SHAPE Society

1. Everybody Has Atherosclerosis
The Question Is Who Has
Vulnerable Plaque
Paradigm Shift in Cardiology
“Magnetic Resonance Imaging of Plaque Inflammation”
CIMIT Vulnerable Plaque Program
February 11th, 2002
Morteza Naghavi, MD
University of Texas Houston and Texas Heart Institute

2. Sudden Cardiac Death
Acute MI
Vulnerable
Plaque(s)
Stop Vulnerable Plaque, Prevent Heart Attack!

3.  On the basis of his studies of the
triggers of MI, James E. Muller et al
described “coronary occlusive
thrombi occurs when atherosclerotic
plaques become vulnerable to
rupture … during vulnerable
periods…" 5 years later in 1994 he
coined the term of
History of Atherosclerosis from www.VP.org
Who Brought the Name of “Vulnerable Plaque”
to Medical Literature?
Muller JE, Abela GS, Nesto RW, Tofler GH.
Triggers, acute risk factors and vulnerable plaques: the lexicon of a new frontier.
J Am Coll Cardiol. 1994 Mar 1;23(3):809-13. Review.
Vulnerable Plaque.

4. Vulnerable Plaque, the youngest creature in the land of cardiology
has just turned in 8 y!
VPiologists call him VP!!

5. Carl von Rokitansky (1804-1878)
Rokitansky gaveearly
detailed descriptionsof
arterial disease. Heis
alleged to haveperformed
30,000 autopsies.
Rokitansky in 1841 championed theThrombogenic Theory. Heproposed that the
depositsobserved in theinner layer of thearterial wall derived primarily from fibrin and other
blood elementsrather than being theresult of apurulent process. Subsequently, theatheroma
resulted from thedegeneration of thefibrin and other blood proteinsasaresult of apreexisting
crasisof theblood, and finally thesedepositsweremodified toward apulpy masscontaining
cholesterol crystalsand fatty globules.
Thistheory cameunder attack by Virchow

6. First studies on inflammation of vessels, particularly phlebitis, Started at
a time when Cruveilhier2had just stated: La phlebite domine toute la
pathologie.3 First a great number of preparatory studies on fibrin,
leukocytes, meta-morphosis of blood, published separately. …
Rudolf Virchow 1821-1902
The Father of
Cellular
Pathology
Virchow appreciates prior works.
Virchow presented hisinflammatory theory. Heutilized thenameof "endarteritisdeformans." By thishe
meant that theatheromawasaproduct of an inflammatory processwithin theintimawith thefibrous
thickening evolved asaconsequenceof areactivefibrosisinduced by proliferating connectivetissuecells
within theintima.

7. Olcott 1931 “plaque rupture”
Leary 1934 “rupture of atheromatous abscess”
Wartman 1938 “rupture-induced occlusion”
Horn 1940 “plaque fissure”
Helpern 1957 “plaque erosion”
Crawford 1961 “plaque thrombosis”
Gore 1963 “plaque ulceration”
Friedman 1964 “macrophage accumulation”
Byers 1964 “thrombogenic gruel”
Chapman 1966 “plaque rupture”
Plaque Fissure in Human Coronary Thrombosis (Abstract) Fed. Proc. 1964, 23, 443
Paris Constantinidis
“Thedestruction of thehyalinized wall separating lumen from theatheromawas
almost alwaysobserved to bepreceded by or associated with itsinvasion by
lipid containing macrophages.” Friedman and van den
Bovenkamp 1965
Unheralded Pioneers

8. Published in 1967

9. The Abscess
“Grutzbalg” Hypothesis

10. N Engl J Med 1999
“Atherosclerosis; an
inflammatory disease”
Ross R.
Russell Ross
Atherosclerosis; arterial “Response to Injury”
N Engl J Med 1976 Aug 12;295(7):369-77
The pathogenesis of atherosclerosis (first
of two parts).
Ross R, Glomset JA.

