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Ishikawa T, Sato T, Okumura M, Kokubu T, Takahashi J, Kitagawa T, Tanabe M, Takatsu H, Onda A, Komatsu T, Sakuta K, Sakai K, Umehara T, Mitsumura H, Iguchi Y. Bathing-Related Ischemic Stroke: Association between Stroke Subtype and Cerebral Small Vessel Disease. J Atheroscler Thromb 2024:64933. [PMID: 38825505 DOI: 10.5551/jat.64933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
AIMS Bathing-related ischemic stroke (BIS) is sometimes fatal. However, its mechanisms and risk factors remain unclear. We aimed to identify the incidence of stroke subtypes in BIS, and clarify the impact of cerebral small vessel disease (CSVD) on BIS. METHODS Consecutive patients with ischemic stroke between October 2012 and February 2022 were retrospectively screened. The inclusion criteria were: 1) onset-to-door time within 7 days; and 2) availability of the results of MRI evaluation of CSVD markers during hospitalization. BIS was defined as an ischemic stroke that occurred while or shortly after bathing. We investigated the incidence of the stroke subtype and the correlation between CSVD markers and BIS. RESULTS 1,753 ischemic stroke patients (1,241 [71%] male, median age 69 years) were included. 57 patients (3%) were included in the BIS group. A higher frequency of large artery atherosclerosis (LAA) (prevalence ratio [PR] 2.069, 95% confidence interval [CI] 1.089 to 3.931, p=0.026) and lower frequency of cardio-embolism (CES) (PR 0.362, 95% CI 0.132 to 0.991, p=0.048) in BIS cases were identified. Moreover, lower periventricular hyperintensity (PVH) Fazekas grade (PR 0.671, 95% CI 0.472 to 0.956, p=0.027) and fewer cerebral microbleeds (CMBs) in deep brain region (PR 0.810, 95%CI 0.657 to 0.999, p=0.049) were associated with BIS cases. CONCLUSIONS The BIS group was more likely to develop LAA and less likely to develop CES. Lower PVH grade and fewer CMBs in deep brain region were associated with the development of BIS.
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Affiliation(s)
| | - Takeo Sato
- Department of Neurology, The Jikei University School of Medicine
| | - Motohiro Okumura
- Department of Neurology, The Jikei University School of Medicine
| | - Tatsushi Kokubu
- Department of Neurology, The Jikei University School of Medicine
| | | | | | - Maki Tanabe
- Department of Neurology, The Jikei University School of Medicine
| | - Hiroki Takatsu
- Department of Neurology, The Jikei University School of Medicine
| | - Asako Onda
- Department of Neurology, The Jikei University School of Medicine
| | - Teppei Komatsu
- Department of Neurology, The Jikei University School of Medicine
| | - Kenichi Sakuta
- Department of Neurology, The Jikei University School of Medicine
| | - Kenichiro Sakai
- Department of Neurology, The Jikei University School of Medicine
| | - Tadashi Umehara
- Department of Neurology, The Jikei University School of Medicine
| | | | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine
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2
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Tan Z, Zhang L, Huang L, Qiao H, Guan M, Yang B, Yang P, Zhang Y, Shen H, Zhou Y, Hong B, Shi H, Han H, Leng X, Dong Y, Lian C, Chen W, Xu A, Liu J. Thrombus migration in patients with acute ischaemic stroke undergoing endovascular thrombectomy. Stroke Vasc Neurol 2024; 9:126-133. [PMID: 37290931 PMCID: PMC11103155 DOI: 10.1136/svn-2022-002257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/12/2023] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVE The impact of thrombus migration (TM) prior to endovascular thrombectomy (EVT) on clinical outcomes and revascularisation rates remains unknown. We aimed to examine whether preinterventional TM modifies the treatment effects of direct EVT versus bridging EVT in acute large vessel occlusion patients. METHODS All patients undergoing catheter angiography in the Direct Intra-arterial thrombectomy in order to Revascularise acute ischaemic stroke patients with large vessel occlusion Efficiently in Chinese Tertiary hospitals: A Multicentre randomised clinical Trial were included. TM was determined by radiologists unaware of the study by analysing discrepancies between computed tomographic angiography at baseline and first-run digital subtraction angiography before EVT. The primary outcome was the score on the modified Rankin scale (mRS) assessed at 90 days. RESULTS Of 627 included patients, the TM rate was 11.3% (71/627). In the multivariable logistic regression model, baseline National Institutes of Health Stroke Scale score (adjusted OR 0.956, 95% CI 0.916 to 0.999; p=0.043) and intravenous thrombolysis (adjusted OR 2.614, 95% CI 1.514 to 4.514; p<0.001) were independently associated with TM. The patients with TM were less likely to be completely recanalised than those without TM (21.27% vs 36.23%, p=0.040). The interaction of TM and the EVT treatment effect did not significantly affect mRS shift analysis (p=0.687) or mRS scores of 0 to 1 (p=0.436). CONCLUSION Preinterventional TM does not modify the treatment effects of direct versus bridging EVT on functional outcomes in patients with acute ischaemic stroke with anterior large vessel occlusion. TM leads to a lower complete recanalisation rate. TRIAL REGISTRATION NUMBER
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Affiliation(s)
- ZeFeng Tan
- Neurology, First People's Hospital of Foshan, Foshan, Guangdong, China
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Lei Zhang
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
| | - Li'an Huang
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Hongyu Qiao
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Min Guan
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Bing Yang
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
| | - Hongjian Shen
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
| | - Yu Zhou
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
| | - Bo Hong
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
| | - Huaizhang Shi
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongxing Han
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Xinyi Leng
- Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Yi Dong
- Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Changlin Lian
- Neurology, First People's Hospital of Foshan, Foshan, Guangdong, China
| | - Wenhuo Chen
- Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian, China
| | - Anding Xu
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
- Stroke Center, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
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3
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Gong L, Wright AR, Hynynen K, Goertz DE. Inducing cavitation within hollow cylindrical radially polarized transducers for intravascular applications. ULTRASONICS 2024; 138:107223. [PMID: 38553135 DOI: 10.1016/j.ultras.2023.107223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/31/2023] [Accepted: 12/12/2023] [Indexed: 04/02/2024]
Abstract
Thrombotic occlusions of large blood vessels are increasingly treated with catheter based mechanical approaches, one of the most prominent being to employ aspiration to extract clots through a hollow catheter lumen. A central technical challenge for aspiration catheters is to achieve sufficient suction force to overcome the resistance of clot material entering into the distal tip. In this study, we examine the feasibility of inducing cavitation within hollow cylindrical transducers with a view to ultimately using them to degrade the mechanical integrity of thrombus within the tip of an aspiration catheter. Hollow cylindrical radially polarized PZT transducers with 3.3/2.5 mm outer/inner diameters were assessed. Finite element simulations and hydrophone experiments were used to investigate the pressure field distribution as a function of element length and resonant mode (thickness, length). Operating in thickness mode (∼5 MHz) was found to be associated with the highest internal pressures, estimated to exceed 23 MPa. Cavitation was demonstrated to be achievable within the transducer under degassed water (10 %) conditions using hydrophone detection and high-frequency ultrasound imaging (40 MHz). Cavitation clouds occupied a substantial portion of the transducer lumen, in a manner that was dependent on the pulsing scheme employed (10 and 100 μs pulse lengths; 1.1, 11, and 110 ms pulse intervals). Collectively the results support the feasibility of achieving cavitation within a transducer compatible with mounting in the tip of an aspiration format catheter.
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Affiliation(s)
- Li Gong
- Department of Medical Biophysics, University of Toronto, Canada; Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.
| | - Alex R Wright
- Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Kullervo Hynynen
- Department of Medical Biophysics, University of Toronto, Canada; Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | - David E Goertz
- Department of Medical Biophysics, University of Toronto, Canada; Physical Sciences Platform, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
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4
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Pikija S, Killer-Oberpfalzer M, Pfaff JAR, Griessenauer CJ, Sonnberger M, Vosko M, Mutzenbach JS, Schwarzenhofer D, Constantin H. Thrombus migration in emergent M1 middle cerebral artery occlusion. Clin Neurol Neurosurg 2024; 237:108132. [PMID: 38310761 DOI: 10.1016/j.clineuro.2024.108132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 12/17/2023] [Accepted: 01/22/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND AND PURPOSE Thrombus migration (TM) is a well-established phenomenon in patients with intracranial vessel occlusion, particularly in those who receive alteplase. However, the relationship between TM, reperfusion success, and clinic-radiological outcomes is still being determined. This study aimed to describe the various outcomes in the event of TM in patients with M1 middle cerebral artery (M1 MCA) occlusion. MATERIALS AND METHODS The study involved a retrospective analysis of patients undergoing endovascular thrombectomy (EVT) due to M1 MCA occlusion from two tertiary centers between January 2015 and December 2020. The proximal positions of thrombi were measured using a curve tool on CT or MR angiography before EVT. Subsequently, measurements were taken on angiographic imaging. Patients were grouped based on the amount of difference between the two measurements: growth (≤ - 10 mm), stability (> -10 mm and ≤ 10 mm), migration (> 10 mm), and resolution. RESULTS A total of 463 patients (266 [57%] females, median 76 [interquartile range IQR: 65-83] years) were analyzed. Of them, 106 (22.8%) expressed any degree of TM. In multivariate ordinal regression analysis, the alteplase was significantly associated with TM (t = 2.192, p = 0.028), as was the greater interval from first imaging to angiography (t = 2.574, p = 0.010). In multivariate logistical regression analysis, the good clinical outcome measured by the modified Rankin scale (0-2) was not associated with TM status. CONCLUSIONS Thrombus migration within the M1 MCA segment occurs in almost a quarter of patients, is associated with alteplase administration, and is mainly irrelevant to radiological and clinical outcome.
