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The Vulnerable, or High-Risk, Atherosclerotic Plaque: Noninvasive MR Imaging for Characterization and Assessment¹

¹ From the Departments of Radiology (T.S., N.T., B.C., H.U., W.S.K., J.C., M.S.F., C.Y.) and Surgery (T.S.H.), University of Washington, Seattle, Wash; and Surgical Service, VA Puget Sound Health Care System, Seattle, Wash (T.S.H.). Received October 31, 2005; revision requested December 14; revision received January 17, 2005; accepted March 2; final version accepted July 17; final review and update by T.S. January 9, 2007. Address correspondence to T.S., Department of Clinical Radiology, Grosshadern Campus, University of Munich, Marchioni-nistr 15, 81377 Munich, Germany (e-mail: Tobias_Saam{at}med.uni-muenchen.de).

View larger version (8K): [in this window] [in a new window] [Download PPT slide]   Figure 1: Pie charts show plaque composition as percentage of vessel wall area, calculated per artery and then averaged across all arteries, for MR imaging and histologic specimens. Percentages were compared by using paired t tests. (Reprinted, with permission, from reference 9.)

View larger version (47K): [in this window] [in a new window] [Download PPT slide]   Figure 2: Transverse MR images depict fibrous cap rupture (arrows) in right common carotid artery. The hyperintense region (chevron) on TOF (repetition time msec/echo time msec, 23.0/3.8) and T1-weighted (T1W) (800/9.3) images and hypointense region on intermediate-weighted (IMW) (2500/10.0) and T2-weighted (T2W) (2500/39.9) images is a lipid-necrotic core with type I hemorrhage. Parts of remaining fibrous cap (arrowheads) are visible on TOF image.

View larger version (49K): [in this window] [in a new window] [Download PPT slide]   Figure 3a: (a) Left: Transverse TOF (23/3.8), T1-weighted (T1W) (800/9.3), intermediate-weighted (IMW) (3488/20), and T2-weighted (T2W) (3488/40) MR images depict intraplaque hemorrhage (arrows) deep within highly stenosed carotid plaque with smooth luminal surface. Arrowheads = lumen. Right: Endarterectomy specimen. (b) Left: Transverse TOF (23/3.8), T1-weighted (T1W) (550/9), intermediate-weighted (IMW) (3093/20), and T2-weighted (T2W) (3093/40) MR images depict juxtaluminal hemorrhage/thrombus (arrows) adjacent to the lumen (*), with luminal surface irregularity (chevrons). A calcified area (arrowheads) is hypointense on MR images obtained with all four contrast weightings. Right: Endarterectomy specimen. (Reprinted, with permission, from reference 38.)

View larger version (51K): [in this window] [in a new window] [Download PPT slide]   Figure 3b: (a) Left: Transverse TOF (23/3.8), T1-weighted (T1W) (800/9.3), intermediate-weighted (IMW) (3488/20), and T2-weighted (T2W) (3488/40) MR images depict intraplaque hemorrhage (arrows) deep within highly stenosed carotid plaque with smooth luminal surface. Arrowheads = lumen. Right: Endarterectomy specimen. (b) Left: Transverse TOF (23/3.8), T1-weighted (T1W) (550/9), intermediate-weighted (IMW) (3093/20), and T2-weighted (T2W) (3093/40) MR images depict juxtaluminal hemorrhage/thrombus (arrows) adjacent to the lumen (*), with luminal surface irregularity (chevrons). A calcified area (arrowheads) is hypointense on MR images obtained with all four contrast weightings. Right: Endarterectomy specimen. (Reprinted, with permission, from reference 38.)

View larger version (9K): [in this window] [in a new window] [Download PPT slide]   Figure 4: Scatterplot demonstrates correlation between dynamic contrast-enhanced MR imaging and corresponding histologic findings. There is a highly significant association between Ktrans as measured on MR images and degree of macrophage infiltration of the plaque on histologic specimens (fractional macrophage area) (Pearson R = 0.75, P < .001). (Reprinted, with permission, from reference 48.)

