Dtsch Med Wochenschr 2005; 130(20): 1267-1272
DOI: 10.1055/s-2005-868712
Übersichten
Radiologie / Angiologie
© Georg Thieme Verlag Stuttgart · New York

Diagnostik der Morphologie und Oberflächenstruktur von Plaques der Arteria carotis interna

Vergleich von Sonographie, Computertomographie und KernspintomographieImaging techniques for showing the morphology and surface structure of extracranial internal carotid artery plaquesC. Denzel1 , K. Balzer2 , K. M. Müller3 , M. Lell4 , W. Lang1
  • 1Gefäßchirurgie, Chirurgische Klinik mit Poliklinik, Friedrich Alexander Universität Erlangen Nürnberg, Erlangen
  • 2Gefäßchirurgische Klinik, Evangelisches Krankenhaus, Mülheim
  • 3Institut für Pathologie an den Berufsgenossenschaftlichen Kliniken Bergmannsheil, Bochum
  • 4Institut für Diagnostische Radiologie (IDR), Friedrich Alexander Universität Erlangen Nürnberg, Erlangen
Further Information

Publication History

eingereicht: 20.12.2004

akzeptiert: 25.4.2005

Publication Date:
12 May 2005 (online)

Zusammenfassung

Zur Darstellung der Zusammensetzung von Plaques der extrakraniellen Arteria carotis interna werden der Ultraschall, die Computertomographie und die Kernspintomographie eingesetzt. Anhand der aktuellen Literatur soll die Wertigkeit dieser Verfahren für die klinische Diagnostik dargestellt werden.

Mit dem Ultraschall wird die Echogenität einer Plaque gut erfasst. Sie korreliert mit ipsilateralen Hemisphärensymptomen ohne dass eine klinisch relevante Korrelation mit der Histologie nachgewiesen werden kann. Die Oberflächenstruktur wird nur in optimalen Fällen korrekt erkannt.

Die Computertomographie (CT) zeigt exakt den Anteil und die Verteilung von Kalzium innerhalb der Plaque. Der Lipid- und Fibrinanteil ist dagegen nicht sicher darstellbar. Auch die Oberflächencharakteristik wird trotz verbesserter Auflösung in der Mehrzeilen-CT nicht aussagekräftig wiedergegeben.

Die Kernspintomographie (MRT) stellt unter optimalen Bedingungen in vitro die Zusammensetzung und die endoluminale Oberflächenstruktur der Plaque korrekt dar und detektiert in vivo die fibröse Kappe, einen nekrotischen Kern sowie Einblutungen. Genauere Darstellungen sind derzeit nur schwer interpretierbar.

Weitere klinische Studien müssen zeigen, ob mit Hilfe dieser Methoden auch in vivo und nicht invasiv die Plaquemorphologie dargestellt werden und somit eine angepasste Einteilung der Patienten in unterschiedliche Risikogruppen vorgenommen werden kann.

Summary

Methods of determining plaques in the extracranial internal carotid artery are ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). The goal of this overview is to introduce these methods and discuss their diagnostic and clinical significance.

Ultrasound has the capability of showing the echogenity of the plaques. This method seems to demonstrate a relationship with the incidence of hemispheric symptoms. A histological association could only rarely be seen. The surface structure can only be clearly and correctly evaluated in individual cases under optimal circumstances.

Computed tomography is capable of showing the calcium content and specific site of the plaques. However, lipid content and fibrous tissue cannot be deduced reliably. The currently available image resolutions limit a detailed imaging of surface characteristics.

Magnetic resonance imaging provides, in vitro, a correct rendering of plaque composition and endoluminal surface structure. In vivo it is possible to recognize both the fibrous cap and necrotic core as well as intraplaque hemorrhage. Because of certain artefacts more detailed images are difficult to interpret.

In conclusion, further clinical trials should reveal, whether these methods can be set in clinical routine to detect plaque surface and morphology for stratifying patients at risk of hemispheric symptoms during the spontaneous course as well as during carotid interventions.