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Affiliation(s)
- Slaven Pikija
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.
| | - Monika Killer-Oberpfalzer
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria; Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Johannes A R Pfaff
- Department of Neuroradiology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- Department of Neurosurgery, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Michael Sonnberger
- Department of Neuroradiology, Neuromed Campus, Johannes Kepler University, Linz, Austria
| | - Milan Vosko
- Department of Neurology, Neuromed Campus, Johannes Kepler University, Linz, Austria
| | - Johannes S Mutzenbach
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | | | - Hecker Constantin
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurosurgery, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
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5
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Vandelanotte S, De Meyer SF. Acute Ischemic Stroke Thrombus Composition. Neuroscience 2024:S0306-4522(23)00551-1. [PMID: 38185279 DOI: 10.1016/j.neuroscience.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/09/2024]
Abstract
Ischemic stroke is caused by a thrombus blocking one or multiple arteries in the brain, resulting in irreversible damage in the associated brain tissue. The aim of therapy is to restore the blood flow as fast as possible. Two recanalization strategies are currently available: pharmacological thrombolysis using recombinant tissue plasminogen activator (rt-PA) and mechanical removal of the thrombus. Despite recent advancements, achieving efficient recanalization remains a challenge. The precise causes of therapy failure are not fully understood but thrombus composition is likely a key factor in successful recanalization. This review explores acute ischemic stroke thrombus composition, its recently identified components, and how it affects stroke treatment. It also discusses how new insights could enhance current recanalization strategies for ischemic stroke patients.
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Affiliation(s)
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium.
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6
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Riegler C, Siebert E, Kleine JF, Nolte CH. Thrombus migration in ischemic stroke due to large vessel occlusion: a question of time. J Neurointerv Surg 2023; 15:e216-e222. [PMID: 36319085 PMCID: PMC10646911 DOI: 10.1136/jnis-2022-019365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/08/2022] [Indexed: 05/20/2023]
Abstract
BACKGROUND Thrombus migration (TM) is frequently observed in large vessel occlusion (LVO) ischemic stroke to be treated by endovascular thrombectomy (EVT). TM may impede complete recanalization and hereby worsen clinical outcomes. This study aimed to delineate factors associated with TM and clarify its impact on technical and functional outcome. METHODS All patients undergoing EVT due to LVO in the anterior circulation at two tertiary stroke centers between October 2015 and December 2020 were included. Source imaging data of all individuals were assessed regarding occurrence of TM by raters blinded to clinical data. Patient data were gathered as part of the German Stroke Registry, a multicenter, prospective registry assessing real-world outcomes. Technical outcome was assessed by modified Thrombolysis in Cerebral Infarction scale (mTICI). Functional outcome was assessed by modified Rankin Scale (mRS) at 3 months. RESULTS The study consisted of 512 individuals, of which 71 (13.8%) displayed TM. In adjusted analyses, TM was associated with longer time from primary imaging to reassessment in the angio suite (aOR 2.37 (1.47 to 3.84) per logarithmic step) and intravenous thrombolysis (IVT; aOR 4.07 (2.17 to 7.65)). In individuals with IVT, a needle-to-groin time >1 hour was associated with higher odds for TM (aOR 2.60 (1.20 to 5.99)). TM was associated with lack of complete recanalization (aORmTICI3 0.46 (0.24 to 0.90)) but TM did not worsen odds for good clinical outcome (aORmRS≤2_d90 0.89 (0.47 to 1.68)). CONCLUSIONS TM is associated with IVT and longer time between sequential assessments of thrombus location. Consequently, TM may be of high relevance in patients with drip-and-ship treatment.
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Affiliation(s)
- Christoph Riegler
- Klinik und Hochschulambulanz für Neurologie, Charite Universitatsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institut für Neuroradiologie, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Justus F Kleine
- Institut für Neuroradiologie, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charite Universitatsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charite Universitatsmedizin Berlin, Berlin, Germany
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7
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Sheriff F, Lavezo J, Floresca R, Chaudhury MR, Colina G, Regenhardt R, Gupta V, Rodriguez G, Maud A. Clinicopathologic Analysis of COVID‐19 Associated Thrombi in the Setting of Large Vessel Occlusion: A Prospective Case–Control Study. STROKE: VASCULAR AND INTERVENTIONAL NEUROLOGY 2023. [DOI: 10.1161/svin.123.000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/12/2023] [Indexed: 07/19/2023]
Abstract
BACKGROUND
Acute ischemic stroke secondary to large vessel occlusion is among the most serious complications associated with COVID‐19 infection resulting in worse morbidity and mortality. We sought to study the association between COVID‐19 infection and large vessel occlusion thrombus pathology to better define the etiopathogenesis of this atypical cause of stroke.
METHODS
Thrombi were collected during mechanical thrombectomy and stained using hematoxylin and eosin. Blinded analysis of pathology was prospectively performed by a board‐certified neuropathologist. Red blood cell, fibrin, and white blood cell predominance was ascertained. Concomitant peripheral blood counts and clinical and imaging data were collected and analyzed. All samples underwent performance of reverse transcription polymerase chain reaction for SARS‐CoV2.
RESULTS
Between January 2020 and February 2022, a total of 952 acute ischemic stroke admissions were seen at the University Medical Center of El Paso, TX. Of these, 195 patients (20.5%) had large vessel occlusions and underwent mechanical thrombectomy and 53 patients had thrombus collected and analyzed. Seven patients (3.6%) tested positive for SARS‐CoV2. COVID‐19 positive patients were more likely to be younger (mean 57.4 years;
P
=0.07), male (85.7%;
P
=0.03), and have red blood cell predominant thrombi (85.7%;
P
=0.03). There was a statistically significant association between peripheral neutrophil count and white blood cell lysis in the overall cohort (
P
=0.015), who did not differ according to COVID‐19 status.
CONCLUSION
Thrombi retrieved from patients who were COVID‐19 positive and had stroke demonstrated red blood cell predominance. This finding requires further investigation using appropriate immunohistochemical techniques in a larger cohort of patients.
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Affiliation(s)
- Faheem Sheriff
- Department of Neurology Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
| | - Jonathan Lavezo
- Department of Pathology Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
| | - Ryan Floresca
- Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
| | - Mohammad Rauf Chaudhury
- Department of Neurology University of Texas at Houston Health Sciences Center McGovern Medical School Houston TX
| | - Gabriela Colina
- Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
| | - Robert Regenhardt
- Department of Neurosurgery Massachusetts General Hospital Harvard Medical School Boston MA
| | - Vikas Gupta
- Department of Neurology Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
| | - Gustavo Rodriguez
- Department of Neurology Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
| | - Alberto Maud
- Department of Neurology Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
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8
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Gilbert A, Detraz L, Alexandre PL, Serfaty JM, Desal H, Toquet C, Bourcier R. Magnetic resonance imaging quantitative T2* mapping to predict the red blood cell content of in vivo thrombi retrieved from patients with large vessel occlusions in acute ischemic stroke. Interv Neuroradiol 2022; 28:523-530. [PMID: 34559000 PMCID: PMC9511618 DOI: 10.1177/15910199211042473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 07/27/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE Magnetic resonance imaging quantitative T2* mapping has shown reliable identification of thrombus red blood cell content in vitro. The thrombus composition has been in vivo, associated with outcomes after endovascular therapy for acute ischemic stroke. We aim to analyze the red blood cell content of thrombi retrieved from patients with large vessel occlusions in relation to the thrombus-T2* relaxation time in magnetic resonance imaging. MATERIAL AND METHODS Consecutive acute ischemic stroke patients treated by endovascular therapy were scanned with an magnetic resonance imaging quantitative T2* mapping sequence. Quantitative histologic evaluations of red blood cell content were performed. A linear regression assessed the association between vascular risk factors, comorbidities, antithrombotic drugs intake, baseline National Institutes of Health Stroke Scale (NIHSS), intravenous thrombolysis before endovascular therapy, time between onset and groin puncture, patient's outcome at 3 months, magnetic resonance imaging quantitative T2* mapping results, and the red blood cell content of thrombi. The correlation between the mean thrombus-T2* relaxation time and red blood cell content was assessed by calculating the Pearson correlation coefficient. RESULTS Among 31 thrombi, 16 were "Fibrin rich" and 15 "red blood cell dominant." The median red blood cell content was 39 (range, 0-90; interquartile range, 37). The median (interquartile range) thrombus-T2* relaxation time was shorter in "red blood cell dominant" thrombi (21, interquartile range 6) than in "Fibrin rich" thrombi (24, interquartile range 7), without significant difference (p = 0.15), as shown in the Box plot. An inverse correlation between thrombus-T2* relaxation time and red blood cell content was found, with a correlation coefficient of -0.41 (95% CI, -0.67 to -0.08, p = 0.02). CONCLUSION Our study shows that a shorter thrombus-T2* relaxation time is related to a higher red blood cell content within in vivo thrombi.