View larger version (87K): [in this window] [in a new window] [Download PPT slide]   Figure 5a: Coronary angiography in a 53-year-old man with exertional chest pain. AA = ascending aorta, LA = left atrium, LV = left ventricle, PA = pulmonary artery, RV = right ventricle, RVOT = right ventricular outflow tract. (a) Coronary MR angiogram (left) along left main and left anterior descending coronary arteries and corresponding conventional coronary angiogram in right anterior oblique projection (right) indicate severe stenosis at bifurcation of left anterior descending and left circumflex coronary arteries involving the left main coronary artery (solid arrows) and more distal focal stenosis of left circumflex coronary artery (dotted arrows). (b) Coronary MR angiogram (left) in coronal orientation along course of right coronary artery and corresponding conventional angiogram in left anterior oblique projection (right) indicate two stenoses of proximal (solid arrows) and middle (dotted arrows) right coronary artery. (Reprinted, with permission, from reference 61.)

View larger version (83K): [in this window] [in a new window] [Download PPT slide]   Figure 5b: Coronary angiography in a 53-year-old man with exertional chest pain. AA = ascending aorta, LA = left atrium, LV = left ventricle, PA = pulmonary artery, RV = right ventricle, RVOT = right ventricular outflow tract. (a) Coronary MR angiogram (left) along left main and left anterior descending coronary arteries and corresponding conventional coronary angiogram in right anterior oblique projection (right) indicate severe stenosis at bifurcation of left anterior descending and left circumflex coronary arteries involving the left main coronary artery (solid arrows) and more distal focal stenosis of left circumflex coronary artery (dotted arrows). (b) Coronary MR angiogram (left) in coronal orientation along course of right coronary artery and corresponding conventional angiogram in left anterior oblique projection (right) indicate two stenoses of proximal (solid arrows) and middle (dotted arrows) right coronary artery. (Reprinted, with permission, from reference 61.)

View larger version (54K): [in this window] [in a new window] [Download PPT slide]   Figure 6: Left: Transverse MR images demonstrate usefulness of a multisequence protocol. TOF image (21.0/3.2) reveals two distinct areas (arrows A and B) with irregular lumen boundaries that are not well defined on T1-weighted (T1W, 550/9.0), intermediate-weighted (IMW, 1528/28), and T2-weighted (T2W, 1528/56) images, consistent with juxtaluminal calcification. Right: Histologic specimens demonstrate that material intruding into the lumen contains calcified nodules. Boxes A and B correspond to areas labeled on TOF image.

View larger version (43K): [in this window] [in a new window] [Download PPT slide]   Figure 7a: Representative transverse T1-weighted MR images (800/9.3) of the progression of atherosclerosis with intraplaque hemorrhage. Right carotid artery was imaged (a) at baseline and (b) 18 months later. Lumen area (*) decreased and wall area (arrowheads) increased in each section on b. Bif = bifurcation, CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (Reprinted, with permission, from reference 87.)

View larger version (43K): [in this window] [in a new window] [Download PPT slide]   Figure 7b: Representative transverse T1-weighted MR images (800/9.3) of the progression of atherosclerosis with intraplaque hemorrhage. Right carotid artery was imaged (a) at baseline and (b) 18 months later. Lumen area (*) decreased and wall area (arrowheads) increased in each section on b. Bif = bifurcation, CCA = common carotid artery, ECA = external carotid artery, ICA = internal carotid artery. (Reprinted, with permission, from reference 87.)

View larger version (16K): [in this window] [in a new window] [Download PPT slide]   Figure 8: Bar graphs show changes in atherosclerotic vessel wall dimensions (in square millimeters) after statin treatment: mean vessel wall area (top) and mean lumen area (bottom) at baseline (BL) and after 6, 12, 18, and 24 months of simvastatin treatment for aorta (left) and carotid arteries (right). ANOVA = analysis of variance, error bars = standard error of the mean. (Reprinted, with permission, from reference 100.)