interventional, San Camillo-Forlanini Hospital, Rome, Italy (G.R.)
| | - Michele Porcu
- Department of Radiology, Azienda Ospedaliero-Universitaria, Monserrato (Cagliari), Italy (F.P., M.P., R.C., A.B., L.S.)
| | - Riccardo Cau
- Department of Radiology, Azienda Ospedaliero-Universitaria, Monserrato (Cagliari), Italy (F.P., M.P., R.C., A.B., L.S.)
| | - John C. Benson
- Department of Radiology, Mayo Clinic, Rochester, MN (V.N., J.C.B., G.L.)
| | - Antonella Balestrieri
- Department of Radiology, Azienda Ospedaliero-Universitaria, Monserrato (Cagliari), Italy (F.P., M.P., R.C., A.B., L.S.)
| | - Giuseppe Lanzino
- Department of Radiology, Mayo Clinic, Rochester, MN (V.N., J.C.B., G.L.)
| | - Jasjit S. Suri
- Stroke Diagnosis and Monitoring Division, Atheropoint LLC, Roseville, CA (J.S.S.)
| | - Abdelkader Mahammedi
- Department of Radiology, University of Cincinnati, Cincinnati, OH (B.J.W., A.V., A.M.)
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero-Universitaria, Monserrato (Cagliari), Italy (F.P., M.P., R.C., A.B., L.S.)
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Zhao Y, Gu Y, Liu Y, Guo Z. Evaluation of the Correlation Between Distribution Location and Vulnerability of Carotid Plaque in Patients with Transient Ischemic Attack. Vasc Health Risk Manag 2024; 20:77-87. [PMID: 38464675 PMCID: PMC10922953 DOI: 10.2147/vhrm.s447418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/25/2024] [Indexed: 03/12/2024] Open
Abstract
Purpose To analyze the relationship among distribution location, characteristics, and vulnerability of carotid plaque using CTA and provide more information on the risk factors of carotid atherosclerotic plaque. Patients and Methods We retrospectively analyzed the CTA images of the head and neck of 93 patients with carotid atherosclerosis. Atherosclerosis was developed in 148 carotid arteries. The plaques were divided into a high-risk plaque group and a low-risk plaque group according to whether the plaques had high-risk characteristics. The maximum cross-sectional area of carotid artery bifurcation plaque on the axial image was selected, and the cross-sectional lumen was equally divided into four 90-degree sectors, ventral side wall, dorsal side wall, inner side wall, and outer side wall. The differences in the characteristics and distribution locations of the plaques in the two groups were analyzed. The characteristic parameters of the cross-sectional plaques at the bifurcation of the carotid artery. The logistic regression analysis was used to further analyze the risk factors associated with plaque vulnerability. Results Among 148 carotid arteries,80 were classified as high-risk and 68 as low-risk groups. There were significant differences between the two groups concerning the thickness, length, maximum cross-sectional area, burden, and cross-sectional distribution of the plaques (P < 0.05). The plaque distribution on the dorsal side wall of the carotid bifurcation was higher in the high-risk group than that in the low-risk group (P < 0.05), dorsal side wall plaque-independent risk factors for the development of vulnerability of plaques in transient ischemic attack (TIA) patients (95% CI:1.522~6.991, P<0.05). Conclusion High-risk plaques tend to occur on the dorsal side wall of the carotid bifurcation, whereas low-risk plaques tend to occur on the outer side wall of the carotid bifurcation.
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Affiliation(s)
- Yinan Zhao
- Department of Radiology, The Affiliated Jinzhou Medical University, Jinzhou, People’s Republic of China
| | - Yan Gu
- Department of Radiology, The Affiliated First People’s Hospital of Lianyungang, Lianyungang, People’s Republic of China
| | - Ying Liu
- Department of Radiology, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, People’s Republic of China
| | - Zhongping Guo
- Department of Radiology, The Affiliated Lianyungang Clinical College of Nanjing Medical University, Lianyungang, People’s Republic of China
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3
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Chen J, Wang B, Song J, Qi Z, Deng Y. Multiple techniques to evaluate the relationship between carotid artery plaque and acute stroke. Clin Hemorheol Microcirc 2024; 86:327-337. [PMID: 37927252 DOI: 10.3233/ch-231959] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
AIM To evaluate the important characteristics of the plaque vulnerability using multimodal ultrasound imaging methods (2D, contrast-enhanced ultrasound, and elastography), and to explore the relationship between plaque and acute stroke. METHODS A total of 244 patients with carotid plaque were enrolled, including 104 patients with acute stroke ipsilateral to the plaque as the case group and 140 patients as the control group. All patients underwent conventional carotid ultrasound, contrast-enhanced ultrasound (CEUS) and elastography (SWE). The results of each examination were compared and analyzed, and the relationship between the results and the occurrence of stroke was discussed. RESULTS In the acute stroke group, the men, with a history of alcohol consumption the direction of contrast media diffusion was higher than that in the control group, but the plaque gray value (GSM), maximum, average and minimum Young's elastic modulus imaging values (YM) were slightly lower than those in the control group (P < 0.05). Logistic regression analysis showed that waist to body ratio (WHtR), GSM, YM, neovascularization density and contrast diffusion direction were independent risk factors for predicting acute ischemic stroke. The influence degree of each factor from strong to weak was waist to body ratio, neovascularity density, GSM and YM, respectively. The area under the curve (AUC) for the diagnosis of acute ischemic stroke by regression model was 0.746. CONCLUSION The combination of multiple ultrasound techniques to evaluate the vulnerability of carotid plaque and predict the occurrence of acute stroke provides valuable information for clinical decision making.
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Affiliation(s)
- Jianghong Chen
- First Hospital of Hebei Medical University, Hebei, China
| | | | - Jianshi Song
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Province Key Laboratory of Environment and Human Health, Shijiazhuang, China
| | - Zhengqin Qi
- The First Hospital of Qinhuangdao, Hebei, China
| | - Yandong Deng
- First Hospital of Hebei Medical University, Hebei, China
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He Z, Luo J, Lv M, Li Q, Ke W, Niu X, Zhang Z. Characteristics and evaluation of atherosclerotic plaques: an overview of state-of-the-art techniques. Front Neurol 2023; 14:1159288. [PMID: 37900593 PMCID: PMC10603250 DOI: 10.3389/fneur.2023.1159288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 09/28/2023] [Indexed: 10/31/2023] Open
Abstract
Atherosclerosis is an important cause of cerebrovascular and cardiovascular disease (CVD). Lipid infiltration, inflammation, and altered vascular stress are the critical mechanisms that cause atherosclerotic plaque formation. The hallmarks of the progression of atherosclerosis include plaque ulceration, rupture, neovascularization, and intraplaque hemorrhage, all of which are closely associated with the occurrence of CVD. Assessing the severity of atherosclerosis and plaque vulnerability is crucial for the prevention and treatment of CVD. Integrating imaging techniques for evaluating the characteristics of atherosclerotic plaques with computer simulations yields insights into plaque inflammation levels, spatial morphology, and intravascular stress distribution, resulting in a more realistic and accurate estimation of plaque state. Here, we review the characteristics and advancing techniques used to analyze intracranial and extracranial atherosclerotic plaques to provide a comprehensive understanding of atheroma.
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Affiliation(s)
- Zhiwei He
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jiaying Luo
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Mengna Lv
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qingwen Li
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wei Ke
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xuan Niu
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhaohui Zhang
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, China
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Tanisawa H, Matsumoto H, Cadet S, Higuchi S, Ohya H, Isodono K, Irie D, Kaneko K, Sumida A, Hirano T, Otaki Y, Kitamura R, Slomka PJ, Dey D, Shinke T. Quantification of Low-Attenuation Plaque Burden from Coronary CT Angiography: A Head-to-Head Comparison with Near-Infrared Spectroscopy Intravascular US. Radiol Cardiothorac Imaging 2023; 5:e230090. [PMID: 37908555 PMCID: PMC10613924 DOI: 10.1148/ryct.230090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/09/2023] [Accepted: 08/24/2023] [Indexed: 11/02/2023]
Abstract
Purpose To determine the association between low-attenuation plaque (LAP) burden at coronary CT angiography (CCTA) and plaque morphology determined with near-infrared spectroscopy intravascular US (NIRS-IVUS) and to compare the discriminative ability for NIRS-IVUS-verified high-risk plaques (HRPs) between LAP burden and visual assessment of LAP. Materials and Methods This Health Insurance Portability and Accountability Act-compliant retrospective study included consecutive patients who underwent CCTA before NIRS-IVUS between October 2019 and October 2022 at two facilities. LAPs were visually identified as having a central focal area of less than 30 HU using the pixel lens technique. LAP burden was calculated as the volume of voxels with less than 30 HU divided by vessel volume. HRPs were defined as plaques with one of the following NIRS-IVUS-derived high-risk features: maximum 4-mm lipid core burden index greater than 400 (lipid-rich plaque), an echolucent zone (intraplaque hemorrhage), or echo attenuation (cholesterol clefts). Multivariable analysis was performed to evaluate NIRS-IVUS-derived parameters associated with LAP burden. The discriminative ability for NIRS-IVUS-verified HRPs was compared using receiver operating characteristic analysis. Results In total, 273 plaques in 141 patients (median age, 72 years; IQR, 63-78 years; 106 males) were analyzed. All the NIRS-IVUS-derived high-risk features were independently linked to LAP burden (P < .01 for all). LAP burden increased with the number of high-risk features (P < .001) and had better discriminative ability for HRPs than plaque attenuation by visual assessment (area under the receiver operating characteristic curve, 0.93 vs 0.89; P = .02). Conclusion Quantification of LAP burden improved HRP assessment compared with visual assessment. LAP burden was associated with the accumulation of HRP morphology.Keywords: Coronary CT Angiography, Intraplaque Hemorrhage, Lipid-Rich Plaque, Low Attenuation Plaque, Near-Infrared Spectroscopy Intravascular Ultrasound Supplemental material is available for this article. See also the commentary by Ferencik in this issue.© RSNA, 2023.
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Affiliation(s)
- Hiroki Tanisawa
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Hidenari Matsumoto
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Sebastien Cadet
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Satoshi Higuchi
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Hidefumi Ohya
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Koji Isodono
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Daisuke Irie
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Kyoichi Kaneko
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Arihiro Sumida
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Takaho Hirano
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Yuka Otaki
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Ryoji Kitamura
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Piotr J Slomka
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Damini Dey
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
| | - Toshiro Shinke
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (H.T., H.M., S.H., K.K., A.S., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (S.C., P.J.S., D.D.); Department of Cardiology, Ijinkai Takeda General Hospital, Kyoto, Japan (H.O., K.I., D.I., R.K.); Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (T.H.); and Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan (Y.O.)
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Sakamoto A, Suwa K, Kawakami R, Finn AV, Maekawa Y, Virmani R, Finn AV. Significance of Intra-plaque Hemorrhage for the Development of High-Risk Vulnerable Plaque: Current Understanding from Basic to Clinical Points of View. Int J Mol Sci 2023; 24:13298. [PMID: 37686106 PMCID: PMC10487895 DOI: 10.3390/ijms241713298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
Acute coronary syndromes due to atherosclerotic coronary artery disease are a leading cause of morbidity and mortality worldwide. Intra-plaque hemorrhage (IPH), caused by disruption of intra-plaque leaky microvessels, is one of the major contributors of plaque progression, causing a sudden increase in plaque volume and eventually plaque destabilization. IPH and its healing processes are highly complex biological events that involve interactions between multiple types of cells in the plaque, including erythrocyte, macrophages, vascular endothelial cells and vascular smooth muscle cells. Recent investigations have unveiled detailed molecular mechanisms by which IPH leads the development of high-risk "vulnerable" plaque. Current advances in clinical diagnostic imaging modalities, such as magnetic resonance image and intra-coronary optical coherence tomography, increasingly allow us to identify IPH in vivo. To date, retrospective and prospective clinical trials have revealed the significance of IPH as detected by various imaging modalities as a reliable prognostic indicator of high-risk plaque. In this review article, we discuss recent advances in our understanding for the significance of IPH on the development of high-risk plaque from basic to clinical points of view.
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Affiliation(s)
- Atsushi Sakamoto
- CVPath Institute, Inc., Gaithersburg, MD 20878, USA; (A.S.); (R.K.); (A.V.F.); (R.V.)
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3125, Japan; (K.S.); (Y.M.)
| | - Kenichiro Suwa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3125, Japan; (K.S.); (Y.M.)
| | - Rika Kawakami
- CVPath Institute, Inc., Gaithersburg, MD 20878, USA; (A.S.); (R.K.); (A.V.F.); (R.V.)
| | - Alexandra V. Finn
- CVPath Institute, Inc., Gaithersburg, MD 20878, USA; (A.S.); (R.K.); (A.V.F.); (R.V.)
| | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3125, Japan; (K.S.); (Y.M.)
| | - Renu Virmani
- CVPath Institute, Inc., Gaithersburg, MD 20878, USA; (A.S.); (R.K.); (A.V.F.); (R.V.)
| | - Aloke V. Finn
- CVPath Institute, Inc., Gaithersburg, MD 20878, USA; (A.S.); (R.K.); (A.V.F.); (R.V.)
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Fernández-Alvarez V, Linares-Sánchez M, Suárez C, López F, Guntinas-Lichius O, Mäkitie AA, Bradley PJ, Ferlito A. Novel Imaging-Based Biomarkers for Identifying Carotid Plaque Vulnerability. Biomolecules 2023; 13:1236. [PMID: 37627301 PMCID: PMC10452902 DOI: 10.3390/biom13081236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/30/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Carotid artery disease has traditionally been assessed based on the degree of luminal narrowing. However, this approach, which solely relies on carotid stenosis, is currently being questioned with regard to modern risk stratification approaches. Recent guidelines have introduced the concept of the "vulnerable plaque," emphasizing specific features such as thin fibrous caps, large lipid cores, intraplaque hemorrhage, plaque rupture, macrophage infiltration, and neovascularization. In this context, imaging-based biomarkers have emerged as valuable tools for identifying higher-risk patients. Non-invasive imaging modalities and intravascular techniques, including ultrasound, computed tomography, magnetic resonance imaging, intravascular ultrasound, optical coherence tomography, and near-infrared spectroscopy, have played pivotal roles in characterizing and detecting unstable carotid plaques. The aim of this review is to provide an overview of the evolving understanding of carotid artery disease and highlight the significance of imaging techniques in assessing plaque vulnerability and informing clinical decision-making.
