Clinical Molecular Imaging for Atherosclerotic Plaque

Advancements in non-invasive imaging of atherosclerosis: Future perspectives

Atherosclerosis is a chronic inflammatory disease characterized by the buildup of plaques in arterial walls, leading to cardiovascular diseases and high morbidity and mortality rates worldwide. Non-invasive imaging techniques play a crucial role in evaluating patients with suspected or established atherosclerosis. However, there is a growing body of evidence suggesting the need to visualize the underlying processes of plaque progression and rupture to enhance risk stratification. This review explores recent advancements in non-invasive assessment of atherosclerosis, focusing on computed tomography, magnetic resonance imaging, and nuclear imaging. These advancements provide valuable insights into the assessment and management of atherosclerosis, potentially leading to better risk stratification and improved patient outcomes.

Atherosclerosis and Inflammation: Insights from the Theory of General Pathological Processes

Recent advances have greatly improved our understanding of the molecular mechanisms behind atherosclerosis pathogenesis. However, there is still a need to systematize this data from a general pathology perspective, particularly with regard to atherogenesis patterns in the context of both canonical and non-classical inflammation types. In this review, we analyze various typical phenomena and outcomes of cellular pro-inflammatory stress in atherosclerosis, as well as the role of endothelial dysfunction in local and systemic manifestations of low-grade inflammation. We also present the features of immune mechanisms in the development of productive inflammation in stable and unstable plaques, along with their similarities and differences compared to canonical inflammation. There are numerous factors that act as inducers of the inflammatory process in atherosclerosis, including vascular endothelium aging, metabolic dysfunctions, autoimmune, and in some cases, infectious damage factors. Life-critical complications of atherosclerosis, such as cardiogenic shock and severe strokes, are associated with the development of acute systemic hyperinflammation. Additionally, critical atherosclerotic ischemia of the lower extremities induces paracoagulation and the development of chronic systemic inflammation. Conversely, sepsis, other critical conditions, and severe systemic chronic diseases contribute to atherogenesis. In summary, atherosclerosis can be characterized as an independent form of inflammation, sharing similarities but also having fundamental differences from low-grade inflammation and various variants of canonical inflammation (classic vasculitis).

microRNAs Associated with Carotid Plaque Development and Vulnerability: The Clinician's Perspective

Ischemic stroke (IS) related to atherosclerosis of large arteries is one of the leading causes of mortality and disability in developed countries. Atherosclerotic internal carotid artery stenosis (ICAS) contributes to 20% of all cerebral ischemia cases. Nowadays, atherosclerosis prevention and treatment measures aim at controlling the atherosclerosis risk factors, or at the interventional (surgical or endovascular) management of mature occlusive lesions. There is a definite lack of the established circulating biomarkers which, once modulated, could prevent development of atherosclerosis, and consequently prevent the carotid-artery-related IS. Recent studies emphasize that microRNA (miRNA) are the emerging particles that could potentially play a pivotal role in this approach. There are some research studies on the association between the expression of small non-coding microRNAs with a carotid plaque development and vulnerability. However, the data remain inconsistent. In addition, all major studies on carotid atherosclerotic plaque were conducted on cell culture or animal models; very few were conducted on humans, whereas the accumulating evidence demonstrates that it cannot be automatically extrapolated to processes in humans. Therefore, this paper aims to review the current knowledge on how miRNA participate in the process of carotid plaque formation and rupture, as well as stroke occurrence. We discuss potential target miRNA that could be used as a prognostic or therapeutic tool.

The application of the nnU-Net-based automatic segmentation model in assisting carotid artery stenosis and carotid atherosclerotic plaque evaluation

