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Research ArticleExtracranial Vascular
Open Access

Plaque Composition as a Predictor of Plaque Ulceration in Carotid Artery Atherosclerosis: The Plaque At RISK Study

K. Dilba, D.H.K. van Dam-Nolen, A.C. van Dijk, M. Kassem, A.F.W. van der Steen, P.J. Koudstaal, P.J. Nederkoorn, J. Hendrikse, M.E. Kooi, J.J. Wentzel and A. van der Lugt
American Journal of Neuroradiology January 2021, 42 (1) 144-151; DOI: https://doi.org/10.3174/ajnr.A6868
K. Dilba
aFrom the Departments of Radiology and Nuclear Medicine (K.D., D.H.K.v.D.-N., A.C.v.D., A.v.d.L.)
bCardiology (K.D., A.F.W.v.d.S., J.J.W.)
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D.H.K. van Dam-Nolen
aFrom the Departments of Radiology and Nuclear Medicine (K.D., D.H.K.v.D.-N., A.C.v.D., A.v.d.L.)
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A.C. van Dijk
aFrom the Departments of Radiology and Nuclear Medicine (K.D., D.H.K.v.D.-N., A.C.v.D., A.v.d.L.)
cNeurology (A.C.v.D., P.J.K.), Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
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M. Kassem
dDepartment of Radiology and Nuclear Medicine (M.K., M.E.K.), CARIM School for Cardiovascular Diseases, Maastricht University Medical Center+, Maastricht, the Netherlands
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A.F.W. van der Steen
bCardiology (K.D., A.F.W.v.d.S., J.J.W.)
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P.J. Koudstaal
cNeurology (A.C.v.D., P.J.K.), Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
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P.J. Nederkoorn
eDepartment of Neurology (P.J.N.), University Medical Center Amsterdam, Amsterdam, the Netherlands
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J. Hendrikse
fDepartment of Radiology (J.H.), University Medical Center Utrecht, Utrecht, the Netherlands
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M.E. Kooi
dDepartment of Radiology and Nuclear Medicine (M.K., M.E.K.), CARIM School for Cardiovascular Diseases, Maastricht University Medical Center+, Maastricht, the Netherlands
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J.J. Wentzel
bCardiology (K.D., A.F.W.v.d.S., J.J.W.)
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A. van der Lugt
aFrom the Departments of Radiology and Nuclear Medicine (K.D., D.H.K.v.D.-N., A.C.v.D., A.v.d.L.)
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    FIG 1.

    Flow diagram explaining the reasons for exclusion of a number of carotid arteries in the final data analysis.

  • FIG 2.
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    FIG 2.

    Ulceration development during follow-up and plaque composition at baseline of a 56-year-old female patient. MR imaging of carotid plaque proximal to the ulceration: precontrast T1-weighted turbo field echo sequence (A), postcontrast T1-weighted quadruple inversion recovery TSE sequence (B), T2-weighted TSE sequence (C), time-of-flight sequence (D), and MDCTA of irregular plaque at baseline (E) and of ulceration at 2-year follow-up (F). The asterisk marks the intraplaque hemorrhage. The white arrowhead points to thin-or-ruptured fibrous cap. White arrows point to the ulceration.

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    Table 1:

    The comparison of clinical characteristics and scan intervals between plaques with and without an ulcer at baselinea

    All Baseline (n = 180)Ulcer Baseline Absent (n = 131)Ulcer Baseline Present (n = 49)P Value
    Characteristics
     Age (yr)68 (63–73)68 (62–73)69 (64–73).41
     Sex (male)127 (71%)122 (70%)5 (83%).67
     BMI (kg/m2)26 (24–29)25 (24–29)27 (24–29).45
    Classification event0.01
     TIA76 (42%)64 (49%)12 (25%)
     Stroke85 (47%)54 (41%)31 (63%)
     Amaurosis fugax19 (11%)13 (10%)6 (12%)
    Hypertension117 (65%)85 (65%)32 (65%)1.00
    Hypercholesterolemia140 (78%)101 (77%)39 (80%).84
    Diabetes mellitus42 (23%)35 (27%)7 (14%).11
    Current smoker43 (24%)35 (27%)8 (16%).17
    Interval event/MDCTA (days)34 (15–55)36 (16–53)35 (13–59).85
    Interval event/MR imaging (days)47 (30–67)46 (30–67)48 (28–69).87
    Interval MDCTA/MR imaging (days)1 (1–25)1 (1–27)1 (1–17).70
    • Note:—BMI indicates body mass index.

    • ↵a Data are median (IQR) or No. (%).

