Presentation
Chest pain.
Patient Data
CORONARY CALCIUM SCAN: Small foci of calcification left main coronary and proximal left anterior descending arteries.
CORONARY CT ANGIOGRAM:
Anatomy: The coronary arteries arise normally with right coronary artery dominance.
Left main: The left main coronary trifurcates into the LAD, ramus intermedius and left circumflex. There is a small calcified and noncalcified plaque in the distal left main with minimal luminal stenosis.
Left anterior descending: There is a predominantly noncalcified plaque in the proximal LAD with spotty calcification and severe luminal stenosis greater than 90%. No other visible atherosclerotic plaque or stenosis in the mid or distal LAD.
Left circumflex: There is no significant atherosclerotic plaque or stenosis in the proximal or mid-vessel. There is a noncalcified plaque in the distal left circumflex.
Ramus intermedius branch: No significant atherosclerotic plaque or stenosis.
Right coronary artery: Gives off a patent posterior descending artery and a patent posterior left ventricular branch. There is a small noncalcified plaque in the mid-RCA with minimal luminal stenosis of less than 25%.
Spotty calcifications are formally defined as <3/2 of vessel diameter in length (i.e. along vessel long axis) & <2/3 of vessel diameter in width (i.e. perpendicular to vessel long axis), but it may be easier to just remember that they are small relative to the vessel. In fact, some definitions of spotty calcifications specify that they should be <3 mm in greatest dimension. As with all coronary calcifications, CT density should be ≥130 HU.
Case Discussion
Spotty calcifications are one of four features (the other three are 1) positive remodeling, 2) low attenuation plaque, and 3) the napkin ring sign) of so-called vulnerable plaque, atherosclerotic lesions at high risk of rupture and subsequent thrombosis. In this case, spotty calcification in the proximal LAD was associated with low-density non-calcified plaque and severe luminal stenosis.
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