11. Erling Falk Michael Davies
Autopsy Series
Thin Fibrous Cap + Large Lipid Core + Dense Macrophage
A culprit ruptured plaque
1981-1990

12. Seymour Glagov
Compensatory Enlargement
of Human Atherosclerotic Coronary
Arteries N Engl J Med 1987 May
28;316(22):1371-5
<50%
stenosis
Luminal area is not endangered until more than 40% of
internal elastic lamina is destructed and occupied by plaque
Coronary artery disease is a disease of
arterial wall not lumen.
Positive Remodeling
<80%
stenosis

13. Angiographic progression of coronary
artery disease and the development of
myocardial infarction.
Ambrose JA, Tannenbaum MA, Alexopoulos D, Hjemdahl-Monsen CE, Leavy J, Weiss M, Borrico S, Gorlin R, Fuster V.
Department of Medicine, New York Cardiac Center, Mount Sinai Medical Center, New York 10029.
Simultaneously, Little et al, Haft et al reported that majority of culprit
lesions are found on previously non-critical stenosis plaques.
Conclusion:
“Myocardial infarction frequently develops from non-severe lesions.”
J Am Coll Cardiol 1988 Jul;12(1):56-62
Ambrose, Fuster, and colleagues
X-Ray Angiographically Invisible Plaques

14. Falk E., Shak P.K., Fuster V. Circulation 1995
Non-stenotic (<75%) plaques cause about 80% of deadly MI

15. Macrophage-
driven MMPs
soften plaquecap
and prompt it to
rupture
P.K. Shah
Peter Libby
Thefateof atherosclerosisand
itsthrombotic complication are
governed by immunesystem.
Goran Hansson
Allard van der
Wal
and others

16. •Eroded Plaque
Rupture-prone
plaques are not the
only type of
vulnerable plaque
•Calcium Nodule
van der Wal - Netherlands
Renu Virmani -USA
Thiene - Italy
Kolodgie F., Burk A.P., Farb A., and Virmani R.

17. Dangerous forms of
atherosclerotic
plaques prone to
thrombosis
Vulnerable Plaque?

18. Ruptured Plaques (~70%)
1. Stenotic (~20%)
2. Non-stenotic (~50%)
Non-ruptured Plaques (~
30%)
1. Erosion (~20%)
2. Calcified Nodule (~5%)
Plaque Pathology Responsible for Coronary Thrombotic Death
In summary:

19.  Culprit Plaque; a retrospective terminology
 Vulnerable Plaque; a prospective terminology
 Vulnerable Plaque = Future Culprit Plaque
Terminologies

20. Natural History of
Vulnerable Plaques
Illustrated:

21. ~70%
Percent of stenosis
Frequency of plaques
“Risk” per each plaque
Culprit Risk per
each type of
Vulnerable Plaque
(Log)
Culprit lesions found
in autopsy series of
acute MI
Different Types
of Plaque
Vulnerable to
Thrombosis
All
Male
Female
~10% <5% ~20%
50%
Angiography
~80% <5% ~20%
~55% ~20%
<5%
<5% ~20%
Rupture Prone Eroded Calcified NoduleHemorrhage
Positive Remodeling
Fissured /Healed
Natural History
of Vulnerable
Atherosclerotic
Plaques

22. Rupture-Prone Plaque
Vulnerable Plaque Naghavi et al, Cur Ath Rep 2001
Macrophage
Necrotic lipid
core
Thin fibrouscap

23. Eroded Plaque
Vulnerable Plaque Naghavi et al, Cur Ath Rep 2001
Endothelial
denudation
Proteoglycans

24. Fissured / Healed Plaque
Vulnerable Plaque Naghavi et al, Cur Ath Rep 2001
Mural thrombi
Wounded
plaque

25. Plaque with a Intimal Calcified Nodule
Vulnerable Plaque Naghavi et al, Cur Ath Rep 2001
Calcified nodule

26. Intra-Plaque Hemorrhage with Intact Cap
Vulnerable Plaque Naghavi et al, Cur Ath Rep 2001
Leaking
angiogenesisor
ruptureof vasa
vaserum

