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PLAQUE
CHARACTERIZATION
Imaging TechnologyImaging TechnologyImaging TechnologyImaging Technology
to Identify theto Identify the
Patient at RiskPatient at Risk
PLAQUE CHARACTERIZATIONPLAQUE CHARACTERIZATION
The Impact of Cardiovascular DiseaseThe Impact of Cardiovascular Disease
Cause of Death in the U.S. Cause of Death in the U.S. --
1)1)Heart diseaseHeart disease~ 650,000 / yr~ 650,000 / yr
2)2)CancerCancer ~ 550,000 / yr~ 550,000 / yr
3) Stroke3) Stroke ~ 135,000 / yr~ 135,000 / yr3) Stroke3) Stroke ~ 135,000 / yr~ 135,000 / yr
PLAQUE CHARACTERIZATIONPLAQUE CHARACTERIZATION
The Impact of Cardiovascular DiseaseThe Impact of Cardiovascular Disease
Cause of Death in the U.S. Cause of Death in the U.S. --
Heart diseaseHeart disease
¼ of all deaths each year¼ of all deaths each year
50% women50% women
1 MI every 34 seconds1 MI every 34 seconds
1 death each minute1 death each minute
PLAQUE CHARACTERIZATIONPLAQUE CHARACTERIZATION
The Impact of Cardiovascular DiseaseThe Impact of Cardiovascular Disease
Cause of Death in the U.S. Cause of Death in the U.S. --
Heart disease in womenHeart disease in women
7% of adult women have CAD7% of adult women have CAD
2/3 of MI deaths in women2/3 of MI deaths in women
occur without prior symptomsoccur without prior symptoms
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
The Impact of Cardiovascular DiseaseThe Impact of Cardiovascular Disease
Cause of Death in the U.S. Cause of Death in the U.S. --
Stroke Stroke
1 stroke every 40 seconds1 stroke every 40 seconds
60% women60% women
Stroke Stroke
1 stroke every 40 seconds1 stroke every 40 seconds
60% women60% women
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
The Impact of Cardiovascular DiseaseThe Impact of Cardiovascular Disease
CV Morbidity in the U.S. CV Morbidity in the U.S. --
Heart disease Heart disease
11stst MIMI ~ 800,000 / yr~ 800,000 / yr
>> 22ndnd MIMI ~ 450,000 / yr~ 450,000 / yr
Annual cost Annual cost $ 316.4 Billion$ 316.4 Billion
Heart disease Heart disease
11stst MIMI ~ 800,000 / yr~ 800,000 / yr
>> 22ndnd MIMI ~ 450,000 / yr~ 450,000 / yr
Annual cost Annual cost $ 316.4 Billion$ 316.4 Billion
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
The Impact of Cardiovascular DiseaseThe Impact of Cardiovascular Disease
CV Morbidity in the U.S. CV Morbidity in the U.S. --
Stroke Stroke
11stst strokestroke ~ 600,000 / yr~ 600,000 / yr
>> 22ndnd strokestroke ~ 200,000 / yr~ 200,000 / yr
Leading cause of longLeading cause of long--term disabilityterm disability
Annual cost Annual cost $ 68.9 Billion$ 68.9 Billion
Stroke Stroke
11stst strokestroke ~ 600,000 / yr~ 600,000 / yr
>> 22ndnd strokestroke ~ 200,000 / yr~ 200,000 / yr
Leading cause of longLeading cause of long--term disabilityterm disability
Annual cost Annual cost $ 68.9 Billion$ 68.9 Billion
PLAQUEPLAQUE CHARACTERIZATIONCHARACTERIZATION
The Impact of Cardiovascular DiseaseThe Impact of Cardiovascular Disease
Risk Factors for CV disease Risk Factors for CV disease --
AdultAdult
PopulationPopulation
Inactivity (Exercise)Inactivity (Exercise) 40%40%
Obesity (Diet)Obesity (Diet) 34%34%
HypertensionHypertension 30%30%
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
The Impact of Cardiovascular DiseaseThe Impact of Cardiovascular Disease
Risk Factors for CV disease Risk Factors for CV disease --
AdultAdult
PopulationPopulation
TobaccoTobacco 21%21%
Elevated cholesterolElevated cholesterol 16%16%
DiabetesDiabetes 10%10%
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Cardiovascular Disease Cardiovascular Disease ––
Historically, the clinical significanceHistorically, the clinical significance
of CV disease has been based on theof CV disease has been based on the
severity of blockage (stenosis)severity of blockage (stenosis)
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Today, Contrast AngiographyToday, Contrast Angiography
remains the “Gold Standard”remains the “Gold Standard”
on which treatment is based on which treatment is based
�� Good 2Good 2--D spatial resolution (allows D spatial resolution (allows
quantitative measurements)quantitative measurements)
�� Visualizes vascular anatomyVisualizes vascular anatomy
�� Covers large region of interestCovers large region of interest
�� Limited operator dependence Limited operator dependence
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Newer “lumenographic” techniques Newer “lumenographic” techniques ––
MRAMRA
�� Venous catheterizationVenous catheterizationVenous catheterizationVenous catheterization
Gadolinium based contrastGadolinium based contrast
Bolus injectionBolus injection
�� 33--D reconstructionsD reconstructions
Soft tissue plus vasculatureSoft tissue plus vasculature
PLAQUEPLAQUE CHARACTERIZATIONCHARACTERIZATION
Newer “lumenographic” techniques Newer “lumenographic” techniques ––
MRAMRA
Long signal Long signal Long signal Long signal
processing timesprocessing times
Spatial resolution ? Spatial resolution ?
