Dual-energy computed tomography angiography in identifying stable and unstable components of atherosclerotic plaque: a comparative analysis with histological findings

In recent years, an increasing number of publications have linked ischemic events to features of atherosclerotic plaque instability, drawing growing attention to the potential of noninvasive imaging modalities for detecting such features, including dual-energy computed tomography (DECT).

Objective: to assess the capabilities of dual-energy computed tomography angiography (DECT angiography) in identifying and differentiating components of carotid atherosclerotic plaques and to compare these findings with histological analysis.

Materials and Methods. The study comprised 30 patients admitted to the Almazov National Medical Research Centre (Ministry of Health of the Russian Federation) for planned carotid endarterectomy. All patients provided written informed consent to participate. Preoperative DECT angiography of the brachiocephalic arteries was performed. Resected plaques underwent histological analysis to morphologically identify key components: fibrous, lipid-rich necrotic core, hemorrhagic, and mixed. Correlation between DECT data and histological sections was conducted at corresponding regions of interest (ROI). Statistical analysis was performed using the Jamovi software package, employing analysis of variance (ANOVA) with Tukey’s post hoc test for intergroup comparisons.

Results. Histological examination identified 72 key plaque components: fibrous (n = 18), lipid-rich necrotic core (n = 28), intraplaque hemorrhage (n = 8) and mixed components (n = 18). Mean minimum Z-effective values were significantly higher in fibrous regions compared to lipid-necrotic cores (p < 0.001), hemorrhagic areas (p < 0.01), and mixed components (p < 0.05). A diagnostic threshold of minimum Z-effective ≥ 7.7 was established, enabling differentiation of stable fibrous components from lipid-rich necrotic cores, intraplaque hemorrhages and mixed components–features of plaque instability–with high sensitivity (85.2%) and specificity (88.9%). No statistically significant differences were found among the unstable plaque components.

Conclusions. Dual-energy CT angiography demonstrates high diagnostic value for the noninvasive differentiation of stable and unstable components of atherosclerotic plaques. Further studies with larger patient cohorts are suggested to refine threshold values and standardize the methodology.

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