27. Critically Stenotic but Asymptomatic Plaque
Naghavi et al, Cur Ath Rep 2001Vulnerable Plaque
>75% lumina
narrowing

28. Different Types of Vulnerable Plaques
Major Underlying Cause of Acute Coronary Events
Normal
Rupture-prone
Fissured Eroded
Critical Stenosis Hemorrhage
Naghavi et al, Cur Ath Rep 2001

29. Emerging
Techniques for
Detection of
Vulnerable Plaque

30. Emerging Diagnostic Techniques
A. Invasive Techniques
Angioscopy
IntravascularUltrasound (IVUS)
IntravascularThermography
IntravascularOptical Coherence Tomography (OCT)
IntravascularElastography
Intravascularand Transesophageal MRI
IntravascularNuclearImaging
IntravascularElectrical Impedance Imaging
IntravascularTissue Doppler
IntravascularShearStress Imaging
Intravascular(Photonic) Spectroscopy

31. - Raman Spectroscopy
- Near-Infrared Diffuse Reflectance Spectroscopy
-Fibrousis and lipid measurement
-pH and lactate measurement
- Fluorescence Emission Spectroscopy
- Spectroscopy with contrast media
… Invasive Techniques
Intravascular (Photonic) Spectroscopy
Intra-coronary assessment of endothelial function
Intra-coronary measurement of MMPs and cytokines

32. Emerging Diagnostic Techniques
B. Non-Invasive Techniques:
A. MRI
1- MRI without contrast media
2- MRI with contrast media: Gadolinium-DPTA
2- MR Imaging of Inflammation: Super Paramagnetic
Iron Oxide (SPIO and USPIO)
3- MR Imaging of Thrombosis using monoclonal Ab
B. Electron Beam Tomography (EBT)
C. Multi-Slice Fast Spiral / Helical Computed Tomography
D. Nuclear Imaging (18-FDG, MCP-1, Annexin V, CD40)

33. Emerging Diagnostic Techniques
C. Blood Tests / Serum Markers
- CRP
- ICAM-1, VCAM, p-Selectin, sCD40-L
- Proinflamatory cytokines
- Lp-PLA2
- Ox-LDL Ab
- PAPP-A
D. Endothelial Function Test
-Intra coronary acethylcholine test
-Noninvasive flow mediated dilatation of
brachial artery
- Anti-body against endothelial cells

34. Angioscopy
Advantages:
Intuitive (anatomic)
Simple (easy to understand)
Disadvantages:
Visualizes only the surface of the plaque
Requires a proximal occluding balloon
The spatial resolution is limited
Glistening
yellow plaque
Uchida et al, Japan

35. Intravascular Ultrasound (IVUS):
Advantage:
Reveals the morphology
of the plaque
Differs between soft
(hypo-echoic) and Hard
(hyper-echoic) plaques
Disadvantages:
Doesn’t give information about plaque
inflammation
Low spatial resolution (~ 200 µm)
Nissen, Yock, and
Fitzgerald

36. Optical Coherence Tomography (OCT)
Advantage:
Very high-resolution
Disadvantages:
Needs continuous saline wash / proximal
occlusion
Limited penetration
Does not give information
about plaque inflammation
Light Lab Inc.Mark Brezinski, James Fujimoto, Eric Swanson

37. Intravascular Thermography
Advantages:
Simplicity in theory; hot plaque
Gives information about plaque
inflammation
Disadvantages:
Plaque temperature is affected
by blood flow
Volcano Therapeutics Inc.