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Affiliation(s)
- Verónica Fernández-Alvarez
- Department of Vascular and Endovascular Surgery, Hospital Universitario de Cabueñes, 33394 Gijón, Spain;
| | - Miriam Linares-Sánchez
- Department of Vascular and Endovascular Surgery, Hospital Universitario de Cabueñes, 33394 Gijón, Spain;
| | - Carlos Suárez
- Instituto de Investigacion Sanitaria del Principado de Asturias, 33011 Oviedo, Spain; (C.S.); (F.L.)
| | - Fernando López
- Instituto de Investigacion Sanitaria del Principado de Asturias, 33011 Oviedo, Spain; (C.S.); (F.L.)
- Department of Otorhinolaryngology, Hospital Universitario Central de Asturias, Instituto Universitario de Oncologia del Principado de Asturias, University of Oviedo, CIBERONC, 33011 Oviedo, Spain
| | | | - Antti A. Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital, University of Helsinki, P.O. Box 263, 00029 Helsinki, Finland;
- Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland
- Division of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institute and Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Patrick J. Bradley
- Department of ORLHNS, Queens Medical Centre Campus, Nottingham University Hospitals, Derby Road, Nottingham NG7 2UH, UK;
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35100 Padua, Italy;
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8
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Varga-Szemes A, Maurovich-Horvat P, Schoepf UJ, Zsarnoczay E, Pelberg R, Stone GW, Budoff MJ. Computed Tomography Assessment of Coronary Atherosclerosis: From Threshold-Based Evaluation to Histologically Validated Plaque Quantification. J Thorac Imaging 2023; 38:226-234. [PMID: 37115957 PMCID: PMC10287054 DOI: 10.1097/rti.0000000000000711] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Arterial plaque rupture and thrombosis is the primary cause of major cardiovascular and neurovascular events. The identification of atherosclerosis, especially high-risk plaques, is therefore crucial to identify high-risk patients and to implement preventive therapies. Computed tomography angiography has the ability to visualize and characterize vascular plaques. The standard methods for plaque evaluation rely on the assessment of plaque burden, stenosis severity, the presence of positive remodeling, napkin ring sign, and spotty calcification, as well as Hounsfield Unit (HU)-based thresholding for plaque quantification; the latter with multiple shortcomings. Semiautomated threshold-based segmentation techniques with predefined HU ranges identify and quantify limited plaque characteristics, such as low attenuation, non-calcified, and calcified plaque components. Contrary to HU-based thresholds, histologically validated plaque characterization, and quantification, an emerging Artificial intelligence-based approach has the ability to differentiate specific tissue types based on a biological correlate, such as lipid-rich necrotic core and intraplaque hemorrhage that determine plaque vulnerability. In this article, we review the relevance of plaque characterization and quantification and discuss the benefits and limitations of the currently available plaque assessment and classification techniques.
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Affiliation(s)
- Akos Varga-Szemes
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC
| | - Pal Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - U. Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC
| | - Emese Zsarnoczay
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Robert Pelberg
- Heart and Vascular Institute at The Christ Hospital Health Network, Cincinnati, OH
| | - Gregg W. Stone
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Matthew J. Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA
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9
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Obaid DR, Okonji I, Cheng SF, Giannopoulos AA, Kamalathevan P, Halcox J, Rodriguez-Justo M, Richards T. Identification of vulnerable carotid plaque with histologically validated CT-derived plaque maps. Br J Radiol 2023:20220982. [PMID: 37183910 DOI: 10.1259/bjr.20220982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
OBJECTIVES Ruptured carotid plaque causes stroke, but differentiating rupture-prone necrotic core from fibrous tissue with CT is limited by overlap of X-ray attenuation. We investigated the ability of CT-derived plaque maps created from ratios of plaque/contrast attenuation to identify histologically proven vulnerable plaques. METHODS Seventy patients underwent carotid CT angiography and carotid endarterectomy. A derivation cohort of 20 patients had CT images matched with histology and carotid plaque components attenuation defined. In a validation cohort of 50 patients, CT-derived plaque maps were compared in 43 symptomatic vs 40 asymptomatic carotid plaques and accuracy detecting vulnerable plaques calculated. RESULTS In 250 plaque areas co-registered with histology, the median attenuation (HU) of necrotic core 43(26-63), fibrous plaque 127(110-162) and calcified plaque 964 (816-1207) created significantly different ratios of plaque/contrast attenuation. CT-derived plaque maps revealed symptomatic plaques had larger necrotic core than asymptomatic (13.5%(5.9-33.3) vs 7.4%(2.3-14.3), p = 0.004) with large necrotic core predicting symptoms (area under ROC curve 0.68, p = 0.004). Twenty-four of 47 carotid plaques were histologically classified as most vulnerable (Starry-Type VI). Plaque maps revealed Type VI plaques had a greater necrotic core volume than Type IV/V plaques and a necrotic core/fibrous plaque ratio >0.5 distinguished Type VI plaques with sensitivity 75.0% (55.1-88.0) and specificity of 39.1% (22.2-59.2). CONCLUSIONS Carotid plaque components can be differentiated by CT using a ratio of plaque/contrast attenuation. CT-derived plaque map volumes of necrotic core help distinguished the most vulnerable plaques. ADVANCES IN KNOWLEDGE CT-derived plaque maps based on plaque/contrast attenuation may provide new markers of carotid plaque vulnerability.
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Affiliation(s)
| | - Ike Okonji
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Suk F Cheng
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | | | | | - Toby Richards
- Department of Surgery, University of Western Australia, Perth, Australia
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10
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Cau R, Gupta A, Kooi ME, Saba L. Pearls and Pitfalls of Carotid Artery Imaging: Ultrasound, Computed Tomography Angiography, and MR Imaging. Radiol Clin North Am 2023; 61:405-413. [PMID: 36931758 DOI: 10.1016/j.rcl.2023.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Stroke represents a major cause of morbidity and mortality worldwide with carotid atherosclerosis responsible for a large proportion of ischemic strokes. Given the high burden of the disease , early diagnosis and optimal secondary prevention are essential elements in clinical practice. For a long time, the degree of stenosis had been considered the parameter to judge the severity of carotid atherosclerosis. Over the last 30 years, literature has shifted attention from stenosis to structural characteristics of atherosclerotic lesion, eventually leading to the "vulnerable plaque" model. These "vulnerable plaques" frequently demonstrate high-risk imaging features that can be assessed by various non-invasive imaging modalities.
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Affiliation(s)
- Riccardo Cau
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato, s.s. 554, Monserrato, Cagliari 09045, Italy
| | - Ajay Gupta
- Department of Radiology Weill Cornell Medical College, New York, NY, USA
| | - Marianne Eline Kooi
- Department of Radiology and Nuclear Medicine, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | - 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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11
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Tang Y, Zhang J, Liu W, Jin W, Li S, Qian Z, Kong X, Zhang R, Hu J, Li B, Yuan W, Zhang Y. Analysis of carotid vulnerable plaque MRI high-risk features and clinical risk factors associated with concomitant acute cerebral infarction. BMC Cardiovasc Disord 2023; 23:173. [PMID: 36997869 PMCID: PMC10064680 DOI: 10.1186/s12872-023-03199-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 03/22/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND This study aimed to investigate the correlation between the high-risk characteristics of high-resolution MRI carotid vulnerable plaques and the clinical risk factors and concomitant acute cerebral infarction (ACI). METHODS Forty-five patients diagnosed with a single vulnerable carotid plaque by MRI were divided into two groups based on whether they had ipsilateral ACI. The clinical risk factors and the observation values or frequency of occurrence of high-risk MRI phenotypes of plaque volume, LRNC, IPH and ulcer were statistically compared between the two groups. RESULTS A total of 45 vulnerable carotid artery plaques were found in 45 patients, 23 patients with ACI and 22 patients without ACI. There were no significant differences in age, sex, smoking, serum TC, TG and LDL between the two groups (all P > 0.05), but the ACI group had significantly more patients with hypertension (P < 0.05) and the without ACI group coronary heart disease (P < 0.05). The volume of vulnerable carotid plaque in the group with ACI (1004.19 ± 663.57 mm3) was significantly larger than that in the group without ACI (487.21 ± 238.64 mm3) (P < 0.05). The phenotype of vulnerable carotid artery plaque was 13 cases of LRNC, 8 cases of LRNC + IPH, 5 cases of LRNC + Ulcer, and 19 cases of LRNC + IPH + Ulcer. There was no significant difference in this distribution between the two groups (all P > 0.05) with the exception of LRNC + IPH + Ulcer. The 14 cases of LRNC + IPH + LRNC + IPH + Ulcer (60.87%) in the group with ACI and was significantly greater than the 5 (22.73%) in patients without ACI (P < 0.05). CONCLUSION It is preliminarily thought that hypertension is the main clinical risk factor for vulnerable carotid plaques with ACI and the combination of plaque volume with vulnerable carotid plaque and LRNC + IPH + Ulcer is a high-risk factor for complicated ACI. It has high clinical therapeutic value due to the accurate diagnosis of responsible vessels and plaques with high-resolution MRI.
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Affiliation(s)
- Yongxiang Tang
- Department of Medical Image Center, Tongling People's Hospital, Bijiashan Road 468, Tongling, 244000, Anhui, China
| | - Jinping Zhang
- Department of Medical Image Center, Tongling People's Hospital, Bijiashan Road 468, Tongling, 244000, Anhui, China.
| | - Weizhou Liu
- Department of Neurology, Tongling People's Hospital, Bijiashan Road 468, Tongling, 244000, Anhui, China
| | - Wei Jin
- Department of Neurology, Tongling People's Hospital, Bijiashan Road 468, Tongling, 244000, Anhui, China
| | - Shijian Li
- Department of Medical Image Center, Tongling People's Hospital, Bijiashan Road 468, Tongling, 244000, Anhui, China
| | - Zhen Qian
- Department of Medical Image Center, Tongling People's Hospital, Bijiashan Road 468, Tongling, 244000, Anhui, China
| | - Xiaoquan Kong
- Department of Medical Image Center, Tongling People's Hospital, Bijiashan Road 468, Tongling, 244000, Anhui, China
| | - Ran Zhang
- Department of Medical Image Center, Tongling People's Hospital, Bijiashan Road 468, Tongling, 244000, Anhui, China
| | - Juanjuan Hu
- Department of Medical Image Center, Tongling People's Hospital, Bijiashan Road 468, Tongling, 244000, Anhui, China
| | - Baolin Li
- Department of Medical Image Center, Tongling People's Hospital, Bijiashan Road 468, Tongling, 244000, Anhui, China
| | - Weiming Yuan
- Department of Medical Image Center, Tongling People's Hospital, Bijiashan Road 468, Tongling, 244000, Anhui, China
| | - Yifan Zhang
- Department of Medical Image Center, Tongling People's Hospital, Bijiashan Road 468, Tongling, 244000, Anhui, China
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12
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Tong W, Zhang Y, Hui H, Feng X, Ning B, Yu T, Wang W, Shang Y, Zhang G, Zhang S, Tian F, He W, Chen Y, Tian J. Sensitive magnetic particle imaging of haemoglobin degradation for the detection and monitoring of intraplaque haemorrhage in atherosclerosis. EBioMedicine 2023; 90:104509. [PMID: 36905783 PMCID: PMC10023936 DOI: 10.1016/j.ebiom.2023.104509] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 02/13/2023] [Accepted: 02/20/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Intraplaque haemorrhage (IPH) drives atherosclerosis progression and is a key imaging biomarker of unstable plaques. Non-invasive and sensitive monitoring of IPH is challenging due to the compositional complexity and dynamic nature of atherosclerotic plaques. Magnetic particle imaging (MPI) is a highly sensitive, radiation-free, and no-tissue-background tomographic technique that detects superparamagnetic nanoparticles. Thus, we aimed to investigate whether MPI can in vivo detect and monitor IPH. METHODS Thirty human carotid endarterectomy samples were collected and scanned with MPI. The tandem stenosis (TS) model was employed to establish unstable plaques with IPH in ApoE-/- mice. MPI and 7 T T1-weighted magnetic resonance imaging (MRI) were performed on TS ApoE-/- mice. Plaque specimens were analyzed histologically. FINDINGS Human carotid endarterectomy samples exhibited endogenous MPI signals, which histologically colocalized with IPH. In vitro experiments identified haemosiderin, a haemoglobin degradation product, as a potential source of MPI signals. Longitudinal MPI of TS ApoE-/- mice detected IPH at unstable plaques, of which MPI signal-to-noise ratio values increased from 6.43 ± 1.74 (four weeks) to 10.55 ± 2.30 (seven weeks) and reduced to 7.23 ± 1.44 (eleven weeks). In contrast, 7 T T1-weighted MRI did not detect the small-size IPH (329.91 ± 226.82 μm2) at four weeks post-TS. The time-course changes in IPH were shown to correlate with neovessel permeability providing a possible mechanism for signal changes over time. INTERPRETATION MPI is a highly sensitive imaging technology that allows the identification of atherosclerotic plaques with IPH and may help detect and monitor unstable plaques in patients. FUNDING This work was supported in part by the Beijing Natural Science Foundation under Grant JQ22023; the National Key Research and Development Program of China under Grant 2017YFA0700401; the National Natural Science Foundation of China under Grant 62027901, 81827808, 81730050, 81870178, 81800221, 81527805, and 81671851; the CAS Youth Innovation Promotion Association under Grant Y2022055 and CAS Key Technology Talent Program; and the Project of High-Level Talents Team Introduction in Zhuhai City (Zhuhai HLHPTP201703).