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Affiliation(s)
- Alize Gilbert
- l'institut du thorax Université de Nantes, CHU Nantes, INSERM, CNRS, Nantes, France
- CHU Nantes, Department of Neuroradiology, Nantes, France
| | - Lili Detraz
- l'institut du thorax Université de Nantes, CHU Nantes, INSERM, CNRS, Nantes, France
- CHU Nantes, Department of Neuroradiology, Nantes, France
| | - Pierre-Louis Alexandre
- l'institut du thorax Université de Nantes, CHU Nantes, INSERM, CNRS, Nantes, France
- CHU Nantes, Department of Neuroradiology, Nantes, France
| | - Jean-Michel Serfaty
- l'institut du thorax Université de Nantes, CHU Nantes, INSERM, CNRS, Nantes, France
- CHU Nantes, Department of Neuroradiology, Nantes, France
| | - Hubert Desal
- l'institut du thorax Université de Nantes, CHU Nantes, INSERM, CNRS, Nantes, France
- CHU Nantes, Department of Neuroradiology, Nantes, France
| | - Claire Toquet
- l'institut du thorax Université de Nantes, CHU Nantes, INSERM, CNRS, Nantes, France
- CHU Nantes, Department of Neuroradiology, Nantes, France
| | - Romain Bourcier
- l'institut du thorax Université de Nantes, CHU Nantes, INSERM, CNRS, Nantes, France
- CHU Nantes, Department of Neuroradiology, Nantes, France
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9
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Kobayashi Y, Morizumi T, Okumura G, Nagamatsu K, Shimizu Y, Sasaki T, Sato A, Sekijima Y, Hongo K. Visualization of thrombus using iterative reconstruction and maximum intensity projection of thin-slice CT images. Neuroradiology 2022; 64:2373-2379. [PMID: 35705738 PMCID: PMC9200622 DOI: 10.1007/s00234-022-02996-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 06/09/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Iterative reconstruction (IR) is a noise reduction method that facilitates the synthesis of maximum intensity projection (MIP) from a larger number of slices while maintaining resolution. The present study aimed to analyze whether CT evaluation using IR and MIP is ideal for thrombus evaluation of large vessel occlusions in patients with acute ischemic stroke. METHODS Three types of images for each patient were reconstructed and categorized into three groups: the "conventional group," evaluated using 0.5-mm slice CT, the "MIP group," evaluated using 0.5-mm slice CT processed with MIP, and the "IR + MIP group," evaluated with 0.5-mm slice CT processed with IR and MIP. Noise and image quality were evaluated with noise standard deviation (Noise SD) and contrast-to-noise ratio (CNR). Three experts evaluated the thrombus edge coordinates, made a visual assessment, and compared the data with the digital subtraction angiography (DSA) of the mechanical thrombectomy. RESULTS Twenty-nine patients with cerebral infarction having large vessel occlusion were included in this study. The IR + MIP group had a lower Noise SD and a statistically higher CNR, leading to more favorable image evaluations. The thrombus assessment showed no inter-rater variability in thrombus edge identification, and the visual assessment and comparison with DSA were statistically better in the IR + MIP group. CONCLUSIONS IR reduces noise and improves resolution. MIP in combination with IR facilitates visualization of thrombus.
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Affiliation(s)
- Yuya Kobayashi
- Department of Neurology, Ina Central Hospital, 1313-1, Ina, Nagano, 396-8555, Japan.
| | - Teruya Morizumi
- Department of Neurology, Ina Central Hospital, 1313-1, Ina, Nagano, 396-8555, Japan
| | - Gaku Okumura
- Department of Neurology, Ina Central Hospital, 1313-1, Ina, Nagano, 396-8555, Japan
| | - Kiyoshiro Nagamatsu
- Department of Neurology, Ina Central Hospital, 1313-1, Ina, Nagano, 396-8555, Japan
| | - Yusaku Shimizu
- Department of Neurology, Ina Central Hospital, 1313-1, Ina, Nagano, 396-8555, Japan
| | - Tetsuo Sasaki
- Department of Neurosurgery, Ina Central Hospital, 1313-1, Ina, Nagano, 396-8555, Japan
| | - Atsushi Sato
- Department of Neurosurgery, Ina Central Hospital, 1313-1, Ina, Nagano, 396-8555, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology & Rheumatology), Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Kazuhiro Hongo
- Department of Neurosurgery, Ina Central Hospital, 1313-1, Ina, Nagano, 396-8555, Japan
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10
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Kaneko N, Ghovvati M, Komuro Y, Guo L, Khatibi K, Ponce Mejia LL, Saber H, Annabi N, Tateshima S. A new aspiration device equipped with a hydro-separator for acute ischemic stroke due to challenging soft and stiff clots. Interv Neuroradiol 2022; 28:43-49. [PMID: 33951972 PMCID: PMC8905075 DOI: 10.1177/15910199211015060] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE Fragile soft clots and stiff clots remain challenging in the treatment of acute ischemic stroke. This study aims to investigate the impact of clot stiffness on the efficacy of thrombectomy devices and a new aspiration catheter with a hydro-separator. METHODS The Neurostar aspiration catheter has a novel hydro-separator technology that macerates clots by a stream of saline inside the catheter. The Neurostar catheter and two commercially available devices, the SOFIA aspiration catheter and Solitaire stent retriever, were tested in this study. We evaluated the efficacy of each device on clots with various stiffness in a simple in vitro model. We also assessed single-pass recanalization performance in challenging situations with large erythrocyte-rich clots and fibrin-rich clots in a realistic vascular model. RESULTS We observed an inverse association between the clot stiffness and recanalization rates. The aspiration catheter, SOFIA ingested soft clots but not moderately stiff clots. When removing soft clots with the stent retriever, fragmentation was observed, although relatively stiff clots were well-integrated and removed. The Neurostar ingested soft clots similar to the aspiration catheter, and also aspirated stiff clots by continuous suction with hydro-separator. In the experiments with challenging clots, the Neurostar led to significantly higher recanalization rates than the stent retriever and aspiration catheter. CONCLUSIONS The stiffness of the clots affected the efficacy of endovascular thrombectomy based on the type of device. The Neurostar catheter with hydro-separator resulted in better success rates than a commercially available aspiration catheter and stent retriever in this experimental model.
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Affiliation(s)
- Naoki Kaneko
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Mahsa Ghovvati
- Chemical and Biomolecular Engineering Department, University of California, Los Angeles, USA
| | - Yutaro Komuro
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Lea Guo
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Kasra Khatibi
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Lucido L Ponce Mejia
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Hamidreza Saber
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Nasim Annabi
- Chemical and Biomolecular Engineering Department, University of California, Los Angeles, USA
| | - Satoshi Tateshima
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA,Satoshi Tateshima, Division of Interventional Neuroradiology, Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA.
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11
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Cahalane R, Boodt N, Akyildiz AC, Giezen JA, Mondeel M, van der Lugt A, Marquering H, Gijsen F. A review on the association of thrombus composition with mechanical and radiological imaging characteristics in acute ischemic stroke. J Biomech 2021; 129:110816. [PMID: 34798567 DOI: 10.1016/j.jbiomech.2021.110816] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 10/07/2021] [Accepted: 10/08/2021] [Indexed: 02/05/2023]
Abstract
Thrombus composition and mechanical properties significantly impact the ease and outcomes of thrombectomy procedures in patients with acute ischemic stroke. A wide variation exists in the composition of thrombi between patients. If a relationship can be determined between the composition of a thrombus and its mechanical behaviour, as well as between the composition of a thrombus and its radiological imaging characteristics, then there is the potential to personalise thrombectomy treatment based on each individual thrombus. This review aims to give an overview of the current literature addressing this issue. Here, we present a scoping review detailing associations between thrombus composition, mechanical behaviour and radiological imaging characteristics. We conducted two searches 1) on the association between thrombus composition and the mechanical behaviour of the tissue and 2) on the association between radiological imaging characteristics and thrombus composition in the acute stroke setting. The review suggests that higher fibrin and lower red blood cell (RBC) content contribute to stiffer thrombi independent of the loading mode. Further, platelet-contracted thrombi are stiffer than non-contracted compositional counterparts. Fibrin content contributes to the elastic portion of viscoelastic behaviour while RBC content contributes to the viscous portion. It is possible to identify fibrin-rich or RBC-rich thrombi with computed tomography and magnetic resonance imaging vessel signs. Standardisation is required to quantify the association between thrombus density on non-contrast computed tomography and the RBC content. The characterisation of the thrombus fibrin network has not been addressed so far in radiological imaging but may be essential for the prediction of device-tissue interactions and distal thrombus embolization. The association between platelet-driven clot contraction and radiological imaging characteristics has not been explicitly investigated. However, evidence suggests that perviousness may be a marker of clot contraction.