38. Casscells W, et al.
Thermal detection of cellular infiltrates in living atherosclerotic
plaques: possible implications for plaque rupture and thrombosis.
Lancet. 1996 May 25;347(9013):1447-51.
Vulnerable plaques are hot and acidic!
Ward Casscells and James Willerson showed ex-vivo that human
carotid atherosclerotic plaques have temperature heterogeneity
and plaques with thinner cap and higher macrophage infiltration
give off more heat. Two years later Morteza Naghavi invented
Thermosensor Basket catheter and showed invivo temperature
heterogeneity in Hypercholestrolemic Dogs and Watanabe
Rabbits. Coincidentally Stefanadis et al in 1999 confirmed
significant temperature heterogeneity invivo in patients with
unstable angina and acute MI.
Stefanadis C, et al.
Thermal heterogeneity within human atherosclerotic coronary arteries detected in
vivo: A new method of detection by application of a special thermography catheter.
Circulation. 1999 Apr 20;99(15):1965-71.

39. Photonic Spectroscopy
Advantage:
 Chemical compounds
Disadvantage:
Based on statistical analysis and
calibration is always an issue
S/N is a serious problem
Still not proven to be able to distinguish
vulnerable plaques from stable ones
Near Infrared Reflectance Spectroscopy
InfraReDx Inc.
NIR Spectroscopy
Robert Lodder, James Muller, and Pedro Moreno

40. Intravascular Elastography
Advantages:
Provides novel information, showing stiffness
Small added cost to IVUS
Disadvantage:
Does not give any chemical – compositional data,
nor shows inflammation
de Korte et al. Thorax Center, Erasmus University Rotterdam

41. Intravascular Nuclear Imaging
Immuno-scintigraphy
Advantage:
One may use radio-labeled antibodies to detect
specific antigens in plaque like MCP-1
Disadvantages:
Radiation and safety problems
Poor resolution and flow artifacts
Lack of specificity
ImetrX Inc.William Strauss and Vartan Ghazarossian

42. Magnetic Resonance Imaging
Plaque Characterization and Angiography
Advantages:
Lack of ionizing radiation
Non-invasive
Provides enormous information about flow as
well as plaque
Enhancement by contrast agents and NMR
spectroscopy
Disadvantages:
Ineligibility of patients with metal prostheses
High cost
Longer time for adoption by cardiologists

43. Human Carotid Plaque
Courtesy of
Dr. Chun Yuan
University of Washington

44. Fuster and Fayad and colleagues reinforced earlier MRI investigation of plaque for invivo
non-invasive detection of vulnerable plaque with large lipid pool and thin fibrous caps.

45. Noninvasive Coronary Vessel Wall and Plaque Imaging With
Magnetic Resonance Imaging
René M. Botnar; Matthias Stuber; Kraig V. Kissinger; Won Y. Kim; Elmar Spuentrup; Warren J. Manning.
Circulation. 2000;102:2582

46. Intravascular MRI
Advantages:
Lack of ionizing
radiation
High resolution
Potential for NMR spectroscopy
Disadvantages:
Invasive and slower than fluoroscopy
Needs open/short bore high field magnet
Longer time for adoption by cardiologists
Surgi-Vision Inc.Ergin Atalar
IVUS

47. Coronary Calcium Imaging
EBT and MSCT
Advantages:
Quick and easy
Provide information about total
burden of atherosclerosis
Disadvantages:
Cannot distinguish vulnerable from stable plaque
(poor plaque characterization)
Inadequate specificity, may not accurately
predict near future event
May not be suitable for monitoring treatment
Calcium Score
Imatron Inc.Rumberger, Aard, Raggi, and others

48. Race for Non-Invasive Coronary
Angiography
• Multi-Slice Fast Computed
Tomography (MSCT)
• Magnetic Resonance
Angiography
(MRA)
• Electron Beam Tomography
(EBT)