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Affiliation(s)
- Wei Tong
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China; CAS Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing 100190, China
| | - Yingqian Zhang
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Hui Hui
- CAS Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing 100190, China; Beijing Key Laboratory of Molecular Imaging, Beijing, 100190, China; University of Chinese Academy of Sciences, Beijing, 100080, China
| | - Xin Feng
- CAS Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing 100190, China; Beijing Key Laboratory of Molecular Imaging, Beijing, 100190, China; University of Chinese Academy of Sciences, Beijing, 100080, China
| | - Bin Ning
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Tengfei Yu
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Wei Wang
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Yaxin Shang
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, 100069, China
| | - Guanghao Zhang
- CAS Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing 100190, China
| | - Suhui Zhang
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Feng Tian
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China
| | - Wen He
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
| | - Yundai Chen
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, Beijing, 100048, China.
| | - Jie Tian
- CAS Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing 100190, China; Beijing Key Laboratory of Molecular Imaging, Beijing, 100190, China; Key Laboratory of Big Data-Based Precision Medicine (Beihang University), Ministry of Industry and Information Technology of China, Beijing, 100191, China; Zhuhai Precision Medical Center, Zhuhai People's Hospital, Affiliated with Jinan University, Zhuhai, 519000, China.
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13
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Rotzinger DC, Qanadli SD, Fahrni G. Imaging the Vulnerable Carotid Plaque with CT: Caveats to Consider. Comment on Wang et al. Identification Markers of Carotid Vulnerable Plaques: An Update. Biomolecules 2022, 12, 1192. Biomolecules 2023; 13:biom13020397. [PMID: 36830766 PMCID: PMC9953174 DOI: 10.3390/biom13020397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/03/2023] [Accepted: 02/19/2023] [Indexed: 02/22/2023] Open
Abstract
We read with great interest the review by Wang et al. entitled "Identification Markers of Carotid Vulnerable Plaques: An Update", recently published in Biomolecules [...].
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Affiliation(s)
- David C. Rotzinger
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, 1015 Lausanne, Switzerland
- Correspondence: ; Tel.: +41-21-314-44-75
| | - Salah D. Qanadli
- Faculty of Biology and Medicine, University of Lausanne, 1015 Lausanne, Switzerland
- Riviera-Chablais Hospital, 1847 Rennaz, Switzerland
| | - Guillaume Fahrni
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, 1015 Lausanne, Switzerland
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14
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Carotid Plaque Vulnerability Diagnosis by CTA versus MRA: A Systematic Review. Diagnostics (Basel) 2023; 13:diagnostics13040646. [PMID: 36832133 PMCID: PMC9955971 DOI: 10.3390/diagnostics13040646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/01/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
Stenosis grade of the carotid arteries has been the primary indicator for risk stratification and surgical treatment of carotid artery disease. Certain characteristics of the carotid plaque render it vulnerable and have been associated with increased plaque rupture rates. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have been shown to detect these characteristics to a different degree. The aim of the current study was to report on the detection of vulnerable carotid plaque characteristics by CTA and MRA and their possible association. A systematic review of the medical literature was executed, utilizing PubMed, SCOPUS and CENTRAL databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines. The study protocol has been registered to PROSPERO (CRD42022381801). Comparative studies reporting on both CTA and MRA carotid artery studies were included in the analysis. The QUADAS tools were used for risk of bias diagnostic imaging studies. Outcomes included carotid plaque vulnerability characteristics described in CTA and MRA and their association. Five studies, incorporating 377 patients and 695 carotid plaques, were included. Four studies reported on symptomatic status (326 patients, 92.9%). MRA characteristics included intraplaque hemorrhage, plaque ulceration, type VI AHA plaque hallmarks and intra-plaque high-intensity signal. Intraplaque hemorrhage detected in MRA was the most described characteristic and was associated with increased plaque density, increased lumen stenosis, plaque ulceration and increased soft-plaque and hard-plaque thickness. Certain characteristics of vulnerable carotid plaques can be detected in carotid artery CTA imaging studies. Nevertheless, MRA continues to provide more detailed and thorough imaging. Both imaging modalities can be applied for comprehensive carotid artery work-up, each one complementing the other.
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15
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Onnis C, Cadeddu Dessalvi C, Cademartiri F, Muscogiuri G, Angius S, Contini F, Suri JS, Sironi S, Salgado R, Esposito A, Saba L. Quantitative and qualitative features of carotid and coronary atherosclerotic plaque among men and women. Front Cardiovasc Med 2022; 9:970438. [PMID: 36176995 PMCID: PMC9513059 DOI: 10.3389/fcvm.2022.970438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022] Open
Abstract
Cardiovascular diseases (CVDs), particularly ischemic heart disease (IHD) and stroke, present epidemiologically in a different way among sexes. The reasons of these sex-based differences should be delved into sex-specific cardiovascular (CV) risk factors and different mechanisms of atherosclerotic progression. Imaging techniques of both carotid and coronary atherosclerotic plaques represent a tool to demonstrate sex-related features which might be used to further and better assess CV risk of male and female population. The aim of this review is to evaluate current knowledge on sex-specific qualitative and quantitative plaque features of coronary and carotid atherosclerosis. We also discuss the clinical implication of a sex-based plaque phenotype, evaluated with non-invasive imaging techniques, such as CT-angiography and MRI-angiography, to stratify CV risk.
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Affiliation(s)
- Carlotta Onnis
- Department of Radiology, Azienda Ospedaliero-Universitaria (A.O.U.), di Cagliari—Polo di Monserrato, Cagliari, Italy
| | - Christian Cadeddu Dessalvi
- Department of Medical Sciences and Public Health, Università Degli Studi di Cagliari, Cagliari, Italy
- *Correspondence: Christian Cadeddu Dessalvi,
| | | | - Giuseppe Muscogiuri
- Department of Radiology, San Luca Hospital, Istituto Auxologico Italiano IRCCS, University of Milano-Bicocca, Milan, Italy
| | - Simone Angius
- Department of Medical Sciences and Public Health, Università Degli Studi di Cagliari, Cagliari, Italy
| | - Francesca Contini
- Department of Medical Sciences and Public Health, Università Degli Studi di Cagliari, Cagliari, Italy
| | - Jasjit S. Suri
- Stroke Diagnostic and Monitoring Division, AtheroPoint™, United States and Advanced Knowledge Engineering Centre, Global Biomedical Technologies Inc. (GBTI), Roseville, CA, United States
| | - Sandro Sironi
- Department of Radiology, San Luca Hospital, Istituto Auxologico Italiano IRCCS, University of Milano-Bicocca, Milan, Italy
| | - Rodrigo Salgado
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
| | - Antonio Esposito
- Experimental Imaging Center, Istituto di Ricovero e Cure a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero-Universitaria (A.O.U.), di Cagliari—Polo di Monserrato, Cagliari, Italy
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16
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Sakai Y, Lehman VT, Eisenmenger LB, Obusez EC, Kharal GA, Xiao J, Wang GJ, Fan Z, Cucchiara BL, Song JW. Vessel wall MR imaging of aortic arch, cervical carotid and intracranial arteries in patients with embolic stroke of undetermined source: A narrative review. Front Neurol 2022; 13:968390. [PMID: 35968273 PMCID: PMC9366886 DOI: 10.3389/fneur.2022.968390] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
Despite advancements in multi-modal imaging techniques, a substantial portion of ischemic stroke patients today remain without a diagnosed etiology after conventional workup. Based on existing diagnostic criteria, these ischemic stroke patients are subcategorized into having cryptogenic stroke (CS) or embolic stroke of undetermined source (ESUS). There is growing evidence that in these patients, non-cardiogenic embolic sources, in particular non-stenosing atherosclerotic plaque, may have significant contributory roles in their ischemic strokes. Recent advancements in vessel wall MRI (VW-MRI) have enabled imaging of vessel walls beyond the degree of luminal stenosis, and allows further characterization of atherosclerotic plaque components. Using this imaging technique, we are able to identify potential imaging biomarkers of vulnerable atherosclerotic plaques such as intraplaque hemorrhage, lipid rich necrotic core, and thin or ruptured fibrous caps. This review focuses on the existing evidence on the advantages of utilizing VW-MRI in ischemic stroke patients to identify culprit plaques in key anatomical areas, namely the cervical carotid arteries, intracranial arteries, and the aortic arch. For each anatomical area, the literature on potential imaging biomarkers of vulnerable plaques on VW-MRI as well as the VW-MRI literature in ESUS and CS patients are reviewed. Future directions on further elucidating ESUS and CS by the use of VW-MRI as well as exciting emerging techniques are reviewed.
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Affiliation(s)
- Yu Sakai
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Vance T. Lehman
- Department of Radiology, The Mayo Clinic, Rochester, MN, United States
| | - Laura B. Eisenmenger
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States
| | | | - G. Abbas Kharal
- Department of Neurology, Cerebrovascular Center, Neurological Institute, Cleveland, OH, United States
| | - Jiayu Xiao
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Grace J. Wang
- Department of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Zhaoyang Fan
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Brett L. Cucchiara
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jae W. Song
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
- *Correspondence: Jae W. Song
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17
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Saba L, Antignani PL, Gupta A, Cau R, Paraskevas KI, Poredos P, Wasserman B, Kamel H, Avgerinos ED, Salgado R, Caobelli F, Aluigi L, Savastano L, Brown M, Hatsukami T, Hussein E, Suri JS, Mansilha A, Wintermark M, Staub D, Montequin JF, Rodriguez RTT, Balu N, Pitha J, Kooi ME, Lal BK, Spence JD, Lanzino G, Marcus HS, Mancini M, Chaturvedi S, Blinc A. International Union of Angiology (IUA) consensus paper on imaging strategies in atherosclerotic carotid artery imaging: From basic strategies to advanced approaches. Atherosclerosis 2022; 354:23-40. [DOI: 10.1016/j.atherosclerosis.2022.06.1014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/10/2022] [Accepted: 06/14/2022] [Indexed: 12/24/2022]
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18
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Holmes DR, Alkhouli MA, Klaas JP, Brinjikji W, Savastano LE, Lanzino G, Benson JC. Change of Heart: The Underexplored Role of Plaque Hemorrhage in the Evaluation of Stroke of Undetermined Etiology. J Am Heart Assoc 2022; 11:e025323. [PMID: 35475334 PMCID: PMC9238607 DOI: 10.1161/jaha.122.025323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In the evaluation of embolic strokes of undetermined source, great emphasis is often placed on cardiovascular disease, namely on atrial fibrillation. Other pathophysiologic mechanisms, however, may also be involved. Carotid artery intraplaque hemorrhage (IPH)—the presence of blood components within an atheromatous plaque—has become increasingly recognized as a possible etiologic mechanism in some cryptogenic strokes. IPH is a marker of plaque instability and is associated with ipsilateral neurologic ischemic events, even in nonstenotic carotid plaques. As recognition of carotid IPH as an etiology of embolic strokes has grown, so too has the complexity with which such patients are evaluated and treated, particularly because overlaps exist in the risk factors for atrial fibrillation and IPH. In this article, we review what is currently known about carotid IPH and how this clinical entity should be approached in the context of the evaluation of embolic strokes of undetermined source.
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Affiliation(s)
- David R Holmes
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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Benson J, Nardi V, Madhavan A, Bois M, Saba L, Savastano L, Lerman A, Lanzino G. Reassessing the Carotid Artery Plaque "Rim Sign" on CTA: A New Analysis with Histopathologic Confirmation. AJNR Am J Neuroradiol 2022; 43:429-434. [PMID: 35210276 PMCID: PMC8910788 DOI: 10.3174/ajnr.a7443] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/23/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The CTA "rim sign" has been proposed as an imaging marker of intraplaque hemorrhage in carotid plaques. This study sought to investigate such findings using histopathologic confirmation. MATERIALS AND METHODS Included patients had CTA neck imaging <1 year before carotid endarterectomy. On imaging, luminal stenosis and the presence of adventitial (<2-mm peripheral) and "bulky" (≥2-mm) calcifications, total plaque thickness, soft-tissue plaque thickness, calcification thickness, and the presence of ulcerations were assessed. The rim sign was defined as the presence of adventitial calcifications with internal soft-tissue plaque of ≥2 mm in maximum thickness. Carotid endarterectomy specimens were assessed for both the presence and the proportional makeup of lipid material, intraplaque hemorrhage, and calcification. RESULTS Sixty-seven patients were included. Twenty-three (34.3%) were women; the average age was 70.4 years. Thirty-eight (57.7%) plaques had a rim sign on imaging, with strong interobserver agreement (κ = 0.85). A lipid core was present in 64 (95.5%) plaques (average, 22.2% proportion of plaque composition); intraplaque hemorrhage was present in 52 (77.6%), making up, on average, 13.7% of the plaque composition. The rim sign was not associated with the presence of intraplaque hemorrhage (P = .11); however, it was associated with a greater proportion of intraplaque hemorrhage in a plaque (P = .049). The sensitivity and specificity of the rim sign for intraplaque hemorrhage were 61.5% and 60.0%, respectively. CONCLUSIONS The rim sign is not associated with the presence of intraplaque hemorrhage on histology. However, it is associated with a higher proportion of hemorrhage within a plaque and therefore may be a biomarker of more severe intraplaque hemorrhage, if present.
