Neuroradiology. 2010 Feb 13.

[Epub ahead of print]

MR plaque imaging of the carotid artery.

Watanabe Y, Nagayama M. Department of Radiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan, yw5904@kchnet.or.jp. Atherosclerotic carotid plaque represents a major cause of cerebral ischemia. The detection of vulnerable plaque is important for preventing future cardiovascular events. The key factors in advanced plaque that are most likely to lead to patient complications are the condition of the fibrous cap, the size of the necrotic core and hemorrhage, and the extent of inflammatory activity within the plaque. Magnetic resonance (MR) imaging has excellent soft tissue contrast and can allow for a more accurate and objective estimation of carotid wall morphology and plaque composition. Recent advances in MR imaging techniques have permitted serial monitoring of atherosclerotic disease evolution and the identification of intraplaque risk factors for accelerated progression. The purpose of this review article is to review the current state of techniques of carotid wall MR imaging and the characterization of plaque components and surface morphology with MR imaging, and to describe the clinical practice of carotid wall MR imaging for the determination of treatment plan. PMID: 20155353 [PubMed - as supplied by publisher] Int J Cardiovasc Imaging. 2010 Jan 29. [Epub ahead of print]

Recent developments and new perspectives on imaging of atherosclerotic plaque: role of anatomical, cellular and molecular MRI Part I and II.
Te Boekhorst BC, Cramer MJ, Pasterkamp G, van Echteld CJ, Doevendans PA. Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands, b.c.m.teboekhorst@umcutrecht.nl. Atherosclerotic plaque disruption accounts for the major part of cardiovascular mortality and the risk of disruption appears to depend on plaque composition. Carotid plaques in patients, scheduled for endarterectomy, have been successfully characterised with MRI. MRI has the advantage of combining information about morphology and function.

Unfortunately, the tortuosity and size of the coronary arteries, and the respiratory and cardiac motion hinder the in vivo characterisation of human coronary plaque. In addition to plaque composition several molecular markers of the different processes involved in atherosclerosis, such as integrins, matrix metalloproteinases and fibrin seem to correlate with risk of plaque rupture and clinical outcome. These molecular markers can be targeted with antibodies coupled to carriers, which are loaded with gadolinium for detection (molecular MRI). Several cellular/molecular MRI studies in animal models and some in human patients have been conducted with varying levels of success. The advent of clinical high field magnets, the development of contrast agent carriers with high relaxivity and the development of relatively new MR contrast techniques are promising in the field of plaque imaging. Future MRI studies will have to focus on the molecular target of the atherosclerotic process, which has the highest prognostic value with regard to acute coronary syndromes and on the most suitable contrast agent to visualize that target. J Magn Reson Imaging. 2010 Feb;31(2):398-405.

Improved blood suppression in threedimensional (3D) fast spin-echo (FSE) vessel wall imaging using a combination of double inversion-recovery (DIR) and diffusion sensitizing gradient (DSG) preparations.
Makhijani MK, Hu HH, Pohost GM, Nayak KS. Ming Hsieh Department of Electrical Engineering, University of Southern California, Los Angeles, CA, USA. makhijan@usc.edu PURPOSE: To provide improved blood suppression in three-dimensional inner-volume fast spin-echo (3D IV-FSE) carotid vessel wall imaging by using a hybrid preparation consisting of double inversion-recovery (DIR) and diffusion sensitizing gradients (DSG). MATERIALS AND METHODS: Multicontrast black-blood MRI is widely used for vessel wall imaging and characterization of atherosclerotic plaque composition. Blood suppression is difficult when using 3D volumetric imaging techniques. DIR approaches do not provide robust blood suppression due to incomplete replacement of blood spins, and DSG approaches compromise vessel wall signal, reducing the lumen-wall contrast-to-noise ratio efficiency (CNR(eff)). In this work a hybrid DIR+DSG preparation is developed and optimized for blood suppression, vessel wall signal preservation, and vessel-wall contrast in 3D IV-FSE imaging. Cardiac gated T(1)-weighted carotid vessel wall images were acquired in five volunteers with 0.5 x 0.5 x 2.5 mm(3) spatial resolution in 80 seconds. RESULTS: Data from healthy volunteers indicate that the proposed method yields a statistically

significant (P < 0.01) improvement in blood suppression and lumen-wall CNR(eff) compared to standard DIR and standard DSG methods alone. CONCLUSION: A combination of DIR and DSG preparations can provide improved blood suppression and lumen-wall CNR(eff) for 3D IV-FSE vessel wall imaging. Eur J Vasc Endovasc Surg. 2010 Feb;39(2):125-133. Epub 2009 Dec 23.

Advanced Carotid Plaque Imaging.

Hermus L, van Dam GM, Zeebregts CJ. Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. Treatment of carotid artery stenosis by endarterectomy or stenting can significantly reduce stroke risk. In clinical practice, indication for surgery or stenting is primarily based on the degree of stenosis, but there is growing awareness that pathophysiological features within a vulnerable plaque play a key role in predicting stroke risk. Important molecular processes associated with plaque vulnerability are inflammation, lipid accumulation, proteolysis, apoptosis, angiogenesis and thrombosis. The rapidly emerging field of molecular and functional imaging strategies allows identification of pathophysiological processes in carotid artery stenosis. We aimed to review the literature regarding the current most promising advanced imaging techniques in carotid artery disease. Various advanced imaging methods are available, such as high-resolution magnetic resonance imaging (HRMRI), single photon emission computed tomography (SPECT), positron emission tomography (PET) and near-infrared fluorescence (NIRF). Radionuclide and fluorescent tracers that identify inflammation, apoptosis and proteolysis, such as FDG, MMP probes and Annexin A5, are promising. A combination of activity of molecular processes and detailed anatomic information can be obtained, providing a powerful tool in the identification of the vulnerable plaque. With these developments, we are entering a new era of imaging techniques in the selection of patients for carotid surgery. Copyright 2009 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Neuroradiology. 2009 Dec 18. [Epub ahead of print]

Altered carotid plaque signal among different repetition times on T1-weighted magnetic resonance plaque imaging with self-navigated radial-scan technique.