Literatur

  • 1 ACAS. The asymptomatic carotid Arterosclerosis study group . Study design for randomized prospective trial of carotid endarterctomy for asymptomatic atherosclerosis.  Stroke. 1994;  25 2223
  • 2 Arnold J A, Modaresi K B, Thomas N, Taylor P R, Padayachee T S. Carotid plaque characterization by duplex scanning: observer error may undermine current clinical trials.  Stroke. 1999;  30 61-65
  • 3 Balzer K. Treatment of carotid stenosis? carotid surgery or stent: In favor of operation.  Herz. 2004;  29 90-103
  • 4 Cappeller W A, Schluter A, Hammer A, Jassoy A. Morphologische Charakteristika von Karotisplaques.  Chirurg. 2003;  74 743-748
  • 5 Cappendijk V C, Cleutjens K B, Heeneman S. et al . In vivo detection of hemorrhage in human atherosclerotic plaques with magnetic resonance imaging.  J Magn Reson Imaging. 2004;  20 105-110
  • 6 Cappendijk V C, Cleutjens K B, Kessels A G. et al . Assessment of human atherosclerotic carotid plaque components with multisequence MR imaging: initial experience.  Radiology. 2005;  234 487-492
  • 7 Chu B, Kampschulte A, Ferguson M S. et al . Hemorrhage in the atherosclerotic carotid plaque: a high-resolution MRI study.  Stroke. 2004;  35 1079-1084
  • 8 Comerota A J, Katz M L, White J V, Grosh J D. The preoperative diagnosis of the ulcerated carotid atheroma.  J Vasc Surg. 1990;  11 505-510
  • 9 Cumming M J, Morrow I M. Carotid artery stenosis: a prospective comparison of CT angiography and conventional angiography.  Am J Roentgenol. 1994;  163 517-523
  • 10 Denzel C, Balzer K, Muller K M, Fellner F, Fellner C, Lang W. Relative value of normalized sonographic in vitro analysis of arteriosclerotic plaques of internal carotid artery.  Stroke. 2003;  34 1901-1906
  • 11 Denzel C, Fellner F, Wutke R, Balzer K, Muller K M, Lang W. Ultrasonographic analysis of arteriosclerotic plaques in the internal carotid artery.  Eur J Ultrasound. 2003;  16 161-167
  • 12 Denzel C, Lell M, Maak M. et al . Carotid artery calcium: accuracy of a calcium score by computed tomography-an in vitro study with comparison to sonography and histology.  Eur J Vasc Endovasc Surg. 2004;  28 214-220
  • 13 Droste D W, Karl M, Bohle R M, Kaps M. Comparison of ultrasonic and histopathological features of carotid artery stenosis.  Neurol Res. 1997;  19 380-384
  • 14 Estes J M, Quist W C, Lo Gerfo F W, Costello P. Noninvasive characterization of plaque morphology using helical computed tomography.  J Cardiovasc Surg (Torino). 1998;  39 527-534
  • 15 European Carotid Surgery TrialistsŽs Collaborative Group . Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST).  Lancet. 1998;  351 1379-1387
  • 16 Gray-Weale A C, Graham J C, Burnett J R, Byrne K, Lusby R J. Carotid artery atheroma: comparison of preoperative B-mode ultrasound appearance with carotid endarterectomy specimen pathology.  J Cardiovasc Surg (Torino). 1988;  29 676-681
  • 17 Gronholdt M L, Nordestgaard B G, Schroeder T V, Vorstrup S, Sillesen H. Ultrasonic echolucent carotid plaques predict future strokes.  Circulation. 2001;  104 68-73
  • 18 Gronholdt M L, Nordestgaard B G, Wiebe B M, Wilhjelm J E, Sillesen H. Echo-lucency of computerized ultrasound images of carotid atherosclerotic plaques are associated with increased levels of triglyceride-rich lipoproteins as well as increased plaque lipid content.  Circulation. 1998;  97 34-40
  • 19 Hartmann A, Mohr J P, Thompson J L, Ramos O, Mast H. Interrater reliability of plaque morphology classification in patients with severe carotid artery stenosis.  Acta Neurol Scand. 1999;  99 61-64
  • 20 Hatsukami T S, Ferguson M S, Beach K W. et al . Carotid plaque morphology and clinical events.  Stroke. 1997;  28 95-100
