Pfleger R, Campos A, Hacking C, et al. Napkin-ring sign (heart). Reference article, Radiopaedia.org (Accessed on 24 Jan 2025) https://doi.org/10.53347/rID-29447
The napkin-ring sign is a feature of high-risk coronary artery atherosclerotic plaque on CT coronary angiogram (coronary CTA). It has been shown to possess a high predictive value in predicting future cardiac events and is considered one of the imaging correlates of an unstable plaque. It is one of the four described features of vulnerable plaque.
The sign refers to a rupture-prone plaque in a coronary artery, comprising a necrotic core covered by a thin cap (cap thickness <65 μm), also referred to as so-called thin-cap fibroatheroma.
While the cap itself is too thin to be depicted by non-invasive imaging techniques including CT, the necrotic core may be visible on thin sections (<0.6 mm) of modern coronary CTA.
The napkin-ring sign represents a cross-section of a coronary artery showing luminal narrowing by a low attenuating eccentric structure (also called circumferentially extensive necrotic core), that is surrounded by a thin ring-like hyperattenuating rim and may represent indirect evidence of the aforementioned thin, vulnerable cap 1-5.
Treatment and prognosis
The napkin-ring sign has been shown to be associated with future cardiac events presenting as culprit lesion in acute coronary syndrome1.
1. Otsuka K, Fukuda S, Tanaka A et-al. Napkin-ring sign on coronary CT angiography for the prediction of acute coronary syndrome. JACC Cardiovasc Imaging. 2013;6 (4): 448-57. doi:10.1016/j.jcmg.2012.09.016 - Pubmed citation
2. Fujimoto S, Kondo T, Narula J. Evaluation of Plaque Morphology by Coronary CT Angiography. Cardiol Clin. 2012;30(1):69-75. doi:10.1016/j.ccl.2011.10.002 - Pubmed
3. Maurovich-Horvat P, Hoffmann U, Vorpahl M, Nakano M, Virmani R, Alkadhi H. The Napkin-Ring Sign: CT Signature of High-Risk Coronary Plaques? JACC Cardiovasc Imaging. 2010;3(4):440-4. doi:10.1016/j.jcmg.2010.02.003 - Pubmed
4. Narula J, Achenbach S. Napkin-ring necrotic cores: defining circumferential extent of necrotic cores in unstable plaques. JACC Cardiovasc Imaging. 2009;2 (12): 1436-8. doi:10.1016/j.jcmg.2009.10.004 - Pubmed citation
5. Seifarth H, Schlett CL, Nakano M et-al. Histopathological correlates of the napkin-ring sign plaque in coronary CT angiography. Atherosclerosis. 2012;224 (1): 90-6. doi:10.1016/j.atherosclerosis.2012.06.021 - Pubmed citation
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