Signal dropoutSignal dropout
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Newer “lumenographic” techniques Newer “lumenographic” techniques ––
MRAMRA
Requires patient cooperationRequires patient cooperationRequires patient cooperationRequires patient cooperation
Motion artifactsMotion artifacts
ClaustrophobiaClaustrophobia
Metal implant limitationsMetal implant limitations
Venous “contamination”Venous “contamination”
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Newer “lumenographic” techniques Newer “lumenographic” techniques ––
CTACTA
Accuracy comparableAccuracy comparable
to conventionalto conventional
angiographyangiography
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Newer “lumenographic” techniques Newer “lumenographic” techniques ––
CTACTALarge anatomic Large anatomic
region displayedregion displayedregion displayedregion displayed
Soft tissue Soft tissue
plus vasculatureplus vasculature
Minimal operator Minimal operator
dependencedependence
Rapid Rapid
PLAQUEPLAQUE CHARACTERIZATIONCHARACTERIZATION
Newer “lumenographic” techniques Newer “lumenographic” techniques ––
CTACTAIonizing radiation
80%80% Growth in number of CT Growth in number of CT 80%80% Growth in number of CT Growth in number of CT
scans from 2000 scans from 2000 -- 20052005
80%80% Percent of radiation patients Percent of radiation patients
receive from CT scansreceive from CT scans
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Newer “lumenographic” techniques Newer “lumenographic” techniques ––
CTACTAIonizing radiation
A single thoraco A single thoraco ––A single thoraco A single thoraco ––
abdominal CTA can abdominal CTA can
be equivalent to be equivalent to
approximately 300 approximately 300
chest Xchest X--raysrays
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
All of these techniques areAll of these techniques are
still imagestill image--based and providebased and provide
anatomic information only anatomic information only ––
but is that the important data ??but is that the important data ??
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Atherosclerotic Disease Atherosclerotic Disease ––
Can we find techniques whichCan we find techniques whichCan we find techniques whichCan we find techniques which
will identify the atheroscleroticwill identify the atherosclerotic
plaque likely to become symptomatic plaque likely to become symptomatic --
that is, the “vulnerable” that is, the “vulnerable”
or “unstable” plaque ??or “unstable” plaque ??
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Atherosclerotic Disease Atherosclerotic Disease ––
Early efforts at plaque characterizationEarly efforts at plaque characterizationEarly efforts at plaque characterizationEarly efforts at plaque characterization
Identification of ulcerationIdentification of ulceration
Plaque echogenicityPlaque echogenicity
PLAQUEPLAQUE CHARACTERIZATIONCHARACTERIZATION
Atherosclerotic Disease Atherosclerotic Disease –– Ulceration Ulceration
Sx Patient, > 70% stenosisSx Patient, > 70% stenosisSx Patient, > 70% stenosisSx Patient, > 70% stenosis
NonNon--ulceratedulcerated 15% / yr15% / yr
UlceratedUlcerated 40% / yr40% / yr
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Atherosclerotic Disease Atherosclerotic Disease –– Ulceration Ulceration
Ultrasound criteriaUltrasound criteria
Heterogeneous lesionHeterogeneous lesion
Sharp, irregular bordersSharp, irregular borders
> 2mm crater> 2mm crater
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Atherosclerotic Disease Atherosclerotic Disease –– Echogenicity Echogenicity
Plaque type using UltrasoundPlaque type using UltrasoundPlaque type using UltrasoundPlaque type using Ultrasound
II Predominantly anechoicPredominantly anechoic
IIII Heterogeneous, partly anechoicHeterogeneous, partly anechoic
IIIIII Heterogeneous, mostly echogenicHeterogeneous, mostly echogenic
IVIV Homogeneous, echogenicHomogeneous, echogenic
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Atherosclerotic Disease Atherosclerotic Disease –– Echogenicity Echogenicity