  • 21 Hatsukami T S, Ross R, Polissar N L, Yuan C. Visualization of fibrous cap thickness and rupture in human atherosclerotic carotid plaque in vivo with high-resolution magnetic resonance imaging.  Circulation. 2000;  102 959-964
  • 22 Hoffmann U, Kwait D C, Handwerker J, Chan R, Lamuraglia G, Brady T J. Vascular calcification in ex vivo carotid specimens: precision and accuracy of measurements with multi-detector row CT.  Radiology. 2003;  229 375-381
  • 23 Imparato A M, Riles T S, Mintzer R, Baumann F G. The importance of hemorrhage in the relationship between gross morphologic characteristics and cerebral symptoms in 376 carotid artery plaques.  Ann Surg. 1983;  197 195-203
  • 24 Kawasaki M, Takatsu H, Noda T. et al . In vivo quantitative tissue characterization of human coronary arterial plaques by use of integrated backscatter. Intravascular ultrasound and comparison with angioscopic findings.  Circulation. 2002;  105 2487-2492
  • 25 Lal B K, Hobson R W, Pappas P J. et al . Pixel distribution analysis of B-mode ultrasound scan images predicts histologic features of atherosclerotic carotid plaques.  J Vasc Surg. 2002;  35 1210-1217
  • 26 Lang W, Denzel C, Balzer K, Muller K M. Risk evaluation of carotid artery plaque morphology: How can computed tomography add basic information to gray scale analysis by ultrasound?.  J Endovasc Ther. 2005;  12 I-23
  • 27 Lesniak B, Kaluzynski K, Liepsch D, Palko T. The discrimination of stenosed carotid bifurcation models with smooth and irregular plaque surface. Part II. The multivariate statistical analysis of ultrasonic Doppler velocity data.  Med Eng Phys. 2002;  24 319-323
  • 28 Libby P. Inflammation in atherosclerosis.  Nature. 2002;  420 868-874
  • 29 Matsagas M I, Vasdekis S N, Gugulakis A G, Lazaris A, Foteinou M, Sechas M N. Computer-assisted ultrasonographic analysis of carotid plaques in relation to cerebrovascular symptoms, cerebral infarction, and histology.  Ann Vasc Surg. 2000;  14 130-137
  • 30 Moody A R, Murphy R E, Morgan P S. et al . Characterization of complicated carotid plaque with magnetic resonance direct thrombus imaging in patients with cerebral ischemia.  Circulation. 2003;  107 3047-3052
  • 31 Morrisett J, Vick W, Sharma R. et al . Discrimination of components in atherosclerotic plaques from human carotid endarterectomy specimens by magnetic resonance imaging ex vivo.  Magn Reson Imaging. 2003;  21 465-474
  • 32 Murphy R E, Moody A R, Morgan P S. et al . Prevalence of complicated carotid atheroma as detected by magnetic resonance direct thrombus imaging in patients with suspected carotid artery stenosis and previous acute cerebral ischemia.  Circulation. 2003;  107 3053-3058
  • 33 Nandalur K R, Baskurt E, Hagspiel K D, Phillips C D, Kramer C M. Calcified carotid atherosclerotic plaque is associated less with ischemic symptoms than is noncalcified plaque on MDCT.  AJR Am J Roentgenol. 2005;  184 295-298
  • 34 Niwa Y, Katano H, Yamada K. Calcification in carotid atheromatous plaque: delineation by 3D-CT angiography, compared with pathological findings.  Neurol Res. 2004;  26 778-784
  • 35 North American Symptomatic Carotid Endarterectomy Trial Collaborators . Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.  N Engl J Med. 1991;  325 445-453
  • 36 Oliver T B, Lammie G A, Wright A R. et al . Atherosclerotic plaque at the carotid bifurcation: CT angiographic appearance with histopathologic correlation.  Am J Neuroradiol. 1999;  20 897-901
  • 37 Park A E, McCarthy W J, Pearce W H, Matsumura J S, Yao J S. Carotid plaque morphology correlates with presenting symptomatology.  J Vasc Surg. 1998;  27 872-878 , discussion 878 - 879.