Objective: No new U-net (nnU-Net) is a newly-developed deep learning neural network, whose advantages in medical image segmentation have been noticed recently. This study aimed to investigate the value of the nnU-Net-based model for computed tomography angiography (CTA) imaging in assisting the evaluation of carotid artery stenosis (CAS) and atherosclerotic plaque. Methods: This study retrospectively enrolled 93 CAS-suspected patients who underwent head and neck CTA examination, then randomly divided them into the training set (N = 70) and the validation set (N = 23) in a 3:1 ratio. The radiologist-marked images in the training set were used for the development of the nnU-Net model, which was subsequently tested in the validation set. Results: In the training set, the nnU-Net had already displayed a good performance for CAS diagnosis and atherosclerotic plaque segmentation. Then, its utility was further confirmed in the validation set: the Dice similarity coefficient value of the nnU-Net model in segmenting background, blood vessels, calcification plaques, and dark spots reached 0.975, 0.974 0.795, and 0.498, accordingly. Besides, the nnU-Net model displayed a good consistency with physicians in assessing CAS (Kappa = 0.893), stenosis degree (Kappa = 0.930), the number of calcification plaque (Kappa = 0.922), non-calcification (Kappa = 0.768) and mixed plaque (Kappa = 0.793), as well as the max thickness of calcification plaque (intraclass correlation coefficient = 0.972). Additionally, the evaluation time of the nnU-Net model was shortened compared with the physicians (27.3 ± 4.4 s vs. 296.8 ± 81.1 s, p < 0.001). Conclusion: The automatic segmentation model based on nnU-Net shows good accuracy, reliability, and efficiency in assisting CTA to evaluate CAS and carotid atherosclerotic plaques.

Early Assessment of Atherosclerotic Lesions and Vulnerable Plaques in vivo by Targeting Apoptotic Macrophages with AV Nanobubbles

Background

The early detection of atherosclerotic lesions is particularly important for risk prediction of acute cardiovascular events. Macrophages apoptosis was significantly associated with the degree of AS lesions and especially contributed to plaque vulnerability. In this research, we mainly sought to explore the feasibility of a home-made AV-nanobubbles (NB_AV) for visualization of apoptotic macrophages and assessment of atherosclerosis (AS) lesions by contrast-enhanced ultrasound (CEUS) imaging.

Methods

NB_AV were prepared by “Optimized Thin-Film Hydration” and “Biotin-Avidin-Biotin” methods. Then, the characterization and echogenicity of NB_AV were measured and analyzed in vitro. The targeting ability of NB_AV to ox-LDL–induced apoptotic macrophages was observed by laser scanning confocal microscope. The ApoE^−/− mice mode fed with high fat diet were observed by high-frequency ultrasound, microanatomy and oil red O staining. CEUS imaging in vivo was performed on AS plaques with NB_AV and NB_Ctrl injection through the tail vein in turn in ApoE^−/− mice. After CEUS imaging, the plaques were confirmed and analyzed by histopathological and immunological assessment.

Results

The prepared NB_AV had a nano-scale size distribution with a low PDI and a negative zeta potential. Moreover, NB_AV showed an excellent stability and exhibited a significantly echogenic signal than saline in vitro. In addition, we found that NB_AV could target apoptotic macrophages induced by ox-LDL. Compared with NB_Ctrl, CEUS imaging of NB_AV showed strong and sustained echo enhancement in plaque area of aortic arch in vivo. Further research showed that NB_AV sensitive plaques presented more significant pathological changes with several vulnerable plaque features and abundant TUNEL-positive area.

Conclusion

NB_AV displayed a sensitive indicator to evaluate apoptotic macrophages, indicating a promising CEUS molecular probe for AS lesions and vulnerable plaques identification.

Emerging Nuclear Medicine Imaging of Atherosclerotic Plaque Formation

Atherosclerosis is a chronic widespread cardiovascular disease and a major predisposing factor for cardiovascular events, among which there are myocardial infarction and ischemic stroke. Atherosclerotic plaque formation is a process that involves different mechanisms, of which inflammation is the most common. Plenty of radiopharmaceuticals were developed to elucidate the process of plaque formation at different stages, some of which were highly specific for atherosclerotic plaque. This review summarizes the current nuclear medicine imaging landscape of preclinical and small-scale clinical studies of these specific RPs, which are not as widespread as labeled FDG, sodium fluoride, and choline. These include oxidation-specific epitope imaging, macrophage, and other cell receptors visualization, neoangiogenesis, and macrophage death imaging. It is shown that specific radiopharmaceuticals have strength in pathophysiologically sound imaging of the atherosclerotic plaques at different stages, but this also may induce problems with the signal registration for low-volume plaques in the vascular wall.