Spectral computed tomography characterization of coronary atherosclerotic plaque: principles, imaging biomarkers, and clinical significance
Abstract
Background: Coronary atherosclerotic plaque vulnerability is determined not only by luminal stenosis but also by plaque composition, calcification pattern, inflammatory activity, and local microenvironmental changes. Conventional coronary computed tomography angiography (CCTA) is well established for anatomic assessment, but its ability to characterize plaque remains limited by the single-energy imaging framework.
Purpose: To review the technical basis, imaging biomarkers, and clinical significance of spectral computed tomography (CT), including photon-counting computed tomography (PCCT), for coronary plaque characterization.
Content: Spectral CT introduces multi-energy information and material decomposition, thereby extending plaque assessment beyond single-Hounsfield unit-based interpretation. Recent studies suggest three major advances: improved plaque composition characterization through energy-dependent attenuation patterns and material-specific analysis; improved structural fidelity in calcified lesions through higher spatial resolution and reduced blooming, particularly with ultrahigh-resolution PCCT; and extraction of surrogate signals of selected pathobiologic processes through iodine-related metrics and emerging molecular imaging approaches. Current evidence indicates that the most consistent clinical value of spectral CT lies in more accurate assessment of calcified lesions, more reproducible quantification of high-risk plaque burden, and improved downstream…
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