Perivascular adipose tissue attenuation in CT angiography and plaque inflammation in patients with carotid atherosclerosis
- 1Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
Abstract
Background and AimsQuantifying arterial inflammation can augment risk stratification and drug development in atherosclerosis. While perivascular adipose tissue (PVAT) density, captured as fat attenuation index (FAI) on CT angiography (CTA), is an emerging biomarker of coronary inflammation, it remains unclear whether this concept extends to carotid atherosclerosis.
MethodsUsing routine CTA data from hospital-based stroke cohorts, we developed a pipeline to quantify attenuation metrics of PVAT surrounding the distal common and proximal internal carotid arteries. We compared PVAT metrics between culprit and contralateral non-culprit plaques in patients with symptomatic carotid atherosclerosis and between culprit plaques and control carotid segments from patients without symptomatic atherosclerosis. In patients undergoing carotid endarterectomy, we assessed associations of CTA-derived PVAT metrics with histological and proteomic markers of plaque inflammation and stability.
ResultsAcross 107 patients with symptomatic carotid atherosclerosis (75.5{+/-}8.7 years; 63% men), PVAT attenuation metrics did not show significant differences between culprit and contralateral non-culprit lesions (all p>0.2). We also found no evidence for higher PVAT attenuation in culprit lesions, when compared to arteries of patients without symptomatic atherosclerosis. In 82 patients undergoing endarterectomy, pre-operative CTA-derived metrics of PVAT attenuation showed no significant correlations with CD68+ macrophage areas in excised plaques (r -0.11 to 0.07, all p>0.3). Similarly, no PVAT attenuation metrics were associated with thinner fibrous cap or higher plaque levels of pro-inflammatory cytokines (IL-6, TNF).
ConclusionsIn contrast to coronary atherosclerosis, carotid PVAT attenuation was not associated with symptomatic culprit lesions or histological and molecular markers of plaque inflammation and vulnerability.
Structured Graphical AbstractO_ST_ABSKey QuestionC_ST_ABSCan perivascular adipose tissue (PVAT) attenuation on CT, proposed as a marker of coronary artery inflammation, also capture atherosclerotic plaque inflammation and vulnerability in the carotid arteries?
Key FindingIn 107 patients with carotid atherosclerosis-associated stroke, PVAT attenuation did not differ between culprit and contralateral non-culprit lesions and was not associated with histopathological or molecular markers of plaque inflammation and vulnerability.
Take-home MessagePVAT attenuation did not capture local carotid plaque inflammation or vulnerability in this cohort, questioning the transferability of this CT-based marker from coronary to carotid atherosclerosis.
O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=127 SRC="FIGDIR/small/26364115v1_ufig1.gif" ALT="Figure 1"> View larger version (33K): [email protected]@cc7f9eorg.highwire.dtl.DTLVardef@1ce5e7aorg.highwire.dtl.DTLVardef@19cd5f5_HPS_FORMAT_FIGEXP M_FIG C_FIG
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BibTeX
@misc{mayrhofer2026perivascular,
title = {{Perivascular adipose tissue attenuation in CT angiography and plaque inflammation in patients with carotid atherosclerosis}},
author = {S. Mayrhofer and L. Zivkovic and Y. Li and R. Batool and J. Louma and P. Reidler and A. Marei and N. Tsilimparis and DEMDAS study group and M. K. Georgakis},
howpublished = {medRxiv},
year = {2026},
month = sep,
doi = {10.64898/2026.09.27.26364115},
url = {https://www.medrxiv.org/content/10.64898/2026.09.27.26364115v1},
note = {CC BY-NC},
}
RIS
TY - UNPB
TI - Perivascular adipose tissue attenuation in CT angiography and plaque inflammation in patients with carotid atherosclerosis
AU - S. Mayrhofer
AU - L. Zivkovic
AU - Y. Li
AU - R. Batool
AU - J. Louma
AU - P. Reidler
AU - A. Marei
AU - N. Tsilimparis
AU - DEMDAS study group
AU - M. K. Georgakis
PY - 2026
DA - 2026/09/27
PB - medRxiv
DO - 10.64898/2026.09.27.26364115
UR - https://www.medrxiv.org/content/10.64898/2026.09.27.26364115v1
AB - Background and AimsQuantifying arterial inflammation can augment risk stratification and drug development in atherosclerosis. While perivascular adipose tissue (PVAT) density, captured as fat attenuation index (FAI) on CT angiography (CTA), is an emerging biomarker of coronary inflammation, it remains unclear whether this concept extends to carotid atherosclerosis. MethodsUsing routine CTA data from hospital-based stroke cohorts, we developed a pipeline to quantify attenuation metrics of PVAT surrounding the distal common and proximal internal carotid arteries. We compared PVAT metrics between culprit and contralateral non-culprit plaques in patients with symptomatic carotid atherosclerosis and between culprit plaques and control carotid segments from patients without symptomatic atherosclerosis. In patients undergoing carotid endarterectomy, we assessed associations of CTA-derived PVAT metrics with histological and proteomic markers of plaque inflammation and stability. ResultsAcross 107 patients with symptomatic carotid atherosclerosis (75.5{+/-}8.7 years; 63% men), PVAT attenuation metrics did not show significant differences between culprit and contralateral non-culprit lesions (all p>0.2). We also found no evidence for higher PVAT attenuation in culprit lesions, when compared to arteries of patients without symptomatic atherosclerosis. In 82 patients undergoing endarterectomy, pre-operative CTA-derived metrics of PVAT attenuation showed no significant correlations with CD68+ macrophage areas in excised plaques (r -0.11 to 0.07, all p>0.3). Similarly, no PVAT attenuation metrics were associated with thinner fibrous cap or higher plaque levels of pro-inflammatory cytokines (IL-6, TNF). ConclusionsIn contrast to coronary atherosclerosis, carotid PVAT attenuation was not associated with symptomatic culprit lesions or histological and molecular markers of plaque inflammation and vulnerability. Structured Graphical AbstractO_ST_ABSKey QuestionC_ST_ABSCan perivascular adipose tissue (PVAT) attenuation on CT, proposed as a marker of coronary artery inflammation, also capture atherosclerotic plaque inflammation and vulnerability in the carotid arteries? Key FindingIn 107 patients with carotid atherosclerosis-associated stroke, PVAT attenuation did not differ between culprit and contralateral non-culprit lesions and was not associated with histopathological or molecular markers of plaque inflammation and vulnerability. Take-home MessagePVAT attenuation did not capture local carotid plaque inflammation or vulnerability in this cohort, questioning the transferability of this CT-based marker from coronary to carotid atherosclerosis. O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=127 SRC="FIGDIR/small/26364115v1_ufig1.gif" ALT="Figure 1"> View larger version (33K): [email protected]@cc7f9eorg.highwire.dtl.DTLVardef@1ce5e7aorg.highwire.dtl.DTLVardef@19cd5f5_HPS_FORMAT_FIGEXP M_FIG C_FIG
ER -