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Affiliation(s)
- J.C. Benson
- From the Departments of Radiology (J.C.B., A.A.M.)
| | | | | | - M.C. Bois
- Laboratory Medicine and Pathology (M.C.B., A.L.)
| | - L. Saba
- Department of Medical Sciences (L. Saba), University of Cagliari, Cagliari, Italy
| | - L. Savastano
- Neurosurgery (L. Savastano, G.L.), Mayo Clinic, Rochester, Minnesota
| | - A. Lerman
- Laboratory Medicine and Pathology (M.C.B., A.L.)
| | - G. Lanzino
- Neurosurgery (L. Savastano, G.L.), Mayo Clinic, Rochester, Minnesota
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Gimnich OA, Zil-E-Ali A, Brunner G. Imaging Approaches to the Diagnosis of Vascular Diseases. Curr Atheroscler Rep 2022; 24:85-96. [PMID: 35080717 DOI: 10.1007/s11883-022-00988-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Vascular imaging is a complex field including numerous modalities and imaging markers. This review is focused on important and recent findings in atherosclerotic carotid artery plaque imaging with an emphasis on developments in magnetic resonance imaging (MRI) and computed tomography (CT). RECENT FINDINGS Recent evidence shows that carotid plaque characteristics and not only established measures of carotid plaque burden and stenosis are associated independently with cardiovascular outcomes. On carotid MRI, the presence of a lipid-rich necrotic core (LRNC) has been associated with incident cardiovascular disease (CVD) events independent of wall thickness, a traditional measure of plaque burden. On carotid MRI, intraplaque hemorrhage (IPH) presence has been identified as an independent predictor of stroke. The presence of a fissured carotid fibrous cap has been associated with contrast enhancement on CT angiography imaging. Carotid artery plaque characteristics have been associated with incident CVD events, and advanced plaque imaging techniques may gain additional prominence in the clinical treatment decision process.
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Affiliation(s)
- Olga A Gimnich
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Ahsan Zil-E-Ali
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Gerd Brunner
- Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Hershey, PA, USA.
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Trandafir C, Laurent-Chabalier S, Cosma C, Frandon J, Thouvenot E, Renard D. Association of symptomatic atherosclerotic carotid arteries with plaque areas showing low densities on CTA. Eur J Neurol 2021; 29:1056-1061. [PMID: 34941017 DOI: 10.1111/ene.15229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/12/2021] [Accepted: 12/01/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Intraplaque hemorrhage (IPH) is a key feature of vulnerable carotid atherosclerotic plaque (CAP), associated with low densities (<25 Hounsfield unit, HU) on CTA. This study aimed to analyze CAP on routine CTA performed in patients with symptomatic and asymptomatic carotid stenosis undergoing carotid endarterectomy (CEA) by assessing HU of the CAP area showing the lowest density (CAPALD) using radiological tools available in daily clinical practice, and to compare CAPALD values between symptomatic and asymptomatic carotids. MATERIAL AND METHODS We retrospectively screened pre-operative CTA scans of 206 consecutive adult patients undergoing CEA for symptomatic or asymptomatic stenosis. CAPALD values were compared between symptomatic and asymptomatic carotids. Asymptomatic carotids included arteries contralateral to the symptomatic CEA artery, and asymptomatic stenotic arteries undergoing CEA and their contralateral arteries. Carotids were excluded when <30% stenosis, or when CAP could not be identified or CAPALD not measured. RESULTS In total, 95 symptomatic and 112 asymptomatic carotids (derived from 174 patients) were analysed. In multivariate analysis, symptomatic arteries showed more severe stenosis (median 70% vs. 67%, p=0.0228) and lower CAPALD values (median 17 vs. 25 HU, p=0.049), whereas degree of stenosis and CAPALD values were not correlated (rho=-0.02, p=0.77). HU values <25 were more frequent in symptomatic than asymptomatic carotids (68% vs. 47%, p=0.0022). CONCLUSION On CTA, symptomatic carotids are associated with CAP areas with low densities. CTA analysis of CAP may be interesting to help identifying vulnerable plaques at risk for future stroke, especially in patients lacking strict indications for CEA based on the current guidelines.
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Affiliation(s)
| | - Sabine Laurent-Chabalier
- Department of Biostatistics, Clinical Epidemiology, Public Health, and Innovation in Methodology, CHU Nîmes, Univ. Montpellier, Nîmes, France
| | - Catalin Cosma
- Department of Vascular and Thoracic Surgery, CHU Nîmes, Univ. Montpellier, Nîmes, France
| | - Julien Frandon
- Department of Medical Imaging, CHU Nîmes, Univ. Montpellier, Nîmes, France
| | - Eric Thouvenot
- Department of Neurology, CHU Nîmes, Univ. Montpellier, Nîmes, France.,Institut de Génomique Fonctionnelle, CNRS, UMR5203, INSERM 1191, Univ. Montpellier, Montpellier, France
| | - Dimitri Renard
- Department of Neurology, CHU Nîmes, Univ. Montpellier, Nîmes, France
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Kong Y, Kong Y, Dai Y, Zhang J. Prognostic value of color Doppler ultrasound, D-dimer, and Lp-PLA2 levels in carotid atherosclerotic stenosis. Am J Transl Res 2021; 13:13508-13515. [PMID: 35035692 PMCID: PMC8748169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/31/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND This research mainly explored the prognostic value of color Doppler ultrasound combined with D-dimer and Lp-PLA2 levels in carotid atherosclerotic stenosis. METHODS From January 2018 to August 2020, 67 patients (patient group) who were diagnosed as cerebral infarction by neurology and carotid atherosclerotic stenosis by digital subtraction angiography (DSA) were recruited in this research. Fifty healthy people served as controls and were brought into this research. PI (pulsatility index), RI (resistance index), Vd (end diastolic velocity), and Vs (peak systolic velocity) were obtained by color Doppler ultrasound vascular wall imaging. The levels of D-dimer and Lp-PLA2 in serum were examined. The receiver operating characteristics (ROC) curve was employed to analyze the diagnostic efficacy of color Doppler ultrasound imaging parameters, serum D-dimer, and lipoprotein-associated phospholipase A2 (Lp-PLA2) levels on the prognosis of patients with carotid atherosclerotic stenosis. RESULTS The levels of PI, RI, serum D-dimer, and Lp-PLA2 in the patient group were higher than those in the control group (P < 0.05). Levels of Vd and Vs were lower. PI, RI, serum D-dimer, and Lp-PLA2 levels were positively correlated with mRS scores (P < 0.05). Vd and Vs were negatively correlated (P < 0.05). The measurement of VD and Lp-PLA2 levels was more effective in predicting the prognosis of patients with carotid atherosclerotic stenosis. CONCLUSION Vd parameters and Lp-PLA2 levels have high clinical values in carotid atherosclerotic stenosis, and are worthy of clinical application.
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Affiliation(s)
- Yu Kong
- The Second Department of Neurology, Shangqiu First People’s HospitalShangqiu 476000, Henan Province, China
| | - Ying Kong
- Ultrasonography Department, Shangqiu First People’s HospitalShangqiu 476000, Henan Province, China
| | - Yunyi Dai
- The Second Department of Neurology, Shangqiu First People’s HospitalShangqiu 476000, Henan Province, China
| | - Jianping Zhang
- The Second Department of Neurology, Shangqiu First People’s HospitalShangqiu 476000, Henan Province, China
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Sato S, Matsumoto H, Li D, Ohya H, Mori H, Sakai K, Ogura K, Oishi Y, Masaki R, Tanaka H, Kondo S, Tsujita H, Tsukamoto S, Isodono K, Kitamura R, Komori Y, Yoshii N, Sato I, Christodoulou AG, Xie Y, Shinke T. Coronary High-Intensity Plaques at T1-weighted MRI in Stable Coronary Artery Disease: Comparison with Near-Infrared Spectroscopy Intravascular US. Radiology 2021; 302:557-565. [PMID: 34904874 DOI: 10.1148/radiol.211463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background The histologic nature of coronary high-intensity plaques (HIPs) at T1-weighted MRI in patients with stable coronary artery disease remains to be fully understood. Coronary atherosclerosis T1-weighted characterization (CATCH) enables HIP detection by simultaneously acquiring dark-blood plaque and bright-blood anatomic reference images. Purpose To determine if intraplaque hemorrhage (IPH) or lipid is the predominant substrate of HIPs on T1-weighted images by comparing CATCH MRI scans with findings on near-infrared spectroscopy (NIRS) intravascular US (IVUS) images. Materials and Methods This study retrospectively included consecutive patients who underwent CATCH MRI before NIRS IVUS between December 2019 and February 2021 at two facilities. At MRI, HIP was defined as plaque-to-myocardium signal intensity ratio of at least 1.4. The presence of an echolucent zone at IVUS (reported to represent IPH) was recorded. NIRS was used to determine the lipid component of atherosclerotic plaque. Lipid core burden index (LCBI) was calculated as the fraction of pixels with a probability of lipid-core plaque greater than 0.6 within a region of interest. Plaque with maximum LCBI within any 4-mm-long segment (maxLCBI4 mm) greater than 400 was regarded as lipid rich. Multivariable analysis was performed to evaluate NIRS IVUS-derived parameters associated with HIPs. Results There were 205 plaques analyzed in 95 patients (median age, 74 years; interquartile range [IQR], 67-78 years; 75 men). HIPs (n = 42) at MRI were predominantly associated with an echolucent zone at IVUS (79% [33 of 42] vs 8.0% [13 of 163], respectively; P < .001) and a higher maxLCBI4 mm at NIRS (477 [IQR, 258-738] vs 232 [IQR, 59-422], respectively; P < .001) than non-HIPs. In the multivariable model, HIPs were independently associated with an echolucent zone (odds ratio, 24.5; 95% CI: 9.3, 64.7; P < .001), but not with lipid-rich plaque (odds ratio, 2.0; 95% CI: 0.7, 5.4; P = .20). Conclusion The predominant substrate of T1-weighed MRI-defined high-intensity plaques in stable coronary artery disease was intraplaque hemorrhage, not lipid. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Stuber in this issue.
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Affiliation(s)
- Shunya Sato
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Hidenari Matsumoto
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Debiao Li
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Hidefumi Ohya
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Hiroyoshi Mori
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Koshiro Sakai
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Kunihiro Ogura
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Yosuke Oishi
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Ryota Masaki
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Hideaki Tanaka
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Seita Kondo
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Hiroaki Tsujita
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Shigeto Tsukamoto
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Koji Isodono
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Ryoji Kitamura
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Yoshiaki Komori
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Nobuyuki Yoshii
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Ikumi Sato
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Anthony G Christodoulou
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Yibin Xie
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
| | - Toshiro Shinke
- From the Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan (S.S., H. Matsumoto, K.S., K.O., Y.O., R.M., H. Tanaka, S.K., H. Tsujita, S.T., T.S.); Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif (D.L., A.G.C., Y.X.); Departments of Cardiology (H.O., K.I., R.K.) and Radiological Technology (I.S.), Ijinkai Takeda General Hospital, Kyoto, Japan; Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan (H. Mori); MR Research & Collaboration Department, Siemens Healthcare K.K., Tokyo, Japan (Y.K.); and Department of Radiological Technology, Showa University Hospital, Tokyo, Japan (N.Y.)
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Matsumoto H, Xie Y, Li D, Shinke T. Non-lipid-rich low attenuation plaque with intraplaque haemorrhage assessed by multimodality imaging: a case report. Eur Heart J Case Rep 2021; 5:ytab460. [PMID: 34993403 PMCID: PMC8728716 DOI: 10.1093/ehjcr/ytab460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/13/2021] [Accepted: 11/09/2021] [Indexed: 12/01/2022]
Abstract
Background The lipid-rich necrotic core is a major pathological hallmark of acute coronary syndrome. Low attenuation plaque (LAP) on coronary computed tomography angiography (CCTA), defined as plaque CT attenuation of <30 Hounsfield units, is commonly believed to correspond to the lipid component. This report presents a non-lipid-rich LAP with intraplaque haemorrhage of the left main coronary artery (LM), as assessed by CCTA, near-infrared spectroscopy (NIRS), and non-contrast magnetic resonance imaging (MRI) using coronary atherosclerosis T1-weighted characterization with integrated anatomical reference technique, recently developed by our group. Case summary A 75-year-old woman presented with chest discomfort on exertion. Coronary computed tomography angiography revealed severe stenosis of the mid-left circumflex coronary artery and minimal stenosis with a large eccentric LM plaque. The LM lesion had an LAP, with a minimum plaque attenuation of 25 Hounsfield units. On non-contrast T1-weighted MRI, a high-intensity plaque with a plaque-to-myocardium signal intensity ratio of 3.02 was observed within the vessel wall, indicating intraplaque haemorrhage. Near-infrared spectroscopy categorized the lesion as non-lipid-rich, with a maximum lipid core burden index in 4 mm of 169. Discussion Intraplaque haemorrhage is a key feature of plaque instability, which is different from the lipid-rich necrotic core. Non-contrast T1-weighted MRI is ideal for detecting intraplaque haemorrhage with short T1 values. The imaging findings suggest that LAP on CCTA may represent not only lipid-rich plaques but also intraplaque haemorrhage. Magnetic resonance imaging provides a unique insight into plaque vulnerability from a different perspective than lipid assessment. Multimodality imaging, including MRI, facilitates the understanding of complicated plaque morphologies. Keywords Atherosclerosis • Case report • Computed tomography • Intraplaque haemorrhage • Lipid-rich plaque • Magnetic resonance imaging • Near-infrared spectroscopy-intravascular ultrasound
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Affiliation(s)
- Hidenari Matsumoto
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan
| | - Yibin Xie
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Debiao Li
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine, 1-5-8 Hatanodai Shinagawa-ku, Tokyo 142-8555, Japan
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Review of imaging biomarkers for the vulnerable carotid plaque. JVS Vasc Sci 2021; 2:149-158. [PMID: 34617065 PMCID: PMC8489200 DOI: 10.1016/j.jvssci.2021.03.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/23/2021] [Indexed: 12/26/2022] Open
Abstract
Identification of carotid artery atherosclerosis is conventionally based on measurements of luminal stenosis. However, histopathologic studies demonstrate considerable differences between plaques with identical degrees of stenosis and indicate that certain plaque features are associated with increased risk for ischemic events. As a result of the rapid technological evolution in medical imaging, several important steps have been taken in the field of carotid plaque imaging allowing us to visualize the carotid atherosclerotic plaque and its composition in great detail. For computed tomography, magnetic resonance imaging, positron emission tomography, and ultrasound scan, evidence has accumulated on novel imaging-based markers that confer information on carotid plaque vulnerability, such as intraplaque hemorrhage and lipid-rich necrotic cores. In terms of the imaging-based identification of individuals at high risk of stroke, routine assessments of such imaging markers are the way forward for improving current clinical practice. The current review highlights the main characteristics of the vulnerable plaque indicating their role in the etiology of ischemic stroke as identified by intensive plaque imaging.
