Non-lipid-rich low attenuation plaque with intraplaque haemorrhage assessed by multimodality imaging: a case report

BACKGROUND: The lipid-rich necrotic core is a major pathological hallmark of acute coronary syndrome. Low attenuation plaque (LAP) on coronary computed tomography angiography (CCTA), defined as plaque CT attenuation of <30 Hounsfield units, is commonly believed to correspond to the lipid component. This report presents a non-lipid-rich LAP with intraplaque haemorrhage of the left main coronary artery (LM), as assessed by CCTA, near-infrared spectroscopy (NIRS), and non-contrast magnetic resonance imaging (MRI) using coronary atherosclerosis T1-weighted characterization with integrated anatomical reference technique, recently developed by our group. CASE SUMMARY: A 75-year-old woman presented with chest discomfort on exertion. Coronary computed tomography angiography revealed severe stenosis of the mid-left circumflex coronary artery and minimal stenosis with a large eccentric LM plaque. The LM lesion had an LAP, with a minimum plaque attenuation of 25 Hounsfield units. On non-contrast T1-weighted MRI, a high-intensity plaque with a plaque-to-myocardium signal intensity ratio of 3.02 was observed within the vessel wall, indicating intraplaque haemorrhage. Near-infrared spectroscopy categorized the lesion as non-lipid-rich, with a maximum lipid core burden index in 4 mm of 169. DISCUSSION: Intraplaque haemorrhage is a key feature of plaque instability, which is different from the lipid-rich necrotic core. Non-contrast T1-weighted MRI is ideal for detecting intraplaque haemorrhage with short T1 values. The imaging findings suggest that LAP on CCTA may represent not only lipid-rich plaques but also intraplaque haemorrhage. Magnetic resonance imaging provides a unique insight into plaque vulnerability from a different perspective than lipid assessment. Multimodality imaging, including MRI, facilitates the understanding of complicated plaque morphologies. KEYWORDS: Atherosclerosis • Case report • Computed tomography • Intraplaque haemorrhage • Lipid-rich plaque • Magnetic resonance imaging • Near-infrared spectroscopy-intravascular ultrasound