49. Two Major Players in Massive
Clinical VP Screening
•MRI
•CT
•A new competitor is
warming up!

50. Plaque Morphology
vs.
Plaque Activity
Why do we need both?

51. Morphology vs. Activity Imaging
Inactive and
non-inflamed
plaque
Active and
inflamed
plaque
May Appear Similar
in
IVUS OCT MRI
w/o CM
Morphology
Show Different
Activity
Thermography, Spectroscopy,
immunoscientigraphy, MRI with
targeted contrast media…

55. Which one is
vulnerable plaque?

56. High Level of Sensitivity and Specificity Needed
• Knowing the high prevalence of
atherosclerosis in apparently healthy
population, in order to accurately detect
vulnerable plaques and vulnerable patients,
it is imperative to obtain information about
both structure and activity of plaque
assuring minimum false positive and false
negative results.
NO MORE TREADMILL TEST!

57. Major Criteria of Vulnerable Plaque
• Cap Thickness
• Lipid Core
• Plaque inflammation (macrophage density)
For clinical screening of vulnerable plaques,
if you were to have only ONE shot, which
one would you aim at?

58. I would chouse
Inflammation

59. Good News!
•MRI can give us more
than one choice, indeed it
can provide all of them.
• CT is promising too, but there is more
homework for CT fans.

60. Plaque Activity = Plaque Inflammation
Plaque Inflammation =
Plaque Macrophage Density =
Plaque Monocyte Recruitment
Rate
Note: leaking angiogenesis follows
inflammation but is not specific enough.

61. Vulnerable plaque targeted contrast media
needed to identify the following:
1- Inflammation (macrophage infiltration),
2- Fissured/Permeable Cap,
3- Leaking Angiogenesis and
4- Intra-Plaque Hemorrhage
5- Denuded Endothelium

62. SSuperuper PParamagneticaramagnetic IIronron OOxide andxide and
Ultra-small Super Paramagnetic IronUltra-small Super Paramagnetic Iron
OxideOxide
((SPIOSPIO – USPIO)– USPIO)
Blood pool Magnetic resonance (MR) imaging
contrast media with a central core of iron oxide
generally coated by a polysaccharide layer
Shortening MR relaxation time
Engulfed by and accumulated in cells with
phagocytic activity

63. Particle Core Size Particle Size Blood
(nm) (nm) Half-life
Combidex 5-6 20-30 8h
Feridex 4-6 35-50 2.4±0.2h
DDM 43/34/102 6.4 20-30 6h
Clariscan
MION 4-6 17 varies
Feruglose
--- --- --- ---
Examples of Available SPIOs

64. Reported Applications of SPIO in MR Imaging:
-Detection of Hepatic Lesions
(primary and metastatic cancers)
-Experimental nephritic syndrome in laboratory animals
-Monitoring rejection of transplanted heart or kidney in
the animal model of allograft transplantation.
-Experimental detection of CNS lesions in laboratory
animals.
MR Imaging of Inflammation is not New

65. HypothesisHypothesis
Active macrophages residing inside
the plaque and recruitment of
monocytes into an inflamed
vulnerable plaques can be visualized
by SPIO contrast enhanced MRI.
Decrease in MR signal intensity
(negative enhancement) is correlated
with the density of active
macrophages residing inside plaque.

66. Our proposed solution: SPIO MR Imaging
MR contrast media for imaging inflammation and other characteristics of vulnerable plaque

67. USPIOs Enter the AtheroscleroticUSPIOs Enter the Atherosclerotic
Plaque ThroughPlaque Through
Monocyte containing
engulfed SPIO particles
Fissured or thin cap
 Extensive angiogenesis
l and leaking vasa vasorum
 Intra plaque hemorrhage

68. In-vitro Study of Macrophage
SPIO Uptake
 In a series of in-vitro studies we have tested
the rate of SPIO uptake by human activated
monocytes in different conditions regarding
incubation time and concentration of SPIO.
All SPIO were labeled by a fluorescent dye
(DCFA).

