Prediction of Carotid Intraplaque Hemorrhage Using Adventitial Calcification and Plaque Thickness on CTA.
Carotid intraplaque hemorrhage is associated with stroke, plaque thickness, stenosis, ulceration, and adventitial inflammation. Conflicting data exist on whether calcification is a marker of plaque instability, and no data exist on adventitial calcification. Our goal was to determine whether adventitial calcification and soft plaque (a rim sign) help predict carotid intraplaque hemorrhage.



This was a retrospective cohort study of 96 patients who underwent carotid MRA and CTA within 1 month, from 2009 to 2016. We excluded occlusions (n = 4) and near occlusions (n = 0), leaving 188 carotid arteries. Intraplaque hemorrhage was detected by using MPRAGE. Calcification, adventitial pattern, stenosis, maximum plaque thickness (total, soft, and hard), ulceration, and intraluminal thrombus on CTA were recorded. Atherosclerosis risk factors and medications were recorded. We used mixed-effects multivariable Poisson regression, accounting for 2 vessels per patient. For the final model, backward elimination was used with a threshold of P < .10. Receiver operating characteristic analysis determined intraplaque hemorrhage by using the area under the curve.



Our final model included the rim sign (prevalence ratio = 11.9, P < .001) and maximum soft-plaque thickness (prevalence ratio = 1.2, P = .06). This model had excellent intraplaque hemorrhage prediction (area under the curve = 0.94), outperforming the rim sign, maximum soft-plaque thickness, NASCET stenosis, and ulceration (area under the curve = 0.88, 0.86, 0.77, and 0.63, respectively; P < .001). Addition of the rim sign performed better than each marker alone, including maximum soft-plaque thickness (area under the curve = 0.94 versus 0.86, P < .001), NASCET stenosis (area under the curve = 0.90 versus 0.77, P < .001), and ulceration (area under the curve = 0.90 versus 0.63, P < .001).



The CTA rim sign of adventitial calcification with internal soft plaque is highly predictive of carotid intraplaque hemorrhage.
From the Department of Radiology (L.B.E., B.W.A., S.-E.K., G.S.T., D.L.P., J.S.M.), Utah Center for Advanced Imaging Research.
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0000-0001-9294-7645
LB
Eisenmenger
From the Department of Radiology (L.B.E., B.W.A., S.-E.K., G.S.T., D.L.P., J.S.M.), Utah Center for Advanced Imaging Research.
B W
0000-0003-1805-0359
BW
Aldred
From the Department of Radiology (L.B.E., B.W.A., S.-E.K., G.S.T., D.L.P., J.S.M.), Utah Center for Advanced Imaging Research.
S-E
0000-0002-7232-3621
SE
Kim
Department of Orthopedics (G.J.S.), Design and Biostatistics Center.
G J
0000-0002-6292-276X
GJ
Stoddard
Department of Neurology (A.d.H.).
A
0000-0001-8178-8597
A
de Havenon
From the Department of Radiology (L.B.E., B.W.A., S.-E.K., G.S.T., D.L.P., J.S.M.), Utah Center for Advanced Imaging Research Department of Surgery (G.S.T.), University of Utah, Salt Lake City, Utah Department of Surgery (G.S.T.), VA Salt Lake City Health Care System, Salt Lake City, Utah.
G S
0000-0002-1376-2536
GS
Treiman
From the Department of Radiology (L.B.E., B.W.A., S.-E.K., G.S.T., D.L.P., J.S.M.), Utah Center for Advanced Imaging Research.
D L
0000-0003-2557-8952
DL
Parker
From the Department of Radiology (L.B.E., B.W.A., S.-E.K., G.S.T., D.L.P., J.S.M.), Utah Center for Advanced Imaging Research scott.mcnally@hsc.utah.edu.
J S
0000-0003-3770-1153
JS
McNally
D000368:Aged; D019540:Area Under Curve; D002114:Calcinosis / Q000000981:diagnostic imaging* / Q000473:pathology; D016893:Carotid Stenosis / Q000000981:diagnostic imaging* / Q000473:pathology; D015331:Cohort Studies; D000072226:Computed Tomography Angiography / Q000379:methods*; D005260:Female; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D058226:Plaque, Atherosclerotic / Q000000981:diagnostic imaging* / Q000473:pathology; D015995:Prevalence; D012372:ROC Curve; D012189:Retrospective Studies; D012307:Risk Factors