IMR Press / RCM / Volume 22 / Issue 4 / DOI: 10.31083/j.rcm2204167
Open Access Original Research
The role of magnetic resonance imaging and the expression of MMP-9 protein in the analysis of carotid atherosclerotic plaques in patients undergoing carotid endarterectomy: a prospective pilot study
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1 Department of Cardiac Surgery, The Barts Heart Centre, St. Bartholomew’s Hospital, Barts Health NHS Trust, EC1A 7BE London, UK
2 School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
3 Andrija Stampar School of Public Health, 10000 Zagreb, Croatia
4 Department of Cardiac Surgery, University Hospital Centre Rijeka, 51000 Rijeka, Croatia
5 Department of Vascular Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia
6 Polyclinic for Radiology and Neurology “Dijagnostika 2000”, 10000 Zagreb, Croatia
7 Department of Radiology, University Hospital Centre Rijeka, 51000 Rijeka, Croatia
8 School of Medicine, University of Rijeka, 51000 Rijeka, Croatia
9 Department of Vascular Surgery, University Hospital Centre Rijeka, 51000 Rijeka, Croatia
10 Department of Pathology, University Hospital Merkur, 10000 Zagreb, Croatia
11 Department of Diagnostic and Interventional Radiology, University Hospital Merkur, 10000 Zagreb, Croatia
*Correspondence: (Davorin Sef)
Academic Editor: Peter A. McCullough
Rev. Cardiovasc. Med. 2021, 22(4), 1611–1620;
Submitted: 13 August 2021 | Revised: 22 September 2021 | Accepted: 27 September 2021 | Published: 22 December 2021
Copyright: © 2021 The Author(s). Published by IMR Press.
This is an open access article under the CC BY 4.0 license (

Components of carotid atherosclerotic plaque can be analysed preoperatively by non-invasive advanced imaging modalities such as magnetic resonance imaging (MRI). The expression of matrix metalloproteinase-9 protein (MMP-9), which has a potential role in remodelling of atherosclerotic plaques, can be analysed immunohistochemically. The aim of the present prospective pilot study is to analyse histological characteristics and expression of MMP-9 in carotid plaques of patients undergoing carotid endarterectomy (CEA) and to investigate the correlation with preoperative clinical symptoms and MRI features. Preoperative clinical assessment, MRI imaging, postoperative histological and immunohistochemical analyses were performed. Fifteen patients with symptomatic (7/15; 47%) and asymptomatic carotid artery stenosis undergoing CEA were included. Among symptomatic patients, 5 (71%) had recent stroke and 2 (29%) had recent transient ischaemic attack with a median timing of 6 weeks (IQR: 1, 18) before the surgery. Both groups did not significantly differ in respect to preoperative characteristics. Prevalence of unstable plaque was higher in symptomatic than asymptomatic patients, although it was not significant (63% vs. 37%, p = 0.077). The expression of MMP-9 in CD68 cells within the plaque by semiquantitative analysis was found to be significantly higher in symptomatic as compared to asymptomatic patients (86% vs. 25% with the highest expression, p = 0.014). The average microvascular density was found to be higher and lipid core area larger among both symptomatic patients and unstable carotid plaque specimens, although this did not reach statistical significance (p = 0.064 and p = 0.132, p = 0.360 and p = 0.569, respectively). Our results demonstrate that MRI is reliable in classifying carotid lesions and differentiating unstable from stable plaques. We have also shown that the expression of MMP-9 is significantly higher among symptomatic patients undergoing CEA.

Trial Registration: This study has been registered at the ISRCTN registry (ID ISRCTN46536832), Identifier:

Carotid endarterectomy
Unstable plaque
Magnetic resonance imaging
Matrix metalloproteinase
Leica MMP9-439 antibodies/Inel – Medical Technologies
Fig. 1.
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