Key result
Low-attenuation carotid calcifications linked to ~5.5-fold higher intraplaque hemorrhage volume versus high-attenuation.
Why the study?
Despite the high prevalence of carotid plaque calcifications, the association between morphologic and attenuation features of calcifications and intraplaque hemorrhage remained unclear.
Are carotid plaque calcification attenuation and volume associated with intraplaque hemorrhage volumes in patients with embolic stroke of undetermined source?
Cross-Sectional (n=70)
No
Are carotid plaque calcification attenuation and volume associated with intraplaque hemorrhage volumes in patients with embolic stroke of undetermined source?
Low-attenuation carotid plaque calcifications are associated with higher intraplaque hemorrhage volumes, suggesting that calcification attenuation characteristics may serve as a noninvasive imaging biomarker for plaque instability.
Should not yet inform carotid plaque assessment in embolic stroke; leaves open attenuation as a potential instability biomarker pending prospective studies.
Background and Purpose Despite the high prevalence of plaque calcifications in carotid atherosclerosis, the association between morphologic and attenuation features of calcifications and intraplaque hemorrhage (IPH) remains unclear. Methods Carotid bifurcation calcific plaques were identified on neck CTAs from patients with unilateral anterior circulation ischemic stroke consistent with embolic stroke of undetermined source. Plaque calcifications were manually segmented using 3D Slicer to measure volume, surface area, shape, and attenuation (Hounsfield Units (HU)) characteristics. IPH volume (IPHvol) was quantified using a semi-automated software. A linear mixed regression model evaluated associations between calcification features and IPHvol, adjusting for sex, age, and cardiovascular risk factors. An interaction term between calcification volume and attenuation was included after dichotomizing attenuation (>924HU) and volume (>30mm 3 ) as high versus low based on median values. Results From 70 patients (median age 68 years, 50% female), 116 calcific plaques containing 269 plaque calcifications were analyzed. Adjusting for age, cardiovascular risk factors and plaque calcification features, being female showed lower IPHvols compared to males (mean ratio 0.34, p=0.002). A significant interaction between calcification volume and attenuation emerged (p=0.042). Among plaques with low volumes (<30mm 3 ) of plaque calcifications, plaques with low-attenuation (<924HU) calcifications showed 5.53 times higher IPHvols than plaques with high-attenuation calcifications (p=0.003). Among plaques with high-attenuation calcifications (>924HU), plaques with high volumes of these calcifications showed 4.40 times higher IPHvols compared to low-volumes of high-attenuation calcifications (p=0.011). Conclusions Plaque calcification attenuation characteristics are associated with IPHvols. Beyond presence or volumes of plaque calcifications, calcification attenuation characteristics should be considered when evaluating unstable plaque components.
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Rubin et al. (2025) conducted a cross-sectional in Embolic stroke of undetermined source (ESUS) with carotid calcific plaques (n=70). Low-attenuation plaque calcifications vs. High-attenuation plaque calcifications was evaluated on Intraplaque hemorrhage (IPH) volume (Mean ratio 5.53, p=0.003). Among carotid plaques with low calcification volumes, low-attenuation calcifications were associated with 5.53 times higher intraplaque hemorrhage volumes compared to high-attenuation calcifications.
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