Histological validation of three-dimensional variable flip angle turbo spin echo multi-contrast magnetic resonance vessel wall imaging in characterizing carotid vulnerable atherosclerotic plaques.

Background: Accurate assessment of the vulnerability of carotid atherosclerotic plaques is crucial for stroke prevention. The three-dimensional (3D) magnetic resonance (MR) vessel wall imaging (VWI) has been increasingly employed to evaluate carotid plaques due to its extensive coverage and isotropic high spatial resolution. However, the accuracy of such techniques lacks validation by histology. Therefore, this study aims to validate the accuracy of 3D multi-contrast MR VWI with variable-flip-angle (VFA) and turbo spin echo (TSE) readout in identifying vulnerable carotid plaques, using histological analysis as a reference.

Methods: Twenty-one male patients (mean age: 64.4 ± 7.2 years old) scheduled for carotid endarterectomy (CEA) were recruited in this study. All patients underwent carotid multi-contrast MR VWI, including 3D T1- and T2-weighted VFA-TSE sequences, as well as 3D time of flight (TOF) MR angiography (MRA), using a 3.0T MR system before surgery. Histological processing was performed for carotid plaque specimens. The presence or absence, along with the area measurements, of lipid-rich necrotic core (LRNC), intraplaque hemorrhage (IPH), and calcifications (CA) were independently evaluated on both MR images and histological sections. Cohen's kappa (κ) analysis was utilized to determine the agreement between 3D multi-contrast MR VWI and histology in identifying carotid plaque compositions before and after excluding compositions bellow certain size threshold. Spearman's correlation analysis was also conducted to assess the agreement in quantifying plaque compositions.

Results: A total of 81 slices of MR images were successfully matched with histological sections. Moderate to almost perfect agreements were observed between 3D MR VWI and histology in the identification of LRNC (κ: 0.85 and 0.89), IPH (κ: 0.65 and 0.69), and CA (κ: 0.46 and 0.62) before and after excluding compositions smaller than 0.79 mm. Strong to very strong correlations were found in the quantification of plaque compositions including LRNC (r=0.88), IPH (r=0.80), and CA (r=0.74) between MR imaging and histology.

Conclusion: The 3D VFA-TSE multi-contrast MR VWI is capable of accurately characterizing vulnerable carotid atherosclerotic plaques.