Carotid plaque morphometric assessment with three-dimensional ultrasound imaging Khalid AlMuhanna, MS, Md Murad Hossain, MS, Limin Zhao, MBBS, Jonathan.

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Carotid plaque morphometric assessment with three-dimensional ultrasound imaging Khalid AlMuhanna, MS, Md Murad Hossain, MS, Limin Zhao, MBBS, Jonathan Fischell, BS, Gregory Kowalewski, MS, Moira Dux, PhD, Siddhartha Sikdar, PhD, Brajesh K. Lal, MD Journal of Vascular Surgery Volume 61, Issue 3, Pages 690-697 (March 2015) DOI: 10.1016/j.jvs.2014.10.003 Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 1 Duplex ultrasound (US) imaging for plaque morphometry. A, Standard Doppler measurements to localize the plaque and measure peak systolic and end-diastolic velocities to estimate the percentage of stenosis. B, Best longitudinal view as determined by the sonographer. The luminal (red line) and adventitial (yellow line) boundaries were outlined to obtain the plaque area in the longitudinal section and the least luminal diameter (LLD). C, Cross-sectional image at the region with tightest stenosis, with the luminal and adventitial boundaries outlined to measure the plaque cross-sectional area. D, The 4DL14-5/38 US transducer (Ultrasonix, Richmond, BC, Canada) used for volume acquisition. E, Different slices of the acquired three-dimensional (3D) volume. F, Reconstructed volume generated after segmentation of the vessel wall volume (VWV). Journal of Vascular Surgery 2015 61, 690-697DOI: (10.1016/j.jvs.2014.10.003) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 2 Quantification of shape variations between and within observers. Dice similarity coefficient (DSC), defined as the percentage of overlapping area between outlines produced by two observers (highlighted in green) divided by the average area between the two contours. Modified Hausdorff distance (MHD), is the mean distance between corresponding points of two contours produced by two different observers (black dashed lines). Journal of Vascular Surgery 2015 61, 690-697DOI: (10.1016/j.jvs.2014.10.003) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 3 Variations in least luminal diameter (LLD) measurement depend on the angle of insonation of the transducer. A, B-mode cross-sectional view of the region of tightest stenosis. The yellow solid lines indicate different angles of insonation. The corresponding longitudinal sectional images acquired along the respective insonation angles are shown for (B) anterior-posterior (AP), (C) right anterior oblique (RAO), and (D) left anterior oblique (LAO). In this example, the luminal diameter was (B) 4.9 mm when viewed in the AP projection, (C) 6.6 mm in RAO projection, and (D) 4.6 mm in the LAO projection. Journal of Vascular Surgery 2015 61, 690-697DOI: (10.1016/j.jvs.2014.10.003) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 4 Reliability of the longitudinal plaque area measurement obtained from a standard clinical B-mode image. A, Multiobserver Bland-Altman plot for interobserver variability in vessel wall area (VWA), with each color representing an observer (O). B, Bland-Altman plot for intraobserver variability, with each square representing the difference between two measurements made by the same observer. The black solid lines are 1.96 × the standard deviation. Journal of Vascular Surgery 2015 61, 690-697DOI: (10.1016/j.jvs.2014.10.003) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 5 Reliability of plaque volume measurement with the three-dimensional (3D) transducer. A, Multiobserver Bland-Altman plot for interobserver variability, with each color representing an observer (O). B, Bland-Altman plot for intraobserver variability, with each square representing the difference between two measurements made by the same observer. The black solid lines are 1.96 × the standard deviation. Journal of Vascular Surgery 2015 61, 690-697DOI: (10.1016/j.jvs.2014.10.003) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

Fig 6 Reliability of shape measurement of plaque volume as evaluated by the Dice similarity coefficient (DSC) and the modified Hausdorff distance (MHD). The box-and-whisker plots include all images from each individual. The central line is the median; the bottom and top edges are the 25th and 75th percentiles, respectively, the whiskers represent the range, and outliers are plotted individually. Interobserver analysis shows the mean overlap between all possible combinations of the three observers (1 vs 2, 1 vs 3, and 2 vs 3) (A) for DSC and for (B) MHD. Journal of Vascular Surgery 2015 61, 690-697DOI: (10.1016/j.jvs.2014.10.003) Copyright © 2015 Society for Vascular Surgery Terms and Conditions