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Affiliation(s)
- Rachel Cahalane
- Department of Biomedical Engineering, Thoraxcenter, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Nikki Boodt
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ali Cagdas Akyildiz
- Department of Biomedical Engineering, Thoraxcenter, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - Jo-Anne Giezen
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - Manouk Mondeel
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Henk Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Frank Gijsen
- Department of Biomedical Engineering, Thoraxcenter, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands.
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12
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Higashida T, Kanazawa R, Uchida T, Takahashi Y, Suzuki K, Kimura K. Difference of Thrombus Location between Initial Noninvasive Vascular Image and First DSA Findings in Mechanical Thrombectomy for Intracranial Large Vessel Occlusion: Post Hoc Analysis of the SKIP Study. Neurol Med Chir (Tokyo) 2021; 61:640-646. [PMID: 34421095 PMCID: PMC8592813 DOI: 10.2176/nmc.oa.2021-0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In patients who undergo mechanical thrombectomy for intracranial large vessel occlusion, the occluded site is sometimes distal to the site shown in the initial vascular imaging. We investigated the factors related to the change in the occluded site between the sequential imagings. The 203 patients in the SKIP study were reviewed retrospectively. Magnetic resonance angiography (MRA) or computed tomography angiography (CTA) was used to assess the occluded site. The occluded site shown in the cerebral angiography appeared to be distal to the occluded site shown in the initial vascular imaging in 55 patients (group A). The location of the occluded site in the remaining 148 patients did not change between the sequential imagings (group B). MRA was used more often than CTA in group A (54 MRA, 1 CTA; P <0.01). Patients with middle cerebral artery (M1) occlusion were more likely to show change of the occluded site than patients with internal carotid artery (ICA) occlusion (M1: 38%, ICA: 9%; P <0.01). The number of patients who received intravenous recombinant tissue plasminogen activator did not differ between the two groups (group A: 54%, group B: 49%; P = 0.5). In patients with acute intracranial large vessel occlusion who require mechanical thrombectomy, physicians should be aware that the location of the thrombus may be distal to the occluded site shown in the initial vascular imaging, particularly in patients with M1 occlusion shown by MRA.
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13
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Staessens S, François O, Brinjikji W, Doyle KM, Vanacker P, Andersson T, De Meyer SF. Studying Stroke Thrombus Composition After Thrombectomy: What Can We Learn? Stroke 2021; 52:3718-3727. [PMID: 34517770 PMCID: PMC8545837 DOI: 10.1161/strokeaha.121.034289] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The composition of ischemic stroke thrombi has gained an increasing amount of interest in recent years. The implementation of endovascular procedures in standard stroke care has granted researchers the unique opportunity to examine patient thrombus material. Increasing evidence indicates that stroke thrombi are complex and heterogenous, consisting of various biochemical (eg, fibrin, von Willebrand Factor, and neutrophil extracellular traps) and cellular (eg, red blood cells, platelets, leukocytes, and bacteria) components. This complex composition may explain therapeutic limitations and also offer novel insights in several aspects of stroke management. Better understanding of thrombus characteristics could, therefore, potentially lead to improvements in the management of patients with stroke. In this review, we provide a comprehensive overview of the lessons learned by examining stroke thrombus composition after endovascular thrombectomy and its potential relevance for thrombectomy success rates, thrombolysis, clinical outcomes, stroke etiology, and radiological imaging.
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Affiliation(s)
- Senna Staessens
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | | | | | - Karen M. Doyle
- CÚRAM-Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Peter Vanacker
- Department of Neurology, AZ Groeninge, Kortrijk, Belgium
- Department of Neurology, University Hospitals Antwerp, Antwerp, Belgium
- Department of Translational Neuroscience, University of Antwerp, Antwerp, Belgium
| | - Tommy Andersson
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
- Department of Neuroradiology, Karolinska University Hospital and Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Simon F. De Meyer
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
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14
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Aliena-Valero A, Baixauli-Martín J, Torregrosa G, Tembl JI, Salom JB. Clot Composition Analysis as a Diagnostic Tool to Gain Insight into Ischemic Stroke Etiology: A Systematic Review. J Stroke 2021; 23:327-342. [PMID: 34649378 PMCID: PMC8521257 DOI: 10.5853/jos.2021.02306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/24/2021] [Accepted: 09/02/2021] [Indexed: 12/22/2022] Open
Abstract
Mechanical thrombectomy renders the occluding clot available for analysis. Insights into thrombus composition could help establish the stroke cause. We aimed to investigate the value of clot composition analysis as a complementary diagnostic tool in determining the etiology of large vessel occlusion (LVO) ischemic strokes (International Prospective Register of Systematic Reviews [PROSPERO] registration # CRD42020199436). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we ran searches on Medline (using the PubMed interface) and Web of Science for studies reporting analyses of thrombi retrieved from LVO stroke patients subjected to mechanical thrombectomy (January 1, 2006 to September 21, 2020). The PubMed search was updated weekly up to February 22, 2021. Reference lists of included studies and relevant reviews were hand-searched. From 1,714 identified studies, 134 eligible studies (97 cohort studies, 31 case reports, and six case series) were included in the qualitative synthesis. Physical, histopathological, biological, and microbiological analyses provided information about the gross appearance, mechanical properties, structure, and composition of the thrombi. There were non-unanimous associations of thrombus size, structure, and composition (mainly proportions of fibrin and blood formed elements) with the Trial of Org 10172 in Acute Stroke Treatment (TOAST) etiology and underlying pathologies, and similarities between cryptogenic thrombi and those of known TOAST etiology. Individual thrombus analysis contributed to the diagnosis, mainly in atypical cases. Although cohort studies report an abundance of quantitative rates of main thrombus components, a definite clot signature for accurate diagnosis of stroke etiology is still lacking. Nevertheless, the qualitative examination of the embolus remains an invaluable tool for diagnosing individual cases, particularly regarding atypical stroke causes.
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Affiliation(s)
- Alicia Aliena-Valero
- Joint Cerebrovascular Research Unit, La Fe Health Research Institute, University of Valencia, Valencia, Spain
| | | | - Germán Torregrosa
- Joint Cerebrovascular Research Unit, La Fe Health Research Institute, University of Valencia, Valencia, Spain
| | - José I. Tembl
- Stroke Unit, Neurology Service, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Juan B. Salom
- Joint Cerebrovascular Research Unit, La Fe Health Research Institute, University of Valencia, Valencia, Spain
- Department of Physiology, University of Valencia, Valencia, Spain
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15
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Meyer L, Stracke CP, Wallocha M, Broocks G, Sporns PB, Piechowiak EI, Kaesmacher J, Maegerlein C, Dorn F, Zimmermann H, Naziri W, Abdullayev N, Kabbasch C, Behme D, Jamous A, Maus V, Fischer S, Möhlenbruch M, Weyland CS, Langner S, Meila D, Miszczuk M, Siebert E, Lowens S, Krause LU, Yeo LL, Tan BY, Gopinathan A, Gory B, Arenillas JF, Navia P, Raz E, Shapiro M, Arnberg F, Zeleňák K, Martínez-Galdámez M, Kastrup A, Papanagiotou P, Kemmling A, Psychogios MN, Andersson T, Chapot R, Fiehler J, Hanning U. Thrombectomy for secondary distal, medium vessel occlusions of the posterior circulation: seeking complete reperfusion. J Neurointerv Surg 2021; 14:654-659. [PMID: 34272260 DOI: 10.1136/neurintsurg-2021-017742] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/26/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Whether to approach distal occlusions endovascularly or not in medium-sized vessels secondary to proximal large vessel occlusion stroke remains unanswered. OBJECTIVE To investigates the technical feasibility and safety of thrombectomy for secondary posterior circulation distal, medium vessel occlusions (DMVO). METHODS TOPMOST (Treatment fOr Primary Medium vessel Occlusion STroke) is an international, retrospective, multicenter, observational registry of patients treated for distal cerebral artery occlusions. This study subanalysis endovascularly treated occlusions of the posterior cerebral artery in the P2 and P3 segment secondary preprocedural or periprocedural thrombus migration between January 2014 and June 2020. Technical feasibility was evaluated with the modified Thrombolysis in Cerebral Infarction (mTICI) scale. Procedural safety was assessed by the occurrence of symptomatic intracranial hemorrhage (sICH) and intervention-related serious adverse events. RESULTS Among 71 patients with secondary posterior circulation DMVO who met the inclusion criteria, occlusions were present in 80.3% (57/71) located in the P2 segment and in 19.7% (14/71) in the P3 segment. Periprocedural migration occurred in 54.9% (39/71) and preprocedural migration in 45.1% (32/71) of cases. The first reperfusion attempt led in 38% (27/71) of all cases to mTICI 3. On multivariable logistic regression analysis, increased numbers of reperfusion attempts (adjusted odds ratio (aOR)=0.39, 95% CI 0.29 to 0.88, p=0.009) and preprocedural migration (aOR=4.70, 95% CI,1.35 to 16.35, p=0.015) were significantly associated with mTICI 3. sICH occurred in 2.8% (2/71). CONCLUSION Thrombectomy for secondary posterior circulation DMVO seems to be safe and technically feasible. Even though thrombi that have migrated preprocedurally may be easier to retract, successful reperfusion can be achieved in the majority of patients with secondary DMVO of the P2 and P3 segment.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Paul Stracke
