bendick ncus - plaque characterization - handout1 [read-only] · plaque characterization the impact...

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




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




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



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



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




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


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


PLAQUEPLAQUE CHARACTERIZATIONCHARACTERIZATION


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%



Risk Factors for CV disease Risk Factors for CV disease --

AdultAdult

PopulationPopulation

TobaccoTobacco 21%21%

Elevated cholesterolElevated cholesterol 16%16%

DiabetesDiabetes 10%10%


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)


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


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



MRAMRA

Long signal Long signal Long signal Long signal

processing timesprocessing times

Spatial resolution ? Spatial resolution ?

Signal dropoutSignal dropout



MRAMRA

Requires patient cooperationRequires patient cooperationRequires patient cooperationRequires patient cooperation

Motion artifactsMotion artifacts

ClaustrophobiaClaustrophobia

Metal implant limitationsMetal implant limitations

Venous “contamination”Venous “contamination”



CTACTA

Accuracy comparableAccuracy comparable

to conventionalto conventional

angiographyangiography



CTACTALarge anatomic Large anatomic

region displayedregion displayedregion displayedregion displayed

Soft tissue Soft tissue

plus vasculatureplus vasculature

Minimal operator Minimal operator

dependencedependence

Rapid Rapid



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



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


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 ??


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 ??


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


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


Atherosclerotic Disease Atherosclerotic Disease –– Ulceration Ulceration

Ultrasound criteriaUltrasound criteria

Heterogeneous lesionHeterogeneous lesion

Sharp, irregular bordersSharp, irregular borders

> 2mm crater> 2mm crater


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


Atherosclerotic Disease Atherosclerotic Disease –– Echogenicity Echogenicity

Type I Type I –– Intraplaque hemorrhageIntraplaque hemorrhage


Gray Scale Median (GSM)Gray Scale Median (GSM)

� Normalize image echogenicityNormalize image echogenicity



�� Use histogram featureUse histogram feature



�� 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




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




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




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




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%


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:


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:


Driven by clinical dataDriven by clinical data

Bedside Bedside �� Bench Bench �� BedsideBedside

2121stst century 3century 3--D Duplex UltrasoundD Duplex Ultrasound


2121stst century Duplex Ultrasoundcentury Duplex Ultrasound

33--DD


33--DD

Next generation ultrasound Next generation ultrasound --

Fusion withFusion with


Fusion withFusion with

-- CTCT

MRMR

USUS

. . . . . .

Next generation ultrasound Next generation ultrasound --

Intravascular Ultrasound (IVUS)Intravascular Ultrasound (IVUS)


Intravascular Ultrasound (IVUS)Intravascular Ultrasound (IVUS)

-- Pixel codingPixel coding

-- Virtual histologyVirtual histology

-- Integrated backscatter Integrated backscatter

bendick ncus - plaque characterization - handout1 [read-only] · plaque characterization the impact...

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