Evaluating Vulnerable Atherosclerotic Plaque with MRI

valuating Vulnerable Atherosclerotic Plaque with MRI

Fabien Hya l and Zahi A. Fayad24

Despite important clinical advances in prevention and treatment of atherosclerosis

during the past 20 years, coronary artery disease remains the rst cause of mortality

1in industrialized countries. Atherosclerosis affects medium- and large-diameter

arteries and is characterized by a thickening of the arterial intima typically composed

of a lipid core with an overlying brous cap. Angiography remains the gold standard

for diagnosis and quanti cation of atherosclerotic plaques that result in ow-limiting

arterial stenoses but offers only an indirect view of atherosclerosis burden.2 Positive

remodeling of the arterial wall—a process in which the vessel dilates to limit the nar-

rowing of the lumen in presence of atherosclerotic plaques—leads to a clear underes-

timation of the true extension of atherosclerosis disease with angiography.3

High-resolution magnetic resonance imaging (MRI) has emerged as a very promis-

ing imaging technique to detect atherosclerotic plaques. Thanks to advances in both

hardware and software, MRI now offers an inframillimetric resolution of the arterial

wall, allowing for direct evaluation of atherosclerosis burden。 Moreover, MRI does

not expose patients to ionizing radiation and seems therefore well suited to monitor

the extension of atherosclerotic disease and follow its evolution under antiatheroscle-

rotic treatments。

However, symptomatic atherosclerotic plaques are mostly characterized by their

speci c composition rather than by their size or impact on the vessel lumen. Acute

ischemic events (acute coronary syndromes, strokes) are most frequently caused by

the endothelial disruption of atherosclerotic plaques (super cial intimal erosion or

brous cap rupture), triggering the formation of an intraluminal thrombus。4 These

atherosclerotic plaques are typically described as containing a large lipid core repre-

senting more than half of the plaque volume, a thin brous cap (<65 µm), and a

heavy in ltrate of in ammatory cells (macrophages and lymphocytes). On the pos-

tulate that early identi cation of such lesions could preclude ischemic events, imaging

techniques amied at the detection of vulnerable plaques, at high risk of acute throm-

bosis, are growing at a rapid pace。 The most useful techniques will combine high

spatial resolution with the detection of biological activities in atherosclerotic

plaques.

In this chapter, we will describe the strategies to detect vulnerable atherosclerotic

plaques with MRI. Multicontrast MRI can discriminate the components of atheroscle-

rotic plaques with different intrinsic relaxivity properties. In addition, analysis of the

accumulation intra-vascular MR contrast agents in atherosclerotic plaques allows for

a better identi cation of the cellular composition of plaques。 Finally, using an approach

360

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