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Endovascular Therapy, Alfred-Krupp Hospital, Essen, Germany.,Department of Interventional Neuroradiology, University Hospital Muenster, University Hospital Muenster, Muenster, Germany
| | - Marta Wallocha
- Department of Endovascular Therapy, Alfred-Krupp Hospital, Essen, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter B Sporns
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Eike I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, Inselspital - Bern University Hospital, Switzerland, Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, Inselspital - Bern University Hospital, Switzerland, Bern, Switzerland.,Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität, Munich, Germany
| | - Franziska Dorn
- Institute for Neuroradiology, Ludwig Maximilians University (LMU) Munich, Munich, Bayern, Germany
| | - Hanna Zimmermann
- Institute for Neuroradiology, Ludwig Maximilians University (LMU) Munich, Munich, Bayern, Germany
| | - Weis Naziri
- Department of Neuroradiology, Westpfalz Hospital, Kaiserslautern, Rheinland-Pfalz, Germany.,Department of Neuroradiology, University Hospital Luebeck, Luebeck, Germany
| | - Nuran Abdullayev
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Sachsen-Anhalt, Germany.,Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Niedersachsen, Germany
| | - Ala Jamous
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Niedersachsen, Germany
| | - Volker Maus
- Department of Neuroradiology, Ruhr-Universität Bochum Medizinische Fakultät, Bochum, Nordrhein-Westfalen, Germany
| | - Sebastian Fischer
- Department of Neuroradiology, Ruhr-Universität Bochum Medizinische Fakultät, Bochum, Nordrhein-Westfalen, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | | | - Soenke Langner
- Department of Neuroradiology, Rostock University Medical Center, Rostock, Mecklenburg-Vorpommern, Germany
| | - Dan Meila
- Department of Interventional Neuroradiology, Johanna-Étienne-Hospital, Neuss, Germany
| | - Milena Miszczuk
- Institute of Neuroradiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan Lowens
- Department of Radiology, Klinikum Osnabrück GmbH, Osnabruck, Niedersachsen, Germany
| | - Lars Udo Krause
- Department of Neurology, Klinikum Osnabrück GmbH, Osnabruck, Niedersachsen, Germany
| | - Leonard Ll Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Benjamin Yq Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Anil Gopinathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France.,Imagerie Adaptative Diagnostique et Interventionnelle, INSERM U1254, Université de Lorraine, Nancy, France
| | - Juan F Arenillas
- Stroke Unit, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Pedro Navia
- Department of Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Eytan Raz
- Department of Radiology, NYU, New York, New York, USA
| | | | - Fabian Arnberg
- Department of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital; Karolinska Institutet, Stockholm, Sweden
| | - Kamil Zeleňák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Mario Martínez-Galdámez
- Department of Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte gGmbH, Bremen, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany.,Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz Hospital, Kaiserslautern, Rheinland-Pfalz, Germany.,Department of Neuroradiology, University Hospital Luebeck, Luebeck, Germany
| | - Marios N Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Tommy Andersson
- Department of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital; Karolinska Institutet, Stockholm, Sweden
| | - René Chapot
- Department of Endovascular Therapy, Alfred-Krupp Hospital, Essen, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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16
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Alkarithi G, Duval C, Shi Y, Macrae FL, Ariëns RAS. Thrombus Structural Composition in Cardiovascular Disease. Arterioscler Thromb Vasc Biol 2021; 41:2370-2383. [PMID: 34261330 PMCID: PMC8384252 DOI: 10.1161/atvbaha.120.315754] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Thrombosis is a major complication of cardiovascular disease, leading to myocardial infarction, acute ischemic stroke, or venous thromboembolism. Thrombosis occurs when a thrombus forms inside blood vessels disrupting blood flow. Developments in thrombectomy to remove thrombi from vessels have provided new opportunities to study thrombus composition which may help to understand mechanisms of disease and underpin improvements in treatments. We aimed to review thrombus compositions, roles of components in thrombus formation and stability, and methods to investigate thrombi. Also, we summarize studies on thrombus structure obtained from cardiovascular patients and animal models. Thrombi are composed of fibrin, red blood cells, platelets, leukocytes, and neutrophil extracellular traps. These components have been analyzed by several techniques, including scanning electron microscopy, laser scanning confocal microscopy, histochemistry, and immunohistochemistry; however, each technique has advantages and limitations. Thrombi are heterogenous in composition, but overall, thrombi obtained from myocardial infarction are composed of mainly fibrin and other components, including platelets, red blood cells, leukocytes, and cholesterol crystals. Thrombi from patients with acute ischemic stroke are characterized by red blood cell- and platelet-rich regions. Thrombi from patients with venous thromboembolism contain mainly red blood cells and fibrin with some platelets and leukocytes. Thrombus composition from patients with myocardial infarction is influenced by ischemic time. Animal thrombosis models are crucial to gain further mechanistic information about thrombosis and thrombus structure, with thrombi being similar in composition compared with those from patients. Further studies on thrombus composition and function are key to improve treatment and clinical outcome of thrombosis.
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Affiliation(s)
- Ghadir Alkarithi
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (G.A., C.D., Y.S., F.L.M., R.A.S.A.).,Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia (G.A.)
| | - Cédric Duval
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (G.A., C.D., Y.S., F.L.M., R.A.S.A.)
| | - Yu Shi
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (G.A., C.D., Y.S., F.L.M., R.A.S.A.)
| | - Fraser L Macrae
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (G.A., C.D., Y.S., F.L.M., R.A.S.A.)
| | - Robert A S Ariëns
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (G.A., C.D., Y.S., F.L.M., R.A.S.A.)
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17
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Factors associated with early reperfusion improvement after intra-arterial fibrinolytics as rescue for mechanical thrombectomy. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2021. [DOI: 10.1177/2514183x211017363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To identify factors associated with early angiographic reperfusion improvement (EARI) following intra-arterial fibrinolytics (IAF) after failed or incomplete mechanical thrombectomy (MT). Methods: A subset of patients treated with MT and IAF rescue after incomplete reperfusion included in the INFINITY (INtra-arterial FIbriNolytics In ThrombectomY) multicenter observational registry was analyzed. Multivariable logistic regression was used to identify factors associated with EARI. Heterogeneity of the clinical effect of EARI on functional independence (defined as modified Rankin Score ≤2) was tested with interaction terms. Results: A total of 228 patients (median age: 72 years, 44.1% female) received IAF as rescue for failed or incomplete MT and had a post-fibrinolytic angiographic control run available (50.9% EARI). A cardioembolic stroke origin (adjusted odds ratio (aOR) 3.72, 95% confidence interval (CI) 1.39–10.0) and shorter groin puncture to IAF intervals (aOR 0.82, 95% CI 0.71–0.95 per 15-min delay) were associated with EARI, while pre-interventional thrombolysis showed no association (aOR 1.15, 95% CI 0.59–2.26). The clinical benefit of EARI after IAF seemed more pronounced in patients without or only minor early ischemic changes (Alberta Stroke Program Early Computed Tomography Score (ASPECTS) ≥9, aOR 4.00, 95% CI 1.37–11.61) and was absent in patients with moderate to severe ischemic changes (ASPECTS ≤8, aOR 0.94, 95% CI 0.27–3.27, p for interaction: 0.095). Conclusion: Early rescue and a cardioembolic stroke origin were associated with more frequent EARI after IAF. The clinical effect of EARI seemed reduced in patients with already established infarcts. If confirmed, these findings can help to inform patient selection and inclusion criteria for randomized-controlled trials evaluating IAF as rescue after MT.