  • 38 Pedro L M, Pedro M M, Goncalves I. et al . Computer-assisted carotid plaque analysis: characteristics of plaques associated with cerebrovascular symptoms and cerebral infarction.  Eur J Vasc Endovasc Surg. 2000;  19 118-123
  • 39 Rakebrandt F, Crawford D C, Havard D, Coleman D, Woodcock J P. Relationship between ultrasound texture classification images and histology of atherosclerotic plaque.  Ultrasound Med Biol. 2000;  26 1393-1402
  • 40 Ratliff D A, Gallagher P J, Hames T K, Humphries K N, Webster J H, Chant A D. Characterisation of carotid artery disease: comparison of duplex scanning with histology.  Ultrasound Med Biol. 1985;  11 835-840
  • 41 Sabetai M M, Tegos T J, Clifford C. et al . Carotid plaque echogenicity and types of silent CT-brain infarcts? Is there an association in patients with asymptomatic carotid stenosis?.  Int Angiol. 2001;  20 51-57
  • 42 Sabetai M M, Tegos T J, Nicolaides A N. et al . Hemispheric symptoms and carotid plaque echomorphology.  J Vasc Surg. 2000;  31 39-49
  • 43 Schminke U, Motsch L, Hilker L, Kessler C. Three-dimensional ultrasound observation of carotid artery plaque ulceration.  Stroke. 2000;  31 1651-1655
  • 44 Schulte-Altedorneburg G, Droste D W, Haas N. et al . Preoperative B-mode ultrasound plaque appearance compared with carotid endarterectomy specimen histology.  Acta Neurol Scand. 2000;  101 188-194
  • 45 Shinnar M, Fallon J T, Wehrli S. et al . The diagnostic accuracy of ex vivo MRI for human atherosclerotic plaque characterization.  Arterioscler Thromb Vasc Biol. 1999;  19 2756-2761
  • 46 Streifler J Y, Eliasziw M, Fox A J. et al . Angiographic detection of carotid plaque ulceration. Comparison with surgical observations in a multicenter study. North American Symptomatic Carotid Endarterectomy Trial.  Stroke. 1994;  25 1130-1132
  • 47 Tegos T J, Sohail M, Sabetai M M. et al . Echomorphologic and histopathologic characteristics of unstable carotid plaques.  Am J Neuroradiol. 2000;  21 1937-1944
  • 48 Tegos T J, Stavropoulos P, Sabetai M M, Khodabakhsh P, Sassano A, Nicolaides A N. Determinants of carotid plaque instability: echogenicity versus heterogeneity.  Eur J Vasc Endovasc Surg. 2001;  22 22-30
  • 49 Thickman D I, Kundel H L, Wolf G. Nuclear magnetic resonance characteristics of fresh and fixed tissue: the effect of elapsed time.  Radiology. 1983;  148 183-185
  • 50 Toussaint J F, Southern J F, Fuster V, Kantor H L. T2-weighted contrast for NMR characterization of human atherosclerosis.  Arterioscler Thromb Vasc Biol. 1995;  15 1533-1542
  • 51 Trivedi R A, UK-I J, Graves M J. et al . Multi-sequence in vivo MRI can quantify fibrous cap and lipid core components in human carotid atherosclerotic plaques.  Eur J Vasc Endovasc Surg. 2004;  28 207-213
  • 52 Trivedi R A, UK-I J M, Graves M J. et al . MRI-derived measurements of fibrous-cap and lipid-core thickness: the potential for identifying vulnerable carotid plaques in vivo.  Neuroradiology. 2004;  46 738-743
  • 53 Troyer A, Saloner D, Pan X M, Velez P, Rapp J H. Major carotid plaque surface irregularities correlate with neurologic symptoms.  J Vasc Surg. 2002;  35 741-747
  • 54 Yuan C, Mitsumori L M, Ferguson M S. et al . In vivo accuracy of multispectral magnetic resonance imaging for identifying lipid-rich necrotic cores and intraplaque hemorrhage in advanced human carotid plaques.  Circulation. 2001;  104 2051-2056

Prof. Dr. med. Werner Lang

Chirurgische Klinik mit Poliklinik, Gefäßchirurgie, Friedrich Alexander Universität Erlangen Nürnberg

Krankenhausstraße 12

91054 Erlangen

Phone: +49/9131/8532968

Fax: +49/9131/8539115

Email: w.lang@gch-erlangen.de

    >