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Benson JC, Savastano L, Nardi V, Lanzino G, Lerman A, Brinjikji W. Intraplaque CTA characteristics as predictors of symptomatology: a semiautomated volumetric analysis. Emerg Radiol 2021; 29:75-80. [PMID: 34613574 DOI: 10.1007/s10140-021-01941-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Prior studies comparing CT characteristics of carotid plaques to symptomatology have relied on gross morphologic imaging features. This study sought to determine if volumetric measurements of carotid plaque components are associated with ipsilateral neurologic symptoms. MATERIALS AND METHODS CTA images of consecutive patients that underwent a carotid endarterectomy were reviewed with a semiautomated software package. Intraplaque volumes of intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), and matrix were computed, as was the degree of arterial stenosis. Statistics were analyzed on a per cerebral hemisphere basis, and dichotomized into symptomatic and asymptomatic. Clinical and radiological endpoints included transient ischemic attack (TIA), ischemic stroke diagnosed on imaging studies, ophthalmologically diagnosed central or branch retinal artery occlusion (RAO), or amaurosis fugax. RESULTS One hundred sixty-eight carotid plaques were reviewed. The average age is 70.8 years (SD = 8.8); 32/87 (36.8%) were female. Sixty-seven of eighty-seven (77.0%) patients were symptomatic. Sixty-six of one hundred sixty-eight (39.3%) plaques were ipsilateral to the patient's symptoms, while 102/168 (60.7%) were ipsilateral to an asymptomatic hemisphere. Greater intraplaque volumes of IPH (p = 0.03), LRNC (p = 0.008), and matrix (p = 0.0008) were associated with symptoms, as was greater proportion of LRNC in regard to plaque volume (p = 0.04). All but proportion of LRNC remained statistically significant after adjustment for plaque size. More severe luminal stenosis was also associated with ipsilateral neurologic symptoms, both when calculated by smallest diameter or by area (p < 0.0001 for both). CONCLUSION Higher volumes of intraplaque IPH, LRNC, matrix, and degree of arterial stenosis are associated with ipsilateral neurologic symptoms. Greater intraplaque proportions of LRNC are also associated with ipsilateral ischemic manifestations, suggesting that larger relative composition of lipids may be particularly predictive of symptomatology.
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Benson JC, Nardi V, Hunt CH, Lerman A, Lanzino G, Brinjikji W. Cardiovascular risk factors and cervical carotid plaque features on CT angiography. Neuroradiol J 2021; 35:346-351. [PMID: 34569868 DOI: 10.1177/19714009211047450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Little is known about the impact that cardiovascular (CV) risk factors have on the formation of various carotid atherosclerotic plaque features. This study set out to assess the association between CV risk factors and plaque characteristics on computed tomography (CT) angiography (CTA). MATERIALS AND METHODS A retrospective review was completed of consecutive patients that underwent a carotid endarterectomy and had CTA imaging of the head and neck vasculature. Atherosclerotic plaques of both carotid arteries were evaluated for calcification(s), low-density plaque (LDP) components, ulceration(s), and degree of stenosis. Various clinical CV risk factors were assessed using medical records. Last recorded laboratory levels were dichotomized into categories: total cholesterol <200 or ≥200 mg/dL, low-density lipoprotein (LDL) <130 or ≥130 mg/dL, high-density lipoprotein <35 or ≥35 mg/dL, and triglyceride <200 or ≥200 mg/dL. RESULTS Of 97 included patients, 62 were male (63.9%); the average age was 72.7 (standard deviation = 9.5). Calcifications were in 95/97 (97.9%) of patients (one or both carotid plaques); LDP components were in 73/97 (75.3%), and ulcerations were in 21/97 (21.6%). Elevated total cholesterol and elevated LDL levels were both associated with a higher likelihood of LDP components (p = 0.004 and p = 0.02, respectively). There were no other statistically significant associations between individual plaque features or severity of arterial stenosis and CV risk factors. CONCLUSION In carotid atherosclerotic plaques, LDP components are more frequently present in one or both carotid arteries in patients with elevated total cholesterol and/or LDL levels. Such findings raise the possibility that cholesterol levels may be directly related to the formation of specific high-risk plaque features.
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Affiliation(s)
| | - Valentina Nardi
- Department of Cardiovascular Medicine, 6915Mayo Clinic, Mayo Clinic, USA
| | - Christopher H Hunt
- Department of Cardiovascular Medicine, 6915Mayo Clinic, Mayo Clinic, USA
| | | | | | - Waleed Brinjikji
- Department of Cardiovascular Medicine, 6915Mayo Clinic, Mayo Clinic, USA
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Utility of Dual-Layer Spectral-Detector CTA to Characterize Carotid Atherosclerotic Plaque Components: An Imaging-Histopathology Comparison in Patients Undergoing Endarterectomy. AJR Am J Roentgenol 2021; 218:517-525. [PMID: 34549604 DOI: 10.2214/ajr.21.26540] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: The composition of non-calcified portions of carotid atherosclerotic plaque represents an important marker of plaque vulnerability and ischemia risk. Objective: To assess the utility of dual-layer spectral-detector CTA (DLCTA) parameters for carotid plaque component characterization, using histologic results from carotid endarterectomy (CEA) as reference. Methods: Seven patients (5 male, 2 female; 61.6±8.5 years old) with carotid plaque awaiting CEA were prospectively enrolled and underwent preoperative supra-aortic DLCTA. A neuroradiologist and pathologist performed joint slice-by-slice review of histologic slices of resected plaques and CTA images. ROIs were placed on non-calcified components [lipid-rich necrotic core (LRNC), intraplaque hemorrhage (IPH), fibrous tissue, loose matrix (LM)] on CTA images in comparison with corresponding histologic slices using anatomic landmarks. For each ROI, attenuation was recorded for polyenergetic images (CTPI) and virtual monoenergetic images with keV ranging from 40-140 (CT40-140keV); attenuation spectrum curve slope was calculated; and Z-effective value (representing effective atomic number) was recorded. DLCTA parameters were compared among plaque components. Results: Seven plaques with a total of 65 slices and 364 ROIs (159 fibrous tissue, 96 LRNC, 86 loose matrix, 23 IPH) were analyzed. All parameters (CTPI, CT40-140keV, slope from 40 to 140 keV, Z-effective value) showed significant differences between LRNC and the other components (all p<.001). For example, mean CTPI was 37.1±15.1 HU for LRNC, 58.4±21.6 HU for IPH, 69.7±20.5 HU for fibrous tissue, and 69.6±19.6 HU for loose matrix; mean CT40keV was 28.1±36.7 HU for LRNC, 87.5±48.9 HU for IPH, 106.3±47.5 HU for fibrous tissue, and 102.6±48.0 HU for loose matrix. AUC for differentiating LRNC from other components was highest (0.945) for CT40kev and decreased with higher keV; AUC for CTPI was 0.908. CT40kev also had highest accuracy (90.4%); at cutoff of 55.7 HU, CT40kev had 88.5% sensitivity and 90.9% specificity. For differentiating IPH from fibrous tissue and loose matrix, AUC was highest at 0.652 for CTPI and 0.645 for CT40kev. Conclusion: DLCTA showed strong performance in differentiating LRNC from other non-calcified plaque components; CT40kev had highest accuracy, outperforming conventional polyenergetic images. Clinical Impact: DLCTA parameters may help characterize carotid plaque composition as a marker of vulnerable plaque and ischemia risk.
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Migdalski A, Jawien A. New insight into biology, molecular diagnostics and treatment options of unstable carotid atherosclerotic plaque: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1207. [PMID: 34430648 PMCID: PMC8350668 DOI: 10.21037/atm-20-7197] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/24/2021] [Indexed: 12/23/2022]
Abstract
Indications for intervention in hemodynamically relevant carotid artery stenosis (carotid endarterectomy or stenting) are primarily based on a degree of stenosis and symptomatology. To date the plaque vulnerability is rarely taken into account in clinical decision making although development of molecular imaging allows a better understanding of plaque biology and provides new techniques detecting potentially vulnerable plaque at risk. A significant number of reports describing the mechanisms of unstable plaque formation suggest that it is a multifactorial process. Inflammation, lipid accumulation, apoptosis, proteolysis, the thrombotic process and angiogenesis are among the main factors of carotid plaque destabilization. Although inflammation is a key process in development of plaque vulnerability, the hemostasis and neoangiogenesis should be regarded as equally important. Only a small group of asymptomatic patients may benefit from the invasive treatment and it remains a challenge to determine whether initially asymptomatic carotid plaque become unstable or vulnerable. Currently, the main task of research on atherosclerotic lesion imaging is focused on functional state of the plaque. The presence of one or more features such as stenosis progression, large plaque area, large juxta-luminal black area, plaque echolucency, intra-plaque hemorrhage, impaired cerebral vascular reserve and spontaneous embolization may indicate patients at higher risk for stroke suitable for revascularization. Treatment of carotid stenosis as one of the manifestations of generalized atherosclerosis requires a broad approach. Nowadays pharmacological treatment options for the atherosclerotic process are largely aimed at stimulating the plaque stabilization, but in symptomatic patients and selected asymptomatic patients, carotid plaque should be removed as a potential source of embolism.
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Affiliation(s)
- Arkadiusz Migdalski
- Department of Vascular Surgery and Angiology, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Arkadiusz Jawien
- Department of Vascular Surgery and Angiology, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
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Benson JC, Nardi V, Bois MC, Saba L, Brinjikji W, Savastano L, Lanzino G, Lerman A. Correlation between computed tomography angiography and histology of carotid artery atherosclerosis: Can semi-automated imaging software predict a plaque's composition? Interv Neuroradiol 2021; 28:332-337. [PMID: 34397307 DOI: 10.1177/15910199211031093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Using computed tomography angiography to differentiate between components of carotid atherosclerotic lesions remains largely elusive. This study sought to validate a semi-automated software for computed tomography angiography plaque analysis using histologic comparisons. MATERIALS AND METHODS A retrospective review was performed of consecutive patients that underwent a carotid endarterectomy, with pre-procedural computed tomography angiography imaging of the cervical arterial vasculature available for review. Images were evaluated using a commercially-available software package, which produced segmented analyses of intraplaque components (e.g. intraplaque hemorrhage, lipid-rich necrotic core, and calcifications). On imaging, each component was assessed in terms of its (1) presence or absence, and (2) both volume and proportion of the total plaque volume (if present). On histological evaluation of carotid endarterectomy specimens, each component was evaluated as an estimated proportion of total plaque volume. RESULTS Of 80 included patients, 30 (37.5%) were female. The average age was 69.7 years (SD = 9.1). Based on imaging, intraplaque hemorrhage was the smallest contributor to plaque composition (1.2% of volumes on average). Statistically significant linear associations were noted between the proportion of intraplaque hemorrhage, lipid-rich necrotic core, and calcifications on histology and the volume of each component on imaging (p values ranged from 0.0008 to 0.01). Area under curve were poor for intraplaque hemorrhage and lipid-rich necrotic core (0.59 and 0.61, respectively) and acceptable for calcifications (0.73). CONCLUSION Semi-automated analyses of computed tomography angiography have limited diagnostic accuracy in the detection of intraplaque hemorrhage and lipid-rich necrotic core in carotid artery plaques. However, volumetric imaging measurements of different components corresponded with histologic analysis.
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Affiliation(s)
| | | | - Melanie C Bois
- Department of Laboratory Medicine and Pathology, 6915Mayo Clinic, USA
| | - Luca Saba
- Department of Medical Sciences, 3111University of Cagliari, Italy
| | | | | | | | - Amir Lerman
- Department of Cardiovascular Medicine, 6915Mayo Clinic, USA
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Zaman RT, Kosuge H, Gambhir SS, Xing L. Detection of Carotid Artery Stenosis with Intraplaque Hemorrhage and Neovascularization Using a Scanning Interferometer. NANO LETTERS 2021; 21:5714-5721. [PMID: 34156253 DOI: 10.1021/acs.nanolett.1c01441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Carotid artery stenosis (CAS) is a major cause of stroke or transient ischemic attack (TIA, mini-stroke) in the United States. Carotid endarterectomy (CEA), a surgical procedure, is used to treat CAS. According to the American Heart Association, 1 out of 5 patients underwent CEA inappropriately, which was most commonly due to apparent overestimation of stenosis severity, and half had uncertain indicators. The current imaging modalities are limited in providing critical information on carotid arterial plaque content, extent, and biology. To circumvent these limitations, we developed a sensing interferometer (SI) imaging system to assess vulnerable carotid plaques noninvasively to detect stenosis, neovascularization, and intraplaque hemorrhage (IPH). We have custom-built a SI prototype and its peripheral systems with back-mode-projection capability. We detected stenosis, neo-vessels, and IPH through SI imaging system in in vivo mice carotid atherosclerotic plaques and further verified the same plaques ex vivo through a histology scope, CRi Maestro, and histological analysis.
