Evaluation of carotid artery atherosclerotic plaque distribution by using long-axis high-resolution black-blood magnetic resonance imaging

Clinical article

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Object

The goal of this study was to evaluate the usefulness of long-axis black-blood MR (BB–MR) imaging for assessing plaque morphology and distribution in patients with atherosclerotic carotid artery (CA) stenosis.

Methods

Sixty-eight carotid arteries in 67 patients who were scheduled to undergo CA endarterectomy or CA stent placement due to atherosclerotic stenosis were included in this study. The patients had undergone CA BB–MR imaging and digital subtraction (DS) angiography within 3 weeks of revascularization. The DS angiography studies were performed using the transfemoral artery approach with selective common CA catheterization. The BB–MR images were acquired using a 1.5-T whole-body MR imaging unit, and T1-weighted images parallel to the long axis of the artery at 1-mm intervals were obtained. Plaque distribution was evaluated by measuring the distance between the CA bifurcation and the point that appeared to be the distal extent of the plaque on BB–MR imaging (D–MR imaging) and DS angiography images (D–DS angiography).

Results

Plaque distribution was clearly shown in 88.2% of the cases using long-axis BB–MR images, except for 8 arteries with poor image quality. In 4 arteries, D–DS angiography could not be obtained because the distal plaque end could not be confirmed. In 56 vessels, both the D–DS angiography and D–MR imaging could be measured; the mean D–MR imaging (19.75 ± 6.85 mm [standard deviation]) was significantly longer than the average D–DS angiography (16.32 ± 7.07 mm).

Conclusions

Long-axis BB–MR imaging can provide a noninvasive and accurate way to show CA plaque distribution; it is of great use not only for stroke risk assessment in patients with CA atherosclerosis but also for preoperative evaluation in patients requiring CA endarterectomy or CA stent placement.

Abbreviations used in this paper: BB = black-blood; CA = carotid artery; CAS = CA stent placement; CEA = CA endarterectomy; DS = digital subtraction; ICA = internal CA; NASCET = North American Symptomatic Carotid Endarterectomy Trial.

Article Information

Address correspondence to: Kazumichi Yoshida, M.D., Ph.D., Department of Neurosurgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki City, Okayama 710-8602, Japan. email: ky7694@kchnet.or.jp.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Preoperative DS angiography and long-axis CA BB–MR imaging in a patient with symptomatic right CA stenosis. Arrow A and arrow B designate the points identified as the CA bifurcation and the distal end of the plaque on DS angiography and BB–MR imaging, respectively. The plaque distribution was evaluated by measuring the distance between the CA bifurcation and the distal plaque end on MR images (D–MR imaging) and DS angiograms (D–DS angiography). A: Lateral projection DS angiogram showing 66% stenosis based on the NASCET criteria. In this case, D–DS angiography was 19.6 mm. B and C: Long-axis T1-weighted BB–MR imaging slices showing the CA bifurcation (B) and the distal end of the plaque (C). Eccentric plaque (arrowheads) was clearly demonstrated as a high signal on T1-weighted BB–MR images. The D–MR imaging was calculated to be 20.1 mm on the workstation using electronic calipers.

  • View in gallery

    A: Preoperative DS angiogram obtained in a patient with a right CA pseudoocclusion who presented with impending stroke. The stringlike lumen of the ICA up to the intracranial segment was slowly demonstrated. In this case, D–DS angiography could not be measured because the distal plaque end could not be identified on the DS angiogram. The asterisk indicates the external CA. B: Long-axis T1-weighted BB–MR imaging slice showing the CA bifurcation (arrow). The asterisk indicates the external CA. C: Long-axis T1-weighted BB–MR imaging slice showing the distal end of the plaque (arrow). Virtually total luminal occlusion with atherosclerotic plaque (large arrowheads) and also a collapsed distal ICA (small arrowheads) are clearly demonstrated. In this case, successful ICA reconstruction was achieved with CEA.

  • View in gallery

    A: Preoperative DS angiogram of the left CA obtained in a patient presenting with recurrent minor strokes in the left hemisphere despite aggressive antithrombotic therapy and showing slight wall irregularity of the bulb (arrow) but no significant luminal narrowing. B: Long-axis T1-weighted BB–MR imaging slice showing the CA bifurcation and the distal plaque end. A large amount of plaque (arrowheads) without narrowing of the ICA lumen is clearly shown. C: A T1-weighted BB–MR imaging slice perpendicular to the long axis of the ICA at the bifurcation showing expansive remodeling (arrowheads). The asterisk indicates the ICA lumen. D: The excised CEA specimen had a yellowish luminal surface and an extensively disrupted fibrous cap. E: Low-power photomicrograph of a histological section that corresponds to the portion with fibrous cap disruption in panel D, demonstrating not only discontinuation of the fibrous cap (arrowheads) but also massive intraplaque hemorrhage. Masson trichrome, original magnification × 3.12.

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