69. Fluorescent-labeled SPIO incubated with macrophages 24 hr
Macrophages avidly take up SPIO nano-particles

70. SPIO and T2 Effect
In-vitro relaxation study shows the effect
of SPIO dose and incubation time on
intra-macrophage SPIO negative
enhancement

72. 0
10
20
30
40
50
60
70
80
90
50 250 control
20 min
60 min
6 hours
24 hours
Macrophage Uptake of Feridex with Time
and Concentration Shown by T2 Reduction
Concentration µmol/ml

73. In-vivo distribution of SPIO in ApoE
deficient and wild type mice:
•For the initial study, we use the mouse model of
atherosclerosis.
•
•ApoE deficient mouse has similar atherosclerotic
lesions to human and the lesions are more common in
the aortic arch and thoracic aorta.
• We used ApoE deficient mice and normal variant
(C57BL mice) as control.
•The SPIO that we used was Feridex (Berlex) injectable
solution.
•Animals were sacrificed on day 3 and 5 after injection.

74. Pre and Post-SPIO Enhanced Magnetic
Resonance Imaging of ApoE K/O and Wild
Type Mice:
We used 4.7 tesla MRI unit in our study.
After baseline MR imaging with respiratory gating, we
injected 1mMolFe/kg super paramagnetic iron oxide to
six ApoE deficient and two C57bl mice through the tail
vein.
Post-contrast MR imaging were performed in day 5 with
the same parameters (TR=2.5 sec, TE=0.012 sec,
FOV=6.6 cm, slice thickness=2.0mm, flip angle
(orient)=trans, and matrices=256x256).
We selected the aorta at the level of kidney for
comparison of the baseline and post-contrast images.

75. Apo E deficient mice MRI SPIO experiment

76. SPIO Accumulation in
Atherosclerotic Plaque
Atherosclerotic plaque
in aortic root
Normal aortic segment
Iron staining of Apo E K/O Aorta, 24 hour after SPIO injection
Iron
particles

77. Histopathologic study of the Mouse injected
With SPIO (Thoracic Aorta)
ApoE KO mouse, Movat staining,
proximal aorta
Coronary
Cross section
Atherosclerosis
plaque

78. Histopathologic study of ApoE KO Mouse injected
With SPIO (Thoracic Aorta)
CD68 staining
(aortic plaque)
Iron Staining (aortic plaque) Iron Staining (coronary section)
Iron particles Iron particles

79. Histopathologic study of ApoE KO Mouse
injected With SPIO (Abdominal Aorta)
H&E staining
Iron Staining CD 68 staining
Iron particles

80. Histopathologic study of wild type Mouse
injected With SPIO (Thoracic Aorta)
H&E staining
CD68 stainingIron staining

81. MR Image of Abdominal Aorta
After SPIO Injection in Mouse
Apo E
deficient
mouse
C57B1
(control)
mouse
Before Injection After Injection (5 Days )
Dark (negatively enhanced) aortic wall, full of iron particles
Bright aortic lumen and wall without negative enhancement
and no significant number of iron particles

82. Rabbit Aorta, x10 magnification
Iron Staining H&E Staining

83. Rabbit Aorta, x40 magnified
Iron Staining H&E Staining

84. Histopathologic studies of Thoracic aorta in Watanabe
Hereditary Hypercholesterolemic rabbit after SPIO injection
H&E staining
Iron staining Macrophage staining

85. Histopathologic studies of Thoracic aorta in Watanabe
Hereditary Hypercholesterolemic rabbit after SPIO injection
H&E staining
Iron staining
Iron staining
Iron particles

86. Plaque Cell Density vs SPIO
0
10
20
30
40
50
60
0 10 20 30 40 50 60 70
Cell Denity in H&E staining
SPIOpositivecell-Iron
staining
Series1
R=0.956
Correlation between Iron positive cells in Iron
staining and cell density in H&E staining in rabbit
atherosclerotic aorta.