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Affiliation(s)
- Raiyan Tripti Zaman
- Department of Radiology, Harvard Medical School, Boston, Massachusetts 02129, United States
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Boston, Massachusetts 02129, United States
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, United States
- Division of Medical Physics, Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California 94305, United States
| | - Hisanori Kosuge
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, United States
| | - Sanjiv Sam Gambhir
- Department of Radiology, Stanford University School of Medicine, Stanford, California 94304, United States
| | - Lei Xing
- Division of Medical Physics, Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California 94305, United States
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18Fluorodeoxyglucose uptake in relation to fat fraction and R2* in atherosclerotic plaques, using PET/MRI: a pilot study. Sci Rep 2021; 11:14217. [PMID: 34244569 PMCID: PMC8270927 DOI: 10.1038/s41598-021-93605-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/24/2021] [Indexed: 12/20/2022] Open
Abstract
Inflammation inside Atherosclerotic plaques represents a major pathophysiological process driving plaques towards rupture. Pre-clinical studies suggest a relationship between lipid rich necrotic core, intraplaque hemorrhage and inflammation, not previously explored in patients. Therefore, we designed a pilot study to investigate the feasibility of assessing the relationship between these plaque features in a quantitative manner using PET/MRI. In 12 patients with high-grade carotid stenosis the extent of lipid rich necrotic core and intraplaque hemorrhage was quantified from fat and R2* maps acquired with a previously validated 4-point Dixon MRI sequence in a stand-alone MRI. PET/MRI was used to measure 18F-FDG uptake. T1-weighted images from both scanners were used for registration of the quantitative Dixon data with the PET images. The plaques were heterogenous with respect to their volumes and composition. The mean values for the group were as follows: fat fraction (FF) 0.17% (± 0.07), R2* 47.6 s−1 (± 10.9) and target-to-blood pool ratio (TBR) 1.49 (± 0.48). At group level the correlation between TBR and FFmean was − 0.406, p 0.19 and for TBR and R2*mean 0.259, p 0.42. The lack of correlation persisted when analysed on a patient-by-patient basis but the study was not powered to draw definitive conclusions. We show the feasibility of analysing the quantitative relationship between lipid rich necrotic cores, intraplaque haemorrhage and plaque inflammation. The 18F-FDG uptake for most patients was low. This may reflect the biological complexity of the plaques and technical aspects inherent to 18F-FDG measurements. Trial registration: ISRCTN, ISRCTN30673005. Registered 05 January 2021, retrospectively registered.
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Abstract
Carotid atherosclerosis is an important contributor to ischemic stroke. When imaging carotid atherosclerosis, it is essential to describe both the degree of luminal stenosis and specific plaque characteristics because both are risk factors for cerebrovascular ischemia. Carotid atherosclerosis can be accurately assessed using multiple imaging techniques, including ultrasonography, computed tomography angiography, and magnetic resonance angiography. By understanding the underlying histopathology, the specific plaque characteristics on each of these imaging modalities can be appreciated. This article briefly describes some of the most commonly encountered plaque features, including plaque calcification, intraplaque hemorrhage, lipid-rich necrotic core, and plaque ulceration.
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Affiliation(s)
- Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA.
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, 525 East 68th Street, Box 141, New York, NY 10021, USA; Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
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34
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Advances in Multimodality Carotid Plaque Imaging: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:16-26. [PMID: 33438455 DOI: 10.2214/ajr.20.24869] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Contemporary imaging methods provide detailed visualization of carotid athero-sclerotic plaque, enabling a major evolution of in vivo carotid plaque imaging evaluation. The degree of luminal stenosis in the carotid artery bifurcation, as assessed by ultrasound, has historically served as the primary imaging feature for determining ischemic stroke risk and the potential need for surgery. However, stroke risk may be more strongly driven by the presence of specific characteristics of vulnerable plaque, as visualized on CT and MRI, than by traditional ultrasound-based assessment of luminal narrowing. This review highlights six promising imaging-based plaque characteristics that harbor unique information regarding plaque vulnerability: maximum plaque thickness and volume, calcification, ulceration, intraplaque hemorrhage, lipid-rich necrotic core, and thin or ruptured fibrous cap. Increasing evidence supports the association of these plaque characteristics with risk of ischemic stroke, although these characteristics have varying suitability for clinical implementation. Key aspects of CT and MRI protocols for carotid plaque imaging are also considered. Practical next steps and hurdles are explored for implementing routine imaging assessment of these plaque characteristics in addition to, or even as replacement for, traditional assessment of the degree of vascular stenosis on ultrasound, in the identification of individuals at high risk of ischemic stroke.
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Saba L, Mossa-Basha M, Abbott A, Lanzino G, Wardlaw JM, Hatsukami TS, Micheletti G, Balestrieri A, Hedin U, Moody AR, Wintermark M, DeMarco JK. Multinational Survey of Current Practice from Imaging to Treatment of Atherosclerotic Carotid Stenosis. Cerebrovasc Dis 2021; 50:108-120. [PMID: 33440369 DOI: 10.1159/000512181] [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: 07/21/2020] [Accepted: 10/07/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In the last 20-30 years, there have been many advances in imaging and therapeutic strategies for symptomatic and asymptomatic individuals with carotid artery stenosis. Our aim was to examine contemporary multinational practice standards. METHODS Departmental Review Board approval for this study was obtained, and 3 authors prepared the 44 multiple choice survey questions. Endorsement was obtained by the European Society of Neuroradiology, American Society of Functional Neuroradiology, and African Academy of Neurology. A link to the online questionnaire was sent to their respective members and members of the Faculty Advocating Collaborative and Thoughtful Carotid Artery Treatments (FACTCATS). The questionnaire was open from May 16 to July 16, 2019. RESULTS The responses from 223 respondents from 46 countries were included in the analyses including 65.9% from academic university hospitals. Neuroradiologists/radiologists comprised 68.2% of respondents, followed by neurologists (15%) and vascular surgeons (12.9%). In symptomatic patients, half (50.4%) the respondents answered that the first exam they used to evaluate carotid bifurcation was ultrasound, followed by computed tomography angiography (CTA, 41.6%) and then magnetic resonance imaging (MRI 8%). In asymptomatic patients, the first exam used to evaluate carotid bifurcation was ultrasound in 88.8% of respondents, CTA in 7%, and MRA in 4.2%. The percent stenosis upon which carotid endarterectomy or stenting was recommended was reduced in the presence of imaging evidence of "vulnerable plaque features" by 66.7% respondents for symptomatic patients and 34.2% for asymptomatic patients with a smaller subset of respondents even offering procedural intervention to patients with <50% symptomatic or asymptomatic stenosis. CONCLUSIONS We found heterogeneity in current practices of carotid stenosis imaging and management in this worldwide survey with many respondents including vulnerable plaque imaging into their decision analysis despite the lack of proven benefit from clinical trials. This study highlights the need for new clinical trials using vulnerable plaque imaging to select high-risk patients despite maximal medical therapy who may benefit from procedural intervention.
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Affiliation(s)
- Luca Saba
- Department of Radiology, University of Cagliari, Cagliari, Italy,
| | - Mahmoud Mossa-Basha
- Department of Neuroradiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Anne Abbott
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Michigan, USA
| | - Joanna M Wardlaw
- Neuroimaging Sciences, Centre for Clinical Brain Sciences, Edinburgh Imaging and UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Thomas S Hatsukami
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | | | | | - Ulf Hedin
- Department of Vascular Surgery and Molecular Medicine and Surgery, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Alan R Moody
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Max Wintermark
- Neuroradiology Division, Department of Radiology, Stanford University, Stanford, California, USA
| | - J Kevin DeMarco
- Department of Radiology, Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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36
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Baradaran H, Foster T, Harrie P, McNally JS, Alexander M, Pandya A, Anzai Y, Gupta A. Carotid artery plaque characteristics: current reporting practices on CT angiography. Neuroradiology 2020; 63:1013-1018. [PMID: 33236220 DOI: 10.1007/s00234-020-02610-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Extracranial ICA imaging has largely focused on the degree of luminal stenosis, but recent advances suggest specific plaque features are crucial in stroke risk assessment. We evaluated the current state of reporting carotid plaque features on neck CTAs at an academic institution. METHODS In this retrospective observational study, we included neck CTAs performed on patients over age 50 with any reported carotid plaque. We evaluated reports for mention of the following: degree of luminal stenosis, soft plaque, calcified plaque, plaque thickness, quantification of soft and calcified plaque, plaque ulceration, and increased risk associated with specific features. We used Fisher's exact test to compare how often each feature was mentioned. RESULTS We included a total of 651 reports from unique patients (mean age, 68.1 ± 13.3 years). A total of 639 reports (98.1%) explicitly mentioned degree of stenosis per NASCET criteria. Specific plaque features were less frequently characterized: soft plaque in 116 (17.8%); calcified plaque in 166 (25.5%); quantification of the amount of soft plaque and calcified plaque in 24 (3.7%) and 16 (2.5%) reports, respectively; plaque thickness in 12 (1.8%); plaque ulceration in 476 (73.1%); and increased risk associated with plaque in 2 (0.3%). Degree of stenosis was statistically more likely to be mentioned than any other plaque feature (p < 0.001). CONCLUSION Currently, nearly all reports mention the degree of luminal stenosis on neck CTAs while a significant minority mention specific plaque features. Despite mounting evidence of the importance of carotid plaque features in stroke risk assessment, radiology reports do not routinely report these findings.
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Affiliation(s)
- Hediyeh Baradaran
- Department of Radiology and Imaging Sciences, University of Utah, 30 N 1900 E #1A141, Salt Lake City, UT, 84135, USA.
| | - Tyrel Foster
- Department of Radiology and Imaging Sciences, University of Utah, 30 N 1900 E #1A141, Salt Lake City, UT, 84135, USA
| | - Paul Harrie
- Department of Radiology and Imaging Sciences, University of Utah, 30 N 1900 E #1A141, Salt Lake City, UT, 84135, USA
| | - J Scott McNally
- Department of Radiology and Imaging Sciences, University of Utah, 30 N 1900 E #1A141, Salt Lake City, UT, 84135, USA
| | - Matthew Alexander
- Department of Radiology and Imaging Sciences, University of Utah, 30 N 1900 E #1A141, Salt Lake City, UT, 84135, USA
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Yoshimi Anzai
- Department of Radiology and Imaging Sciences, University of Utah, 30 N 1900 E #1A141, Salt Lake City, UT, 84135, USA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA.,Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
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37
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Messas E, Goudot G, Halliday A, Sitruk J, Mirault T, Khider L, Saldmann F, Mazzolai L, Aboyans V. Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review. Eur Heart J Suppl 2020; 22:M35-M42. [PMID: 33664638 PMCID: PMC7916422 DOI: 10.1093/eurheartj/suaa162] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Carotid atherosclerotic plaque is encountered frequently in patients at high cardiovascular risk, especially in the elderly. When plaque reaches 50% of carotid lumen, it induces haemodynamically significant carotid stenosis, for which management is currently at a turning point. Improved control of blood pressure, smoking ban campaigns, and the widespread use of statins have reduced the risk of cerebral infarction to <1% per year. However, about 15% of strokes are still secondary to a carotid stenosis, which can potentially be detected by effective imaging techniques. For symptomatic carotid stenosis, current ESC guidelines put a threshold of 70% for formal indication for revascularization. A revascularization should be discussed for symptomatic stenosis over 50% and for asymptomatic carotid stenosis over 60%. This evaluation should be performed by ultrasound as a first-line examination. As a complement, computed tomography angiography (CTA) and/or magnetic resonance angiography are recommended for evaluating the extent and severity of extracranial carotid stenosis. In perspective, new high-risk markers are currently being developed using markers of plaque neovascularization, plaque inflammation, or plaque tissue stiffness. Medical management of patient with carotid stenosis is always warranted and applied to any patient with atheromatous lesions. Best medical therapy is based on cardiovascular risk factors correction, including lifestyle intervention and a pharmacological treatment. It is based on the tri-therapy strategy with antiplatelet, statins, and ACE inhibitors. The indications for carotid endarterectomy (CEA) and carotid artery stenting (CAS) are similar: for symptomatic patients (recent stroke or transient ischaemic attack ) if stenosis >50%; for asymptomatic patients: tight stenosis (>60%) and a perceived high long-term risk of stroke (determined mainly by imaging criteria). Choice of procedure may be influenced by anatomy (high stenosis, difficult CAS or CEA access, incomplete circle of Willis), prior illness or treatment (radiotherapy, other neck surgery), or patient risk (unable to lie flat, poor AHA assessment). In conclusion, neither systematic nor abandoned, the place of carotid revascularization must necessarily be limited to the plaques at highest risk, leaving a large place for optimized medical treatment as first line management. An evaluation of the value of performing endarterectomy on plaques considered to be at high risk is currently underway in the ACTRIS and CREST 2 studies. These studies, along with the next result of ACST-2 trial, will provide us a more precise strategy in case of carotid stenosis.
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Affiliation(s)
- Emmanuel Messas
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Guillaume Goudot
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Level 6 John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Jonas Sitruk
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Tristan Mirault
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Lina Khider
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Frederic Saldmann
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Lucia Mazzolai
- Angiology Division, CHUV University Hospital, Lausanne, Switzerland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, INSERM 1094 & IRD, Limoges, France
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Mura M, Della Schiava N, Long A, Chirico EN, Pialoux V, Millon A. Carotid intraplaque haemorrhage: pathogenesis, histological classification, imaging methods and clinical value. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1273. [PMID: 33178805 PMCID: PMC7607119 DOI: 10.21037/atm-20-1974] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Vulnerable carotid atherosclerotic plaques are characterised by several risk factors, such as inflammation, neovascularization and intraplaque haemorrhage (IPH). Vulnerable plaques can lead to ischemic events such as stroke. Many studies reported a relationship between IPH, plaque rupture, and ischemic stroke. Histology is the gold standard to evaluate IPH, but it required carotid endarterectomy (CEA) surgery to collect the tissue sample. In this context, several imaging methods can be used as a non-invasive way to evaluate plaque vulnerability and detect IPH. Most imaging studies showed that IPH is associated with plaque vulnerability and stroke, with magnetic resonance imaging (MRI) being the most sensitive and specific to detect IPH as a predictor of ischemic events. These conclusions are however still debated because of the limited number of patients included in these studies; further studies are required to better assess risks associated with different IPH stages. Moreover, IPH is implicated in plaque vulnerability with other risk factors which need to be considered to predict ischemic risk. In addition, MRI sequences standardization is required to compare results from different studies and agree on biomarkers that need to be considered to predict plaque rupture. In these circumstances, IPH detection by MRI could be an efficient clinical method to predict stroke. The goal of this review article is to first describe the pathophysiological process responsible for IPH, its histological detection in carotid plaques and its correlation with plaque rupture. The second part will discuss the benefits and limitations of imaging the carotid plaque, and finally the clinical interest of imaging IPH to predict plaque rupture, focusing on MRI-IPH.