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18
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Novel peripheral blood cell ratios: Effective 3-month post-mechanical thrombectomy prognostic biomarkers for acute ischemic stroke patients. J Clin Neurosci 2021; 89:56-64. [PMID: 34119295 DOI: 10.1016/j.jocn.2021.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/17/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Red blood cell distribution width to platelet ratio (RPR), Monocyte to high-density lipoprotein ratio (MHR), and Neutrophil to lymphocyte ratio (NLR) are novel inflammatory biomarkers in laboratory tests, which are associated with clinical outcomes in malignancy, cardiovascular and cerebrovascular diseases. This study aimed to determine their predictive value for the prognosis of acute ischemic stroke after mechanical thrombectomy (MT). METHODS A total of 286 patients with acute ischemic stroke (AIS) admitted to a tertiary stroke center in China between January 2018 and February 2020 were treated by MT. Demographic characteristics, risk factors, clinical data, laboratory parameters, and clinical outcomes were recorded. The clinical outcome was disability or death at discharge or 90 days (defined as a modified Rankin Scale score of 3-6). The relationship between RPR, MHR, and NLR and functional outcomes was investigated by binary Logistic regression analysis, and further assessed by receiver operating characteristic curve (ROC). The Kaplan-Meier method was used to analyze the survival rate of prognosis factors. RESULTS A total of 286 patients with AIS underwent MT (median age, 70.00; Interquartile range [IQR], 63.00-77.00; 41.6% female). Patients with unfavorable outcome showed higher RPR, MHR, and NLR than those with favorable outcome (RPR, [8.63; IQR, 6.30-10.78] vs [6.17; IQR, 5.11-7.35], P < 0.001; MHR, [0.40; IQR, 0.31-0.53] vs [0.34; IQR, 0.27-0.47], P = 0.005; NLR, [5.28; IQR, 3.63-8.02] vs [3.44; IQR, 2.63-4.63], P < 0.001). In multivariate and ROC curve analysis, higher RPR (>8.565) (odds ratio [OR], 1.671; 95% confidence interval [CI], 1.127-2.479; P = 0.011) and higher MHR (>0.368) (OR, 9.374; 95% CI, 1.160-75.767; P = 0.036), higher NLR (>4.030) (OR, 1.957; 95% CI, 1.382-2.770; P < 0.001) were independently associated with unfavorable outcome. The combined predictive value of the three indexes was higher than that of a single index. Kaplan-Meier survival curve analysis showed that the 90-day survival rate (82.1% vs 66.2%) was significantly different between the low RPR group and the high RPR group (χ2 = 4.960, P = 0.026). CONCLUSION Higher RPR, MHR, and NLR might be independent risk factors for predicting 3-month poor prognosis in patients with AIS who underwent MT.
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Kadowaki M, Tenjin H, Tokuyama T, Kawakatsu T, Kida S, Makita I, Sakamoto T, Takao M, Kasahara M, Saito O, Kurozumi K. Histopathological Composition of Thrombus in Acute Ischemic Stroke May Vary Even Within the Same Patient: A Preliminary Study Examining Clots According to Their Area of Retrieval. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 16:6-11. [PMID: 37502029 PMCID: PMC10370624 DOI: 10.5797/jnet.oa.2020-0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 03/08/2021] [Indexed: 07/29/2023]
Abstract
Objective Mechanical thrombectomy enables histopathological examination of clots in patients who have suffered acute ischemic strokes. Many studies have described about the relationship between the histopathological compositions of retrieved thrombi and imaging findings, clinical outcomes, and stroke etiology without consensus. In this study, we examined the histological composition of thrombi according to their retrieval site and methods. Methods We divided retrieved clots into three parts (those retrieved from the proximal and distal parts of the stent retriever, and those aspirated through the guiding catheter) and then histopathologically analyzed their compositions by measuring the area occupied by red blood cells (RBCs), fibrin/platelets (F/Ps), and white blood cells (WBCs). Results Each specimen showed various composition even within the same patient. For example, the area occupied by RBCs was 20.9% ± 12.1%, 30.5% ± 13.5%, and 41.3% ± 16.1% in the clot retrieved from the proximal and distal parts of the stent retriever, and those aspirated through the guiding catheter, respectively. Conclusion Histopathological clot composition may vary even within the patient. Further research is needed to investigate more objective methods of histopathological analysis and their clinical significance.
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Affiliation(s)
- Makoto Kadowaki
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Hiroshi Tenjin
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Tsutomu Tokuyama
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Toru Kawakatsu
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Satoru Kida
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Ippei Makita
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Tomoya Sakamoto
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Masaki Takao
- Department of Clinical Laboratory, National Center Hospital of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Masao Kasahara
- Department of Pathology, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Osamu Saito
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Kazuhiko Kurozumi
- Department of Neurosurgery, Hamamatsu University Hospital, Hamamatsu, Shizuoka, Japan
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20
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Fitzgerald ST, Liu Y, Dai D, Mereuta OM, Abbasi M, Larco JLA, Douglas AS, Kallmes DF, Savastano L, Doyle KM, Brinjikji W. Novel Human Acute Ischemic Stroke Blood Clot Analogs for In Vitro Thrombectomy Testing. AJNR Am J Neuroradiol 2021; 42:1250-1257. [PMID: 33832952 DOI: 10.3174/ajnr.a7102] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/26/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies have successfully created blood clot analogs for in vitro endovascular device testing using animal blood of various species. Blood components vary greatly among species; therefore, creating clot analogs from human blood is likely a more accurate representation of thrombi formed in the human vasculature. MATERIALS AND METHODS Following approval from the Mayo Clinic institutional review board, human whole-blood and platelet donations were obtained from the blood transfusion service. Twelve clot analogs were created by combining different ratios of red blood cells + buffy coat, plasma, and platelets. Thrombin and calcium chloride were added to stimulate coagulation. Clot composition was assessed using histologic and immunohistochemical staining. To assess the similarities of mechanical properties to patient clots, 3 types of clot analogs (soft, elastic, and stiff) were selected for in vitro thrombectomy testing. RESULTS The range of histopathologic compositions produced is representative of clots removed during thrombectomy procedures. The red blood cell composition ranged from 8.9% to 91.4%, and fibrin composition ranged from 3.1% to 53.4%. Platelets (CD42b) and von Willebrand Factor ranged from 0.5% to 47.1% and 1.0% to 63.4%, respectively. The soft clots had the highest first-pass effect and successful revascularization rates followed by the elastic and stiff clots. Distal embolization events were observed when clot ingestion could not be achieved, requiring device pullback. The incidence rate of distal embolization was the highest for the stiff clots due to the weak clot/device integration. CONCLUSIONS Red blood cell-rich, fibrin-rich, and platelet-rich clot analogs that mimic clots retrieved from patients with acute ischemic stroke were created in vitro. Differing retrieval outcomes were confirmed using in vitro thrombectomy testing in a subset of clots.
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Affiliation(s)
- S T Fitzgerald
- From the Departments of Radiology (S.T.F., Y.L., D.D., O.M.M., M.A., D.F.K., W.B.) .,Department of Physiology (S.T.F., O.M.M., A.S.D., K.M.D.)
| | - Y Liu
- From the Departments of Radiology (S.T.F., Y.L., D.D., O.M.M., M.A., D.F.K., W.B.)
| | - D Dai
- From the Departments of Radiology (S.T.F., Y.L., D.D., O.M.M., M.A., D.F.K., W.B.)
| | - O M Mereuta
- From the Departments of Radiology (S.T.F., Y.L., D.D., O.M.M., M.A., D.F.K., W.B.).,Department of Physiology (S.T.F., O.M.M., A.S.D., K.M.D.).,SFI Centre for Research in Medical Devices (O.M.M., A.S.D., K.M.D.), National University of Ireland Galway, Galway, Ireland
| | - M Abbasi
- From the Departments of Radiology (S.T.F., Y.L., D.D., O.M.M., M.A., D.F.K., W.B.)
| | - J L A Larco
- Neurosurgery (J.L.A.L., L.S., W.B.), Mayo Clinic, Rochester, Minnesota
| | - A S Douglas
- Department of Physiology (S.T.F., O.M.M., A.S.D., K.M.D.).,SFI Centre for Research in Medical Devices (O.M.M., A.S.D., K.M.D.), National University of Ireland Galway, Galway, Ireland
| | - D F Kallmes
- From the Departments of Radiology (S.T.F., Y.L., D.D., O.M.M., M.A., D.F.K., W.B.)
| | - L Savastano
- Neurosurgery (J.L.A.L., L.S., W.B.), Mayo Clinic, Rochester, Minnesota
| | - K M Doyle
- Department of Physiology (S.T.F., O.M.M., A.S.D., K.M.D.).,SFI Centre for Research in Medical Devices (O.M.M., A.S.D., K.M.D.), National University of Ireland Galway, Galway, Ireland
| | - W Brinjikji
- From the Departments of Radiology (S.T.F., Y.L., D.D., O.M.M., M.A., D.F.K., W.B.).,Neurosurgery (J.L.A.L., L.S., W.B.), Mayo Clinic, Rochester, Minnesota
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21
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Jolugbo P, Ariëns RAS. Thrombus Composition and Efficacy of Thrombolysis and Thrombectomy in Acute Ischemic Stroke. Stroke 2021; 52:1131-1142. [PMID: 33563020 DOI: 10.1161/strokeaha.120.032810] [Citation(s) in RCA: 173] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Thrombi retrieved from patients with acute ischemic stroke are highly heterogeneous. Recent data suggest that thrombus composition may impact on mechanical thrombectomy, the number of recanalization manoeuvres, resistance to retrieval, and on thrombolytic potential. Our aim was to summarize evidence describing the impact of thrombus composition on efficacy of mechanical thrombectomy and thrombolysis in patients with acute ischemic stroke. The scoping review methodology guided by the Joanna Briggs Institute, an adaption of the Arksey and O'Malley, was followed. Comprehensive searches were conducted in MEDLINE, EMBASE, SCOPUS, and Web of Science. Articles were classified into 4 key themes: (1) composition of stroke thrombi, (2) thrombus composition and mechanical thrombectomy, (3) thrombus composition and thrombolytic therapy, and (4) novel imaging and endovascular approaches. Our search identified 698 articles published from 1987 to June 2020. Additional articles were extracted from reference lists of the selected articles. Overall, 95 topic-specific articles identified for inclusion published in 40 different journals were included. Reports showed that thrombus composition in stroke was highly heterogeneous, containing fibrin, platelets, red blood cells, VWF (von Willebrand Factor), and neutrophil extracellular traps. Thrombi could roughly be divided into fibrin- and red blood cell-rich clots. Fibrin-rich clots were associated with increased recanalization manoeuvres, longer procedure time, and less favorable clinical outcomes compared with red blood cell-rich clots. Advances in detection or treatment of thrombi that take into account clot heterogeneity may be able to improve future endovascular and thrombolytic treatment of stroke.