Narumi S, Sasaki M, Ohba H, Ogasawara K, Hitomi J, Mori K, Ohura K, Ono A, Terayama Y. Department of Neurology and Gerontology, Iwate Medical University, 19-1 Uchimaru, Morioka, Japan. INTRODUCTION: Magnetic resonance (MR) plaque imaging for carotid arteries is usually performed by using an electrocardiograph (ECG)-gating technique to eliminate pulsationrelated artifacts, which can affect the plaque signals because of varied repetition time (TR) among patients. Hence, we investigated whether differences in TR causes signal alterations of the carotid plaque by using a non-gated plaque imaging technique. METHODS: We prospectively examined 19 patients with carotid stenosis by using a T1-weighted selfnavigated radial-scan technique with TRs of 500, 700, and 900 ms. The signal intensity of the carotid plaque was measured, and the contrast ratio (CR) relative to the adjacent muscle was calculated. RESULTS: CRs of the carotid plaques were 1.39 +/- 0.39, 1.29 +/- 0.29, and 1.23 +/- 0.24 with TRs of 500, 700, and 900 ms, respectively, and were significantly different. Among the plaques, those with a hyperintensity signal (CR > 1.5) and moderateintensity signal (CR 1.2-1.5) at 500 ms showed a TR-dependent signal decrease (hyperintensity plaques, 1.82 +/- 0.26; 1.61 +/- 0.19; and 1.48 +/- 0.17; moderate-intensity plaques, 1.33 +/- 0.08; 1.26 +/- 0.08; and 1.19 +/- 0.07), while those with an isointensity signal (CR < 1.2) remained unchanged regardless of TR (0.96 +/- 0.12, 0.96 +/- 0.11, and 0.97 +/- 0.13). CONCLUSION: The signal intensity of the carotid plaque on T1-weighted imaging significantly varies among different TRs and tends to decrease with longer TR. MR plaque imaging with short and constant TR settings that the ECG-gating method cannot realize woInvest Radiol. 2010 Jan;45(1):36-41.

Minimization of MR contrast weightings for the comprehensive evaluation of carotid atherosclerotic disease.
Zhao X, Underhill HR, Yuan C, Oikawa M, Dong L, Ota H, Hatsukami TS, Wang Q, Ma L, Cai J. Department of Radiology, University of Washington, Seattle, WA, USA. OBJECTIVE: Multicontrast, high-resolution carotid magnetic resonance imaging (MRI) has been validated with histology to quantify atherosclerotic plaque morphology and composition. For evaluating the lipid-rich necrotic core (LRNC) and fibrous cap, both of which are key elements in determining plaque stability, the combined pre- and postcontrast T1-weighted (T1W) sequences have been recently shown to have a higher reproducibility than other contrast weightings. In this study, we sought to determine whether contrast weightings beyond T1W (pre- and postcontrast) are necessary for comprehensive, quantitative, carotid plaque interpretation. MATERIALS AND METHODS: Our HIPAA compliant study protocol was approved by the IRB and all participants gave written,

informed consent. Sixty-five participants with carotid stenosis >50% detected by ultrasound underwent carotid MRI with a standard multicontrast protocol (time-of-flight [TOF], T1W, contrast-enhanced [CE]-T1W, proton density [PD], and T2W). For each subject, images were partitioned into 3 combinations of contrast weightings (CW): (1) 2CW: T1W and CET1W; (2) 3CW: T1W, CE-T1W, and TOF; and (3) 5CW: T1W, CE-T1W, TOF, PD, and T2W. Each CW set was interpreted by 2 reviewers, blinded to results of each of the other CW combinations, via consensus opinion. Wall, lumen, and total vessel volumes, along with mean wall thickness were recorded. The presence or absence of calcification, LRNC, intraplaque hemorrhage (IPH), and surface disruption was also documented. RESULTS: Compared with 5CW, there was strong agreement in the parameters of plaque morphology for 2CW (intraclass correlation coefficient, 0.96-0.99) and 3CW (intraclass correlation coefficient, 0.97-1.00). Agreement with 5CW for the detection of plaque composition was stronger for 3CW compared with 2CW: Cohen's kappa, 0.59 versus 0.42 for calcification; 0.75 versus 0.47 for LRNC; 0.91 versus 0.88 for IPH; and 0.74 versus 0.34 for surface disruption. Using 5CW as the reference standard during receive-operating-characteristics analysis, 3CW compared with 2CW showed a larger area-under-the-curve for classifying the presence or absence of calcification (0.78 vs. 0.69), LRNC (0.98 vs. 0.69), and surface disruption (0.87 vs. 0.65), and similar area-under-the-curve in classifying IPH (0.96 vs. 0.94). CONCLUSION: Comprehensive, quantitative carotid plaque interpretation can be performed with T1W, CE-T1W, and TOF sequences. Elimination of PD and T2W sequences from the carotid MRI protocol may result in a substantial reduction in scan time. The ability to perform plaque interpretation on images acquired within a clinically acceptable scan time may broaden the research utility of carotid MRI and increase translatability to clinical applications. uld be preferable for evaluating plaque characteristics.