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Affiliation(s)
- Mathilde Mura
- Univ Lyon, University Claude Bernard Lyon 1, Interuniversity Laboratory of Human Movement Biology EA7424, Lyon, France
| | - Nellie Della Schiava
- Department of Vascular and Endovascular Surgery, Groupement Hospitalier Est, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,Institut National des Sciences Appliquées Lyon, Laboratoire de Génie Electrique et Ferroélectricité EA 682, Villeurbanne, France
| | - Anne Long
- Univ Lyon, University Claude Bernard Lyon 1, Interuniversity Laboratory of Human Movement Biology EA7424, Lyon, France.,Departement of Internal Medicine and Vascular Medicine, Groupement Hospitalier Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Erica N Chirico
- Department of Biomedical Sciences, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Vincent Pialoux
- Univ Lyon, University Claude Bernard Lyon 1, Interuniversity Laboratory of Human Movement Biology EA7424, Lyon, France.,Institut Universitaire de France, Paris, France
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Groupement Hospitalier Est, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, University Claude Bernard Lyon 1, CarMeN Laboratory, INSERM U1060, Bron, France
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39
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Murgia A, Erta M, Suri JS, Gupta A, Wintermark M, Saba L. CT imaging features of carotid artery plaque vulnerability. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1261. [PMID: 33178793 PMCID: PMC7607080 DOI: 10.21037/atm-2020-cass-13] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Despite steady advances in medical care, cardiovascular disease remains one of the main causes of death and long-term morbidity worldwide. Up to 30% of strokes are associated with the presence of carotid atherosclerotic plaques. While the degree of stenosis has long been recognized as the main guiding factor in risk stratification and therapeutical decisions, recent evidence suggests that features of unstable, or ‘vulnerable’, plaques offer better prognostication capabilities. This paradigmatic shift has motivated researchers to explore the potentialities of non-invasive diagnostic tools to image not only the lumen, but also the vascular wall and the structural characteristics of the plaque. The present review will offer a panoramic on the imaging modalities currently available to characterize carotid atherosclerotic plaques and, in particular, it will focus on the increasingly important role covered by multidetector computed tomographic angiography.
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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), Italy
| | - Marco Erta
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato, s.s. 554 Monserrato (Cagliari), Italy
| | - Jasjit S Suri
- Stroke Monitoring and Diagnosis Division, AtheroPoint(tm), Roseville, CA, USA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell University, New York, NY, USA
| | - Max Wintermark
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari - Polo di Monserrato, s.s. 554 Monserrato (Cagliari), Italy
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40
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Skandha SS, Gupta SK, Saba L, Koppula VK, Johri AM, Khanna NN, Mavrogeni S, Laird JR, Pareek G, Miner M, Sfikakis PP, Protogerou A, Misra DP, Agarwal V, Sharma AM, Viswanathan V, Rathore VS, Turk M, Kolluri R, Viskovic K, Cuadrado-Godia E, Kitas GD, Nicolaides A, Suri JS. 3-D optimized classification and characterization artificial intelligence paradigm for cardiovascular/stroke risk stratification using carotid ultrasound-based delineated plaque: Atheromatic™ 2.0. Comput Biol Med 2020; 125:103958. [PMID: 32927257 DOI: 10.1016/j.compbiomed.2020.103958] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/02/2020] [Accepted: 08/03/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Atherosclerotic plaque tissue rupture is one of the leading causes of strokes. Early carotid plaque monitoring can help reduce cardiovascular morbidity and mortality. Manual ultrasound plaque classification and characterization methods are time-consuming and can be imprecise due to significant variations in tissue characteristics. We report a novel artificial intelligence (AI)-based plaque tissue classification and characterization system. METHODS We hypothesize that symptomatic plaque is hypoechoic due to its large lipid core and minimal collagen, as well as its heterogeneous makeup. Meanwhile, asymptomatic plaque is hyperechoic due to its small lipid core, abundant collagen, and the fact that it is often calcified. We designed a computer-aided diagnosis (CADx) system consisting of three kinds of deep learning (DL) classification paradigms: Deep Convolutional Neural Network (DCNN), Visual Geometric Group-16 (VGG16), and transfer learning, (tCNN). DCNN was 3-D optimized by varying the number of CNN layers and data augmentation frameworks. The DL systems were benchmarked against four types of machine learning (ML) classification systems, and the CADx system was characterized using two novel strategies consisting of DL mean feature strength (MFS) and a bispectrum model using higher-order spectra. RESULTS After balancing symptomatic and asymptomatic plaque classes, a five-fold augmentation process was applied, yielding 1000 carotid scans in each class. Then, using a K10 protocol (trained to test the ratio of 90%-10%), tCNN and DCNN yielded accuracy (area under the curve (AUC)) pairs of 83.33%, 0.833 (p < 0.0001) and 95.66%, 0.956 (p < 0.0001), respectively. DCNN was superior to ML by 7.01%. As part of the characterization process, the MFS of the symptomatic plaque was found to be higher compared to the asymptomatic plaque by 17.5% (p < 0.0001). A similar pattern was seen in the bispectrum, which was higher for symptomatic plaque by 5.4% (p < 0.0001). It took <2 s to perform the online CADx process on a supercomputer. CONCLUSIONS The performance order of the three AI systems was DCNN > tCNN > ML. Bispectrum-based on higher-order spectra proved a powerful paradigm for plaque tissue characterization. Overall, the AI-based systems offer a powerful solution for plaque tissue classification and characterization.
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Affiliation(s)
- Sanagala S Skandha
- CSE Department, CMR College of Engineering & Technology, Hyderabad, India; CSE Department, Bennett University, Greater Noida, UP, India
| | - Suneet K Gupta
- CSE Department, Bennett University, Greater Noida, UP, India
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), Cagliari, Italy
| | - Vijaya K Koppula
- CSE Department, CMR College of Engineering & Technology, Hyderabad, India
| | - Amer M Johri
- Department of Medicine, Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Narendra N Khanna
- Department of Cardiology, Indraprastha APOLLO Hospitals, New Delhi, India
| | - Sophie Mavrogeni
- Cardiology Clinic, Onassis Cardiac Surgery Center, Athens, Greece
| | - John R Laird
- Heart and Vascular Institute, Adventist Health St. Helena, St Helena, CA, USA
| | - Gyan Pareek
- Minimally Invasive Urology Institute, Brown University, Providence, RI, USA
| | - Martin Miner
- Men's Health Center, Miriam Hospital Providence, RI, USA
| | - Petros P Sfikakis
- Rheumatology Unit, National Kapodistrian University of Athens, Greece
| | - Athanasios Protogerou
- Department of Cardiovascular Prevention, National and Kapodistrian Univ. of Athens, Greece
| | - Durga P Misra
- Dept. of Clinical Immunology and Rheumatology, SGPGIMS, Lucknow, India
| | - Vikas Agarwal
- Dept. of Clinical Immunology and Rheumatology, SGPGIMS, Lucknow, India
| | - Aditya M Sharma
- Division of Cardiovascular Medicine, University of Virginia, VA, USA
| | - Vijay Viswanathan
- MV Hospital for Diabetes & Professor M Viswanathan Diabetes Research Centre, Chennai, India
| | - Vijay S Rathore
- Nephrology Department, Kaiser Permanente, Sacramento, CA, USA
| | - Monika Turk
- The Hanse-Wissenschaftskolleg Institute for Advanced Study, Delmenhorst, Germany
| | | | | | | | - George D Kitas
- R & D Academic Affairs, Dudley Group NHS Foundation Trust, Dudley, UK
| | - Andrew Nicolaides
- Vascular Screening and Diagnostic Centre, University of Nicosia, Nicosia, Cyprus
| | - Jasjit S Suri
- Stroke Monitoring and Diagnostic Division, AtheroPoint™, Roseville, CA, USA.
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41
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Cademartiri F, Balestrieri A, Cau R, Punzo B, Cavaliere C, Maffei E, Saba L. Insight from imaging on plaque vulnerability: similarities and differences between coronary and carotid arteries-implications for systemic therapies. Cardiovasc Diagn Ther 2020; 10:1150-1162. [PMID: 32968666 DOI: 10.21037/cdt-20-528] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nowadays it is widely accepted that the rupture of the atherosclerotic plaque in coronary and carotid arteries plays a fundamental role in the development of acute myocardial infarctions or cerebrovascular events. In recent years, imaging techniques have explored, with a new level of detail, the atherosclerotic disease generating new evidences that some plaque characteristics are significantly associated to the risk of rupture and subsequent thrombosis or embolization. Moreover, the recent evidence of the anti-atherosclerotic effects determined by lipid-lowering and anti-inflammatory therapies poses a challenge for the choice of therapeutic approaches (best/optimal medical therapy vs. revascularization), maximized by the evidence that coronary and carotid atherosclerosis share common patterns but also differ regarding some important features. In this Review, we discuss the similarities and differences between coronary and carotid artery vulnerable plaque from the imaging point of view and the potential implications for systemic therapies according to the emerging evidence.
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Affiliation(s)
| | | | - Riccardo Cau
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Bruna Punzo
- Department of Radiology, SDN IRCCS, Naples, Italy
| | | | - Erica Maffei
- Department of Radiology, Area Vasta 1, ASUR Marche, Urbino (PU), Italy
| | - Luca Saba
- Department of Radiology, University of Cagliari, Cagliari, Italy
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42
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Porcu M, Mannelli L, Melis M, Suri JS, Gerosa C, Cerrone G, Defazio G, Faa G, Saba L. Carotid plaque imaging profiling in subjects with risk factors (diabetes and hypertension). Cardiovasc Diagn Ther 2020; 10:1005-1018. [PMID: 32968657 DOI: 10.21037/cdt.2020.01.13] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Carotid artery stenosis (CAS) due to the presence of atherosclerotic plaque (AP) is a frequent medical condition and a known risk factor for stroke, and it is also known from literature that several risk factors promote the AP development, in particular aging, smoke, male sex, hypertension, hyperlipidemia, smoke, diabetes type 1 and 2, and genetic factors. The study of carotid atherosclerosis is continuously evolving: even if the strategies of treatment still depends mainly on the degree of stenosis (DoS) determined by the plaque, in the last years the attention has moved to the study of the plaque components in order to identify the so called "vulnerable" plaque: features like the fibrous cap status and thickness, the volume of the lipid-rich necrotic core and the presence of intraplaque hemorrhage (IPH) are risk factors for plaque rupture, that can be studied with modern imaging techniques. The aim of this review is to give a general overview of the principle histological and imaging features of the subcomponent of carotid AP (CAP), focalizing in particular on the features of CAP of patients affected by hypertension and diabetes (in particular type 2 diabetes mellitus).
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Affiliation(s)
- Michele Porcu
- Department of Radiology, AOU Cagliari, University of Cagliari, Italy
| | | | - Marta Melis
- Department of Neurology, AOU of Cagliari, University of Cagliari, Italy
| | - Jasjit S Suri
- Diagnostic and Monitoring Division, AtheroPoint, Roseville, California, USA
| | - Clara Gerosa
- Department of Pathology, AOU Cagliari, University of Cagliari, Cagliari, Italy
| | - Giulia Cerrone
- Department of Pathology, AOU Cagliari, University of Cagliari, Cagliari, Italy
| | - Giovanni Defazio
- Department of Neurology, AOU of Cagliari, University of Cagliari, Italy
| | - Gavino Faa
- Department of Pathology, AOU Cagliari, University of Cagliari, Cagliari, Italy
| | - Luca Saba
- Department of Radiology, AOU Cagliari, University of Cagliari, Italy
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43
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Zhu G, Hom J, Li Y, Jiang B, Rodriguez F, Fleischmann D, Saloner D, Porcu M, Zhang Y, Saba L, Wintermark M. Carotid plaque imaging and the risk of atherosclerotic cardiovascular disease. Cardiovasc Diagn Ther 2020; 10:1048-1067. [PMID: 32968660 DOI: 10.21037/cdt.2020.03.10] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Carotid artery plaque is a measure of atherosclerosis and is associated with future risk of atherosclerotic cardiovascular disease (ASCVD), which encompasses coronary, cerebrovascular, and peripheral arterial diseases. With advanced imaging techniques, computerized tomography (CT) and magnetic resonance imaging (MRI) have shown their potential superiority to routine ultrasound to detect features of carotid plaque vulnerability, such as intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), fibrous cap (FC), and calcification. The correlation between imaging features and histological changes of carotid plaques has been investigated. Imaging of carotid features has been used to predict the risk of cardiovascular events. Other techniques such as nuclear imaging and intra-vascular ultrasound (IVUS) have also been proposed to better understand the vulnerable carotid plaque features. In this article, we review the studies of imaging specific carotid plaque components and their correlation with risk scores.
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Affiliation(s)
- Guangming Zhu
- Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jason Hom
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ying Li
- Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Palo Alto, CA, USA.,Clinical Medical Research Center, Luye Pharma Group Ltd., Beijing 100000, China
| | - Bin Jiang
- Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Palo Alto, CA, USA
| | - Dominik Fleischmann
- Department of Radiology, Cardiovascular Imaging Section, Stanford University School of Medicine, Palo Alto, CA, USA
| | - David Saloner
- Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Michele Porcu
- Dipartimento di Radiologia, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Yanrong Zhang
- Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Luca Saba
- Dipartimento di Radiologia, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Max Wintermark
- Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Palo Alto, CA, USA
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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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Mark IT, Nasr DM, Huston J, de Maria L, de Sanctis P, Lehman VT, Rabinstein AA, Saba L, Brinjikji W. Embolic Stroke of Undetermined Source and Carotid Intraplaque Hemorrhage on MRI : A Systemic Review and Meta-Analysis. Clin Neuroradiol 2020; 31:307-313. [PMID: 32647922 DOI: 10.1007/s00062-020-00921-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 05/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Embolic stroke of undetermined source (ESUS) has traditionally discounted the significance of internal carotid artery stenosis of <50%; however, recent studies have examined the role of carotid artery intraplaque hemorrhage (IPH) as an etiology in nonstenotic carotid arteries. We performed a systemic review of the literature to determine the prevalence of carotid artery IPH on magnetic resonance imaging (MRI) of the vessel wall in patients with ESUS. METHODS We used PubMed, Epub ahead of print, Ovid MEDLINE in-process and other non-indexed citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane central register of controlled trials, Ovid Cochrane database of systematic reviews and Scopus. Our study consisted of all case series with >10 patients with IPH and ESUS published through October 2018. Additionally, we included 123 patients from an institutional database from 2015-2019. Random effects meta-analysis was used for pooling across studies. Meta-analysis results were expressed as odds ratio (OR) with respective 95% confidence intervals (CI). RESULTS A total of 7 studies with 354 patients were included. The mean age was 67.5 years old. The overall prevalence estimate for prevalence of IPH ipsilateral to the ischemic lesion was 25.8% (95% CI 13.1-38.5). The odds of having IPH on the ipsilateral side versus the contralateral side was 6.92 (95% CI 3.04-15.79). CONCLUSION Patients with ESUS have IPH in the carotid artery ipsilateral to the ischemic stroke in 25.8% of cases. Carotid artery vessel wall MRI should be considered as part of the standard work-up in patients with ESUS.