Type I Type I –– Intraplaque hemorrhageIntraplaque hemorrhage
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Gray Scale Median (GSM)Gray Scale Median (GSM)
� Normalize image echogenicityNormalize image echogenicity
PLAQUEPLAQUE CHARACTERIZATIONCHARACTERIZATION
Gray Scale Median (GSM)Gray Scale Median (GSM)
�� Use histogram featureUse histogram feature
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Gray Scale Median (GSM)Gray Scale Median (GSM)
�� Clinical correlationClinical correlation
Echogenic plaque:Echogenic plaque:
7/64 (11%) associated with CT infarct7/64 (11%) associated with CT infarct
Echolucent plaque:Echolucent plaque:
46/84 (55%) associated with CT infarct46/84 (55%) associated with CT infarct
ElEl--Barghouti Eur J Vasc Endovasc Surg 1995Barghouti Eur J Vasc Endovasc Surg 1995
PLAQUEPLAQUE CHARACTERIZATIONCHARACTERIZATION
Gray Scale Median (GSM)Gray Scale Median (GSM)
�� Clinical correlationClinical correlation
Asymptomatic plaque:Asymptomatic plaque:
GSMGSM 38 +/38 +/-- 2626
Symptomatic plaque:Symptomatic plaque:
GSMGSM 21 +/21 +/-- 1515 p = .002p = .002
Elatrozy Int Angiol 1998Elatrozy Int Angiol 1998
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Gray Scale Median (GSM)Gray Scale Median (GSM)
�� Clinical correlationClinical correlation
Relative stroke risk Relative stroke risk ––
Echolucent (GSM < 74)Echolucent (GSM < 74)
vs Echorich (GSM > 74)vs Echorich (GSM > 74) 3.1X3.1X
8080--99% vs 5099% vs 50--79%79% 1.4X1.4X
Gronholdt Circulation 2001Gronholdt Circulation 2001
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Gray Scale Median (GSM)Gray Scale Median (GSM)
�� Clinical correlationClinical correlation
Echorich plaque: Echorich plaque: 5050--79%79% 8080--99%99%
Relative stroke risk Relative stroke risk –– 1.0X1.0X 3.1X3.1X
Echolucent plaque:Echolucent plaque: 5050--79%79% 8080--99%99%
Relative stroke risk Relative stroke risk –– 4.2X4.2X 7.9X7.9X
Gronholdt Circulation 2001Gronholdt Circulation 2001
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Gray Scale Median (GSM)Gray Scale Median (GSM)
�� Clinical correlationClinical correlation
Biasi Circulation 2004Biasi Circulation 2004
Complications of carotid stenting Complications of carotid stenting ––
GSM<25GSM<25 GSM>25GSM>25
Asx pts.Asx pts. 6.1%6.1% 0.6%0.6%
Sx pts.Sx pts. 9.8%9.8% 3.3%3.3%
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Where are we headed ?Where are we headed ?
�� MSCT tissue characterizationMSCT tissue characterization
MRI / MRSMRI / MRS�� MRI / MRSMRI / MRS
�� PET / PETPET / PET--CT CT
�� IVUS / Fusion ultrasoundIVUS / Fusion ultrasound
�� OCTOCT
�� ThermographyThermography
The Road to The Road to Personalized Medicine Personalized Medicine ––
A Paradigm Shift:A Paradigm Shift:
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Protocol based medical careProtocol based medical care
�� Individualized medical careIndividualized medical care
The Road to The Road to Personalized Medicine Personalized Medicine ––
A Paradigm Shift:A Paradigm Shift:
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Driven by clinical dataDriven by clinical data
Bedside Bedside �� Bench Bench �� BedsideBedside
2121stst century 3century 3--D Duplex UltrasoundD Duplex Ultrasound
PLAQUEPLAQUE CHARACTERIZATIONCHARACTERIZATION
2121stst century Duplex Ultrasoundcentury Duplex Ultrasound
33--DD
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
33--DD
Next generation ultrasound Next generation ultrasound --
Fusion withFusion with
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Fusion withFusion with
-- CTCT
MRMR
USUS
. . . . . .
Next generation ultrasound Next generation ultrasound --
Intravascular Ultrasound (IVUS)Intravascular Ultrasound (IVUS)
PLAQUE PLAQUE CHARACTERIZATIONCHARACTERIZATION
Intravascular Ultrasound (IVUS)Intravascular Ultrasound (IVUS)
-- Pixel codingPixel coding
-- Virtual histologyVirtual histology
-- Integrated backscatter Integrated backscatter
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