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Affiliation(s)
- Precious Jolugbo
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom
| | - Robert A S Ariëns
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom
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22
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Weisel JW, Litvinov RI. Visualizing thrombosis to improve thrombus resolution. Res Pract Thromb Haemost 2021; 5:38-50. [PMID: 33537528 PMCID: PMC7845077 DOI: 10.1002/rth2.12469] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/05/2020] [Accepted: 11/15/2020] [Indexed: 12/12/2022] Open
Abstract
The severity, course, and outcomes of thrombosis are determined mainly by the size and location of the thrombus, but studying thrombus structure and composition has been an important but challenging task. The substantial progress in determination of thrombus morphology has become possible due to new intravital imaging methodologies in combination with mechanical thrombectomy, which allows extraction of a fresh thrombus from a patient followed by microscopy. Thrombi have been found to contain various structural forms of fibrin along with platelet aggregates, leukocytes, and red blood cells, many of which acquire a polyhedral shape (polyhedrocytes) as a result of intravital platelet-driven contraction. The relative volume fractions of thrombus components and their structural forms vary substantially, depending on the clinical and pathogenic characteristics. This review summarizes recent research that describes quantitative and qualitative morphologic characteristics of arterial and venous thrombi that are relevant for the pathogenesis, prophylaxis, diagnosis, and treatment of thrombosis.
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Affiliation(s)
- John W. Weisel
- Department of Cell and Developmental BiologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Rustem I. Litvinov
- Department of Cell and Developmental BiologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
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23
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Khismatullin RR, Nagaswami C, Shakirova AZ, Vrtková A, Procházka V, Gumulec J, Mačák J, Litvinov RI, Weisel JW. Quantitative Morphology of Cerebral Thrombi Related to Intravital Contraction and Clinical Features of Ischemic Stroke. Stroke 2020; 51:3640-3650. [PMID: 33040705 DOI: 10.1161/strokeaha.120.031559] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE The purpose was to assess quantitatively and qualitatively the composition and structure of cerebral thrombi and correlate them with the signs of intravital clot contraction (retraction), as well as with etiology, severity, duration, and outcomes of acute ischemic stroke. METHODS We quantified high-resolution scanning electron micrographs of 41 cerebral thrombi for their detailed cellular and noncellular composition and analyzed histological images for the overall structure with the emphasis on red blood cell compression, fibrin age, and the signs of inflammation. RESULTS Cerebral thrombi were quite compact and had extremely low porosity. The prevailing cell type was polyhedral compressed erythrocytes (polyhedrocytes) in the core, and fibrin-platelet aggregates were concentrated at the periphery; both findings are indicative of intravital contraction of the thrombi. The content of polyhedrocytes directly correlated with the stroke severity. The prevalence of fibrin bundles was typical for more severe cases, while the content of fibrin sponge prevailed in cases with a more favorable course. The overall platelet content in cerebral thrombi was surprisingly small, while the higher content of platelet aggregates was a marker of stroke severity. Fibrillar types of fibrin prevailed in atherothrombogenic thrombi. Older fibrin prevailed in thrombi from the patients who received thrombolytics, and younger fibrin dominated in cardioembolic thrombi. Alternating layers of erythrocytes and fibrin mixed with platelets were common for thrombi from the patients with more favorable outcomes. Thrombi with a higher number of leukocytes were associated with fatal cases. CONCLUSIONS Most cerebral thrombi undergo intravital clot contraction (retraction) that may be of underestimated clinical importance. Despite the high variability of the composition and structure of cerebral thrombi, the content of certain types of blood cells and fibrin structures combined with the morphological signs of intravital contraction correlate with the clinical course and outcomes of acute ischemic stroke.
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Affiliation(s)
- Rafael R Khismatullin
- Department of General Pathology, Kazan State Medical University (R.R.K., A.Z.S.), Russian Federation.,Institute of Fundamental Medicine and Biology, Kazan Federal University (R.R.K., A.Z.S., R.I.L.), Russian Federation.,Department of Cell and Developmental Biology, University of Pennsylvania School of Medicine, Philadelphia (R.R.K., C.N., R.I.L., J.W.W.)
| | - Chandrasekaran Nagaswami
- Department of Cell and Developmental Biology, University of Pennsylvania School of Medicine, Philadelphia (R.R.K., C.N., R.I.L., J.W.W.)
| | - Asia Z Shakirova
- Department of General Pathology, Kazan State Medical University (R.R.K., A.Z.S.), Russian Federation.,Institute of Fundamental Medicine and Biology, Kazan Federal University (R.R.K., A.Z.S., R.I.L.), Russian Federation
| | - Adéla Vrtková
- Department of Applied Mathematics, VSB- Technical University of Ostrava, Czech Republic (A.V.)
| | - Václav Procházka
- Department of Radiology (V.P.), University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Czech Republic
| | - Jaromír Gumulec
- Department of Hematooncology (J.G.), University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Czech Republic
| | - Jiří Mačák
- Department of Pathology (J.M.), University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Czech Republic
| | - Rustem I Litvinov
- Institute of Fundamental Medicine and Biology, Kazan Federal University (R.R.K., A.Z.S., R.I.L.), Russian Federation.,Department of Cell and Developmental Biology, University of Pennsylvania School of Medicine, Philadelphia (R.R.K., C.N., R.I.L., J.W.W.)
| | - John W Weisel
- Department of Cell and Developmental Biology, University of Pennsylvania School of Medicine, Philadelphia (R.R.K., C.N., R.I.L., J.W.W.)
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24
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Kömürcü HF, Gözke E, Doğan Ak P, Kalyoncu Aslan I, Salt I, Özgenç Bi¸er Çİ. Changes in neutrophil, lymphocyte, platelet ratios and their relationship with NIHSS after rtPA and/or thrombectomy in ischemic stroke. J Stroke Cerebrovasc Dis 2020; 29:105004. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 12/18/2022] Open
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25
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Sporns PB, Krähling H, Psychogios MN, Jeibmann A, Minnerup J, Broocks G, Meyer L, Brehm A, Wildgruber M, Fiehler J, Kniep H, Hanning U. Small thrombus size, thrombus composition, and poor collaterals predict pre-interventional thrombus migration. J Neurointerv Surg 2020; 13:409-414. [PMID: 32690758 DOI: 10.1136/neurintsurg-2020-016228] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/11/2020] [Accepted: 06/11/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Different imaging characteristics such as clot burden score, collaterals, and pre-interventional thrombus migration are associated with functional outcome in patients with acute ischemic stroke. Moreover, histological thrombus composition is associated with pre-interventional thrombus migration. We hypothesized that smaller clots may more likely migrate and that collateral status in ischemic stroke patients may mediate this tendency of the clot to migrate. METHODS In this prospective cohort of consecutive ischemic stroke patients, clot burden scores and collateral scores were rated and the retrieved thrombi were histologically analyzed. We then investigated the relationship between clot burden score, probability for thrombus migration, and collateral scores using mediation analysis. RESULTS 163 patients are included of which 36 (22.1%) had a clot migration. Probability of thrombus migration was significantly associated with lower collateral scores (P<0.01), higher clot burden scores (P<0.01), shorter thrombi (P<0.01), and higher RBC count (P<0.01). In the mediator pathway, higher collateral scores were significantly associated with higher clot burden scores (P<0.01) and younger age (P=0.029). The total effect of an increase in clot burden score by one grade on thrombus migration is composed of the direct effect (+18%, P<0.01) and the collateral score-mediated indirect effect (-5%, P<0.01). CONCLUSIONS Smaller, erythrocyte-rich thrombi tend to migrate more often. Good collaterals seem to have a considerable effect on limiting migration. This supports the hypothesis that larger clots have stronger adherence with the vessel wall and that good collaterals increase the counter pressure distal of the clot.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland .,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Krähling
- Institute of Clinical Radiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Marios N Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Astrid Jeibmann
- Institute of Neuropathology, University Hospital Muenster, Pottkamp 2, Münster, Germany
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alex Brehm
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Moritz Wildgruber
- Institute of Clinical Radiology, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany.,Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Muenchen, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abstract
The structure of stroke thrombi has gained an increasing amount of interest in recent years. The advent of endovascular thrombectomy has offered the unique opportunity to provide and analyze thrombi removed from ischemic stroke patients. It has become clear that the composition of ischemic stroke thrombi is relatively heterogenous and various molecular and cellular patterns become apparent. Good understanding of the histopathologic characteristics of thrombi is important to lead future advancements in acute ischemic stroke treatment. In this review, we give a brief overview of the main stroke thrombus components that have been recently characterized in this rapidly evolving field. We also summarize how thrombus heterogeneity can affect stroke treatment.