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Affiliation(s)
- Ian T Mark
- Department of Radiology, Mayo Clinic, 200 1st St. SW, 55905, Rochester, MN, USA
| | - Deena M Nasr
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - John Huston
- Department of Radiology, Mayo Clinic, 200 1st St. SW, 55905, Rochester, MN, USA
| | - Lucio de Maria
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Vance T Lehman
- Department of Radiology, Mayo Clinic, 200 1st St. SW, 55905, Rochester, MN, USA
| | | | - Luca Saba
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 1st St. SW, 55905, Rochester, MN, USA.
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46
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Baradaran H, Gupta A. Carotid Vessel Wall Imaging on CTA. AJNR Am J Neuroradiol 2020; 41:380-386. [PMID: 32029468 DOI: 10.3174/ajnr.a6403] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/17/2019] [Indexed: 02/06/2023]
Abstract
Vessel wall imaging has been increasingly used to characterize plaque beyond luminal narrowing to identify patients who may be at the highest risk of cerebrovascular ischemia. Although detailed plaque information can be obtained from many imaging modalities, CTA is particularly appealing for carotid plaque imaging due to its relatively low cost, wide availability, operator independence, and ability to discern high-risk features. The present Review Article describes the current understanding of plaque characteristics on CTA by describing commonly encountered plaque features, including calcified and soft plaque, surface irregularities, neovascularization, and inflammation. The goal of this Review Article was to provide a more robust understanding of clinically relevant plaque features detectable on routine CTA of the carotid arteries.
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Affiliation(s)
- H Baradaran
- From the Department of Radiology (H.B.), University of Utah, Salt Lake City, Utah
| | - A Gupta
- Department of Radiology (A.G.), Weill Cornell Medicine, New York, New York
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47
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Saba L, Micheletti G, Brinjikji W, Garofalo P, Montisci R, Balestrieri A, Suri JS, DeMarco JK, Lanzino G, Sanfilippo R. Carotid Intraplaque-Hemorrhage Volume and Its Association with Cerebrovascular Events. AJNR Am J Neuroradiol 2019; 40:1731-1737. [PMID: 31558503 DOI: 10.3174/ajnr.a6189] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 07/15/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE Our aim was to assess the relationship between volume and percentage of intraplaque hemorrhage measured using CT and the occurrence of cerebrovascular events at the time of CT. MATERIALS AND METHODS One-hundred-twenty-three consecutive subjects (246 carotid arteries) with a mean age of 69 years who underwent CTA were included in this retrospective study. Plaque volume of components and subcomponents (including intraplaque hemorrhage volume) was quantified with dedicated software. RESULTS Forty-six arteries were excluded because no plaque was identified. In the remaining 200 carotid arteries, a statistically significant difference was found between presentation with cerebrovascular events and lipid volume (P = .002), intraplaque hemorrhage volume (P = .002), percentage of lipid (P = .002), percentage of calcium (P = .001), percentage of intraplaque hemorrhage (P = .001), percentage of lipid-intraplaque hemorrhage (P = .001), and intraplaque hemorrhage/lipid ratio (P = .001). The highest receiver operating characteristic area under the curve was obtained with the intraplaque hemorrhage volume with a value of 0.793 (P = .001), percentage of intraplaque hemorrhage with an area under the curve of 0.812 (P = .001), and the intraplaque hemorrhage/lipid ratio with an area under the curve value of 0.811 (P = .001). CONCLUSIONS Results of our study suggest that Hounsfield unit values <25 have a statistically significant association with the presence of cerebrovascular events and that the ratio intraplaque hemorrhage/lipid volume represents a strong parameter for the association of cerebrovascular events.
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Affiliation(s)
- L Saba
- From the Departments of Radiology (L.S., G.M., P.G., A.B.)
| | - G Micheletti
- From the Departments of Radiology (L.S., G.M., P.G., A.B.)
| | | | - P Garofalo
- From the Departments of Radiology (L.S., G.M., P.G., A.B.)
| | - R Montisci
- Vascular Surgery (R.M., R.S.), Azienda Ospedaliero Universitaria, Monserrato (Cagliari), Italy
| | - A Balestrieri
- From the Departments of Radiology (L.S., G.M., P.G., A.B.)
| | - J S Suri
- Stroke Monitoring and Diagnostic Division (J.S.S.), AtheroPoint, Roseville, California
- Point-of-Care Devices (J.S.S.), Global Biomedical Technologies, Roseville, California
- Department of Electrical Engineering (J.S.S.), University of Idaho, Moscow, Idaho (Affiliated)
| | - J K DeMarco
- Department of Radiology (J.K.D.), Walter Reed Medical Center, Bethesda, Maryland
| | - G Lanzino
- Neurosurgery (G.L.), Mayo Clinic, Rochester, Minnesota
| | - R Sanfilippo
- Vascular Surgery (R.M., R.S.), Azienda Ospedaliero Universitaria, Monserrato (Cagliari), Italy
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48
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Saba L, Lanzino G, Lucatelli P, Lavra F, Sanfilippo R, Montisci R, Suri JS, Yuan C. Carotid Plaque CTA Analysis in Symptomatic Subjects with Bilateral Intraparenchymal Hemorrhage: A Preliminary Analysis. AJNR Am J Neuroradiol 2019; 40:1538-1545. [PMID: 31395662 DOI: 10.3174/ajnr.a6160] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 06/28/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE The presence of IPH is considered the most dangerous feature because it is significantly associated with clinical ipsilateral cerebrovascular events. Our aim was to explore the characterization of plaque with CT in symptomatic subjects with bilateral intraplaque hemorrhage. MATERIALS AND METHODS Three-hundred-forty-three consecutive patients with recent anterior circulation ischemic events (<2 weeks) and CT of the carotid arteries (performed within 14 days of the cerebrovascular event) evaluated between June 2012 and September 2017 were analyzed for plaque volume composition to identify all subjects with bilateral intraplaque hemorrhage. Plaque volume was semiautomatically measured, and tissue components were classified according to the attenuation values such as the following: calcified (for values of ≥130 HU), mixed (for values of ≥60 and <130 HU), lipid (for values of ≥25 and <60 HU), and intraplaque hemorrhage (for values of <25 HU). Twenty-one subjects (15 men; mean age, 70 ± 11 years; range, 44-87 years) had bilateral intraplaque hemorrhage and were included in the analysis. RESULTS Volume measurement revealed significantly larger plaques on the symptomatic side compared with the asymptomatic one (mean, 28 ± 9 versus 22 ± 8 mm, P = .007). Intraplaque hemorrhage volume and percentage were also significantly higher in the plaque ipsilateral to the cerebrovascular event (P < .001 and < .001, respectively). The volume of other plaque components did not show a statically significant association except for lipid and lipid + intraplaque hemorrhage percentages (23% versus 18% and 11% versus 15%), which were significantly different between the symptomatic and the asymptomatic sides (.016 and .011, respectively). The intraplaque hemorrhage/lipid ratio was higher on the symptomatic side (0.596 versus 0.171, P = .001). CONCLUSIONS In patients with bilateral intraplaque hemorrhage and recent ischemic symptoms, the plaque ipsilateral to the symptomatic side has significantly larger volume and a higher percentage of intraplaque hemorrhage compared with the contralateral, asymptomatic side.
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Affiliation(s)
- L Saba
- From the Department of Radiology (L.S., F.L., R.S., R.M.), Azienda Ospedaliero Universitaria di Cagliari, Monserrato (Cagliari), Italy
| | - G Lanzino
- Department of Neurologic Surgery (G.L.), Mayo Clinic, Rochester, Minnesota
| | - P Lucatelli
- Department of Radiological, Oncological and Anatomopathological Sciences-Radiology (P.L.), Sapienza University of Rome, Rome, Italy
| | - F Lavra
- From the Department of Radiology (L.S., F.L., R.S., R.M.), Azienda Ospedaliero Universitaria di Cagliari, Monserrato (Cagliari), Italy
| | - R Sanfilippo
- From the Department of Radiology (L.S., F.L., R.S., R.M.), Azienda Ospedaliero Universitaria di Cagliari, Monserrato (Cagliari), Italy
| | - R Montisci
- From the Department of Radiology (L.S., F.L., R.S., R.M.), Azienda Ospedaliero Universitaria di Cagliari, Monserrato (Cagliari), Italy
| | - J S Suri
- Diagnostic and Monitoring Division (J.S.S.), Atheropoint, Roseville, California.,Department of Electrical Engineering (J.S.S.), University of Idaho, Moscow, Idaho
| | - C Yuan
- Center for Biomedical Imaging Research (C.Y.), Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China.,Department of Radiology (C.Y.), University of Washington, Seattle, Washington
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49
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Porcu M, Anzidei M, Suri JS, A Wasserman B, Anzalone N, Lucatelli P, Loi F, Montisci R, Sanfilippo R, Rafailidis V, Saba L. Carotid artery imaging: The study of intra-plaque vascularization and hemorrhage in the era of the "vulnerable" plaque. J Neuroradiol 2019; 47:464-472. [PMID: 30954549 DOI: 10.1016/j.neurad.2019.03.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 02/04/2019] [Accepted: 03/04/2019] [Indexed: 01/01/2023]
Abstract
Intraplaque hemorrhage (IPH) is one of the main factors involved in atherosclerotic plaque (AP) instability. Its recognition is crucial for the correct staging and management of patients with carotid artery plaques to limit ischemic stroke. Imaging plays a crucial role in identifying IPH, even if the great variability of intraplaque vascularization and the limitations of our current imaging technologies make it difficult. The intent of this review is to give a general overview of the main features of intraplaque vascularization and IPH on Ultrasound (US), Computed Tomography (CT), Magnetic Resonance (MR) and Nuclear Medicine, and a brief description on the future prospectives.
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Affiliation(s)
- Michele Porcu
- Department of Medical Imaging, AOU of Cagliari, University of Cagliari, Cagliari, Italy.
| | - Michele Anzidei
- Department of Radiological, Oncological and Anatomo-pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Jasjit S Suri
- Monitoring and Diagnostic Division, AtheroPoint, Roseville, CA, USA
| | - Bruce A Wasserman
- The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nicoletta Anzalone
- Neuroradiology Unit and CERMAC, San Raffaele Scientific Institute and Vita-Salute San Raffaele University, via Olgettina 60, 20132, Milan, Italy
| | - Pierleone Lucatelli
- Department of Radiological, Oncological and Anatomo-pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Federico Loi
- Department of Biomedial Sciences, Unit of Oncology and Molecular Pathology, University of Cagliari, Cagliari, Italy
| | - Roberto Montisci
- Department of Vascular Surgery, AOU of Cagliari, University of Cagliari, Cagliari, Italy
| | - Roberto Sanfilippo
- Department of Vascular Surgery, AOU of Cagliari, University of Cagliari, Cagliari, Italy
| | - Vasileios Rafailidis
- Department of Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloníki, Greece
| | - Luca Saba
- Department of Medical Imaging, AOU of Cagliari, University of Cagliari, Cagliari, Italy
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50
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Saba L, Saam T, Jäger HR, Yuan C, Hatsukami TS, Saloner D, Wasserman BA, Bonati LH, Wintermark M. Imaging biomarkers of vulnerable carotid plaques for stroke risk prediction and their potential clinical implications. Lancet Neurol 2019; 18:559-572. [PMID: 30954372 DOI: 10.1016/s1474-4422(19)30035-3] [Citation(s) in RCA: 233] [Impact Index Per Article: 46.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 01/15/2023]
Abstract
Stroke represents a massive public health problem. Carotid atherosclerosis plays a fundamental part in the occurence of ischaemic stroke. European and US guidelines for prevention of stroke in patients with carotid plaques are based on quantification of the percentage reduction in luminal diameter due to the atherosclerotic process to select the best therapeutic approach. However, better strategies for prevention of stroke are needed because some subtypes of carotid plaques (eg, vulnerable plaques) can predict the occurrence of stroke independent of the degree of stenosis. Advances in imaging techniques have enabled routine characterisation and detection of the features of carotid plaque vulnerability. Intraplaque haemorrhage is accepted by neurologists and radiologists as one of the features of vulnerable plaques, but other characteristics-eg, plaque volume, neovascularisation, and inflammation-are promising as biomarkers of carotid plaque vulnerability. These biomarkers could change current management strategies based merely on the degree of stenosis.
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Affiliation(s)
- Luca Saba
- Department of Medical Sciences, University of Cagliari, Cagliari, Italy.
| | - Tobias Saam
- Department of Radiology, University Hospital Munich, Ludwig-Maximilians-University Munich, Munich, Germany; Radiologisches Zentrum Rosenheim, Rosenheim, Germany
| | - H Rolf Jäger
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology, London, UK
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, WA, USA
| | | | - David Saloner
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Bruce A Wasserman
- The Russell H Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Leo H Bonati
- Department of Neurology and Stroke Center, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Max Wintermark
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
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