87. MR Angiography 3D with Gadolinium-DTPA in
Watanabe Rabbit
Before SPIO injection After SPIO injection

88. Ex-vivo MR study of the thoracic aorta in Watanabe and
Wild type rabbit after SPIO injection compared to control.
3D MR Angiography with Gadolinium-DTPA
Watanabe rabbit
post-SPIO
Watanabe rabbit
control
NZW rabbit
control
NZW rabbit
post-SPIO

89. Ex-vivo MR study of the thoracic aorta in Watanabe and
Wild type rabbit after SPIO injection compared to control.
(Gradient Echo)
Watanabe rabbit
Post-SPIO
Watanabe rabbit
control
NZW rabbit
Post-SPIO
NZW rabbit
control

90. No cytokine injected
Apo E SPIO Injected
Iron Staining
H&E Staining

91. No cytokines
Apo E SPIO Injected
Iron Staining
H&E Staining

92. No cytokines SPIO Injected Apo E
Only plaque with SPIO C3Ex40

93. No Cytokines SPIO Injected Apo E
C3E
SPIO Found in Circulating Monocytes
Iron Staining
H&E Staining

94. T2Fx10
TNFα/IL-1ß SPIO Injected Apo E
Iron Staining H&E Staining

95. TNFα/IL-1ß SPIO Injected Apo E
H&E StainingH&E Staining
Increased Superficial Macrophage Density

96. TNFα/IL-1ß
Iron Staining Iron Staining

97. TNFα/IL-1ß
Iron Staining H&E Staining

98. TNFα/IL-1ß
Iron Staining Macrophage Staining

99. TNFα/IL-1ß
Iron Staining H&E Staining

100. TNFα/IL-1ß
Iron Staining H&E Staining

101. TNFα/IL-1ß
Iron Staining H&E Staining

102. New SPIO Development
Towards Plaque Targeted SPIO
Six mice were injected IP with mineral oil, and 24
hours later same amount of above SPIOs were
injected IP, 24 hours later, macrophages were
isolated from the mice, 24 hours later, the following
pictures were taken .

103. New SPIO Development
Towards Plaque Targeted SPIO
Bare
SPIO

104. New SPIO Development
Towards Plaque Targeted SPIO
Dextran
Coated

105. New SPIO Development
Towards Plaque Targeted SPIO
Lipid
Coated

106. New SPIO Development
Towards Plaque Targeted SPIO
Receptor
Targeted
SPIO

107. Imaging of inflammation in
rabbit model of atherosclerosis
using USPIO
Ruehm et al. Circulation 2001

108. Gadolinium VS. SPIO
1- Non-Specific (improved by Gd-Lutetium still lipid
targeted rather than inflammation)
2- White on white background
3- Only represent plaque angiogenesis
4- No over-magnification
…

109. SPIO Clinical Trial:
• The first human clinical trial on
detection of carotid vulnerable plaque
using SPIO in patients undergoing
carotid endartherectomy
Baseline
Scan
SPIO
Injection
1hr post-
injection
5days
Scan
Surgery
days 5-7

110. 0.05 mg/kg

111. SPIO Score vs. Calcium Score
The aim of the project is to develop a novel SPIO
Score for quantitative monitoring of plaque
inflammation based on negative enhancement.

112. SPIO Clinical Trial:
• The first human clinical trial on
detection of carotid vulnerable plaque
using SPIO in patients undergoing
carotid endartherectomy
Baseline
Scan
SPIO
Injection
1hr post-
injection
5days
Scan
Surgery
days 5-7

113. … the question is not
only vulnerable plaque
Stay Tuned!

114. HotPlaque.com 2000!

115. Texas Heart Institute University of Texas-Houston
Center for Vulnerable Plaque Research
Denton A. Cooley Building (floor 10th
)
www.CVPR.org
2002

116. Association for Eradication of Heart Attack
www.VP.org