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Affiliation(s)
- Senna Staessens
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
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27
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Moderate Intensity Static Magnetic Fields Prevent Thrombus Formation in Rats and Mice. Bioelectromagnetics 2019; 41:52-62. [DOI: 10.1002/bem.22232] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 11/09/2019] [Indexed: 12/22/2022]
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28
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Khismatullin RR, Shakirova AZ, Weisel JW, Litvinov RI. Age-Dependent Differential Staining of Fibrin in Blood Clots and Thrombi. BIONANOSCIENCE 2019. [DOI: 10.1007/s12668-019-00701-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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29
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Alves HC, Treurniet KM, Jansen IGH, Yoo AJ, Dutra BG, Zhang G, Yo L, van Es ACGM, Emmer BJ, van den Berg R, van den Wijngaard IR, Lycklama À Nijeholt GJ, Vos JA, Roos YBWEM, Schonewille W, Marquering HA, Majoie CBLM. Thrombus Migration Paradox in Patients With Acute Ischemic Stroke. Stroke 2019; 50:3156-3163. [PMID: 31597552 PMCID: PMC6824579 DOI: 10.1161/strokeaha.119.026107] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Supplemental Digital Content is available in the text. The location of the thrombus as observed on first digital subtraction angiography during endovascular treatment may differ from the initial observation on initial noninvasive imaging. We studied the incidence of thrombus dynamics, its impact on patient outcomes, and its association with intravenous thrombolytics.
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Affiliation(s)
- Heitor C Alves
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands.,Biomedical Engineering and Physics (H.C.A., B.G.D., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands.,Department of Radiology, Irmandade Santa Casa de Misericórdia de São Paulo, Brazil (H.C.A., B.G.D.)
| | - Kilian M Treurniet
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Ivo G H Jansen
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Albert J Yoo
- Division of Interventional Neuroradiology, Department of Radiology, Texas Stroke Institute, Plano (A.J.Y.)
| | - Bruna G Dutra
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands.,Biomedical Engineering and Physics (H.C.A., B.G.D., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands.,Department of Radiology, Irmandade Santa Casa de Misericórdia de São Paulo, Brazil (H.C.A., B.G.D.)
| | - Guang Zhang
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Lonneke Yo
- Department of Radiology, Catharina Ziekenhuis, Eindhoven, the Netherlands (L.Y.)
| | - Adriaan C G M van Es
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands (A.C.G.M.v.E.)
| | - Bart J Emmer
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - René van den Berg
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | | | | | - Jan-Albert Vos
- Department of Radiology, St Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.A.V)
| | - Yvo B W E M Roos
- Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands
| | - Wouter Schonewille
- Department of Neurology, University Medical Center, Utrecht, the Netherlands (W.S.)
| | - Henk A Marquering
- Biomedical Engineering and Physics (H.C.A., B.G.D., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
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30
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Bacigaluppi M, Semerano A, Gullotta GS, Strambo D. Insights from thrombi retrieved in stroke due to large vessel occlusion. J Cereb Blood Flow Metab 2019; 39:1433-1451. [PMID: 31213164 PMCID: PMC6681524 DOI: 10.1177/0271678x19856131] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The recent advances of endovascular procedures to treat stroke due to large cerebral vessel occlusion have made it possible to analyze the retrieved thrombus material. Analysis of cerebral thrombi is emerging as a relevant opportunity to complement the diagnostic workup of etiology, to develop new lytic approaches and to optimize the acute treatment of stroke due to large vessel occlusion. Nonetheless, retrieved thrombi are frequently discarded since their informative potential is often neglected and standards are missing. This review provides an overview of the current knowledge and expanding research relating to thrombus composition analysis in large vessel occlusions. We first discuss the heterogeneity of thrombogenic factors that underlie the thrombotic formation in stroke and its implications to identify stroke etiology and thrombus age. Further, we show that understanding structural characteristics of thrombus is pivotal for the development of new-targeted lytic therapies as well as to improve, through thrombus modeling, the development of thrombectomy devices. Finally, we discuss the on-going attempts to identify a signature of thrombus composition indirectly through imaging and peripheral blood biomarkers, which might in future assist treatment decision-making as well as secondary prevention. Thrombus analysis might contribute to the advancement and optimization of personalized stroke treatments.
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Affiliation(s)
- Marco Bacigaluppi
- 1 Neurology and Neuroimmunology Unit, Insititute of Experimental Neurology, San Raffaele Scientific Institute, Milano, Italy
| | - Aurora Semerano
- 1 Neurology and Neuroimmunology Unit, Insititute of Experimental Neurology, San Raffaele Scientific Institute, Milano, Italy
| | - Giorgia Serena Gullotta
- 1 Neurology and Neuroimmunology Unit, Insititute of Experimental Neurology, San Raffaele Scientific Institute, Milano, Italy
| | - Davide Strambo
- 1 Neurology and Neuroimmunology Unit, Insititute of Experimental Neurology, San Raffaele Scientific Institute, Milano, Italy.,2 Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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31
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Sporns PB, Jeibmann A, Minnerup J, Broocks G, Nawabi J, Schön G, Fiehler J, Wildgruber M, Heindel W, Kemmling A, Hanning U. Histological Clot Composition Is Associated With Preinterventional Clot Migration in Acute Stroke Patients. Stroke 2019; 50:2065-2071. [PMID: 31242825 DOI: 10.1161/strokeaha.118.023314] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background and Purpose- The introduction of stent retrievers allows for a complete extraction and histological analysis of human clots. Initial studies describe an impact of preinterventional clot migration on technical and clinical success of thrombectomy and an association with worse clinical outcome. We, therefore, performed a large study of consecutive patients whose clots have been histologically analyzed and tried to determine whether clot composition influences the rates of clot migration and thereby interventional and clinical outcome. Methods- We retrospectively evaluated data of a prospectively collected cohort of 198 consecutive patients with occlusion of the middle cerebral artery. We investigated the relationship between clot histology expressed as percentage of the main components (fibrin, erythrocytes [red blood cell], and white blood cells), the preinterventional computed tomography attenuation of the emboli, embolus length, and clot migration. We defined a binary outcome (clot migration versus no clot migration). The impact of embolus composition and computed tomography features was assessed in univariable and multivariable logistic regression models. Results- One hundred sixty-three patients fulfilled the inclusion criteria, of which 36 (22.1%) showed a clot migration. Patients with proven clot migration had significantly higher levels of red blood cells than patients without clot migration (median 50% versus 26%, P<0.001). Lower amounts of fibrin were significantly more often observed in patients in the clot migration group as compared to the no clot migration group (43.5% versus 62.0%, P<0.001). Stroke cause did not differ between migrated and stable emboli. Multivariable analysis identified a higher amount of erythrocytes (adjusted odds ratio, 1.03 per median percentage, P<0.001) and a shorter embolus length (adjusted odds ratio, 0.90 per mm, P<0.008) as independent predictors of clot migration. Conclusions- Erythrocyte-rich clots and a shorter embolus length are independent reliable predictors for clot migration. This finding is clinically important as clot migration might have a negative impact on technical and clinical outcomes of patients suffering from emergent vessel occlusions of the middle cerebral artery undergoing endovascular therapy.
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Affiliation(s)
- Peter B Sporns
- From the Institute of Clinical Radiology (P.B.S., M.W., W.H., A.K.), University Hospital of Muenster, Germany
| | - Astrid Jeibmann
- Institute of Neuropathology (A.J.), University Hospital of Muenster, Germany
| | - Jens Minnerup
- Department of Neurology (J.M.), University Hospital of Muenster, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology (G.B., J.N., J.F., U.H.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jawed Nawabi
- Department of Diagnostic and Interventional Neuroradiology (G.B., J.N., J.F., U.H.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (G.B., J.N., J.F., U.H.), University Medical Center Hamburg-Eppendorf, Germany
| | - Moritz Wildgruber
- From the Institute of Clinical Radiology (P.B.S., M.W., W.H., A.K.), University Hospital of Muenster, Germany
| | - Walter Heindel
- From the Institute of Clinical Radiology (P.B.S., M.W., W.H., A.K.), University Hospital of Muenster, Germany
| | - André Kemmling
- From the Institute of Clinical Radiology (P.B.S., M.W., W.H., A.K.), University Hospital of Muenster, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology (G.B., J.N., J.F., U.H.), University Medical Center Hamburg-Eppendorf, Germany
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32
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Fitzgerald S, Mereuta OM, Doyle KM, Dai D, Kadirvel R, Kallmes DF, Brinjikji W. Correlation of imaging and histopathology of thrombi in acute ischemic stroke with etiology and outcome. J Neurosurg Sci 2019; 63:292-300. [PMID: 30514073 PMCID: PMC8693286 DOI: 10.23736/s0390-5616.18.04629-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mechanical thrombectomy has become the stand of care for patients with large vessel occlusions, yet major improvements in thrombectomy speed, efficacy, and completeness can still be