    • View popup
    Table 2:

    Characteristics of plaques with and without an ulcer at baseline

    Ulcer Absent (n = 131)Median (IQR) or No. (%)Ulcer Present (n = 49) Median (IQR) or No. (%)Binary Logistic Regression OR (95% CI)ROC Analysis AUC (95% CI)
    NASCET (%)8 (0–29)21 (0–37)1.01 (1.00–1.03)0.61 (0.52–0.71)
    ECST (%)55 (45–65)59 (48–70)1.02 (1.00–1.05)
    Minimal diameter (mm)4 (3.3–4.9)3.4 (2.8–4.7)0.06 (0.00–1.00)0.40 (0.30–0.50)
    Total vessel volume (cm3)1.41 (1.16–1.64)1.60 (1.29–2.12)4.9 (2.1–11.4)0.64 (0.54–0.74)
    Lumen volume (cm3)0.56 (0.45–0.72)0.58 (0.46–0.80)2.8 (0.6–12.1)
    Wall volume (cm3)0.85 (0.70–0.98)1.02 (0.77–1.28)12.1 (3.5–42.0)0.67 (0.58–0.77)
    % Wall volume59 (53–66)61 (57–68)1.01 (0.99–1.04)
    LRNC presence78 (60%)38 (78%)2.4 (1.1–5.0)0.59 (0.50–0.68)
    % LRNC volume1 (0–10)15 (1–31)1.7 (1.3–2.2)0.70 (0.60–0.79)
    IPH presence42 (32%)27 (55%)2.6 (1.3–5.1)0.61 (0.52–0.71)
    % IPH volume0 (0–3)5 (0–23)1.7 (1.3–2.2)0.67 (0.56–0.76)
    Calcifications presence MR imaging118 (90%)44 (90%)0.97 (0.33–2.88)
    % Calcifications volume MR imaging5 (2–8)3 (1–7)0.73 (0.50–1.07)
    Calcification presence MDCTA117 (89%)45 (92%)0.74 (0.23–2.38)
    Calcification absolute volume MDCTA (mm3)31.4 (4.3–80.4)15.8 (2.8–51.9)0.99 (0.999–1.002)
    Thin-or-ruptured FC45 (34%)a,b32 (65%)3.4 (1.7–6.7)0.65 (0.56–0.74)
    • Note:—FC indicates fibrous cap.

    • ↵a Four were missing.

    • ↵b Four had bad quality.

    • View popup
    Table 3:

    Characteristics of plaques with and without a new ulceration at 2-year follow-upa

    New Ulceration Absent (n = 67)New Ulceration Present (n = 6)P Value
    NASCET (%)16 (0–34)11 (0–34).95
    ECST (%)57 (47–68)62 (53–71).45
    Minimal diameter (mm)3.8 (2.8–4.6)3.4 (2.9–4.8).80
    Total vessel volume (cm3)1.49 (1.2–1.75)1.61 (1.53–1.87).17
    Lumen volume (cm3)0.54 (0.44–0.77)0.59 (0.55–0.69).43
    Wall volume (cm3)0.86 (0.73–1.00)1.04 (0.97–1.16).029
    % Wall volume60 (52–67)64 (59–67).37
    LRNC presence41 (61%)6 (100%).08
    % LRNC volume2 (0–14)23 (13–31).002
    IPH presence21 (31%)6 (100%).002
    % IPH volume0 (0–5)14 (8–24)<.001
    Calcifications presence MR imaging63 (94%)6 (100%)1.00
    % Calcifications volume MR imaging5 (3–8)6 (2–9).79
    Calcifications presence MDCTA60 (90%)5 (83%).52
    Calcifications, absolute volume MDCTA (mm3)32.0 (7.0–100.3)1.9 (0.8–91.3).15
    Thin-or-ruptured FC28 (42%)6 (100%).009
    • Note:—FC indicates fibrous cap.

    • ↵a Data are median (IQR) or No. (%).

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K. Dilba, D.H.K. van Dam-Nolen, A.C. van Dijk, M. Kassem, A.F.W. van der Steen, P.J. Koudstaal, P.J. Nederkoorn, J. Hendrikse, M.E. Kooi, J.J. Wentzel, A. van der Lugt
Plaque Composition as a Predictor of Plaque Ulceration in Carotid Artery Atherosclerosis: The Plaque At RISK Study
American Journal of Neuroradiology Jan 2021, 42 (1) 144-151; DOI: 10.3174/ajnr.A6868

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Plaque Composition as a Predictor of Plaque Ulceration in Carotid Artery Atherosclerosis: The Plaque At RISK Study
K. Dilba, D.H.K. van Dam-Nolen, A.C. van Dijk, M. Kassem, A.F.W. van der Steen, P.J. Koudstaal, P.J. Nederkoorn, J. Hendrikse, M.E. Kooi, J.J. Wentzel, A. van der Lugt
American Journal of Neuroradiology Jan 2021, 42 (1) 144-151; DOI: 10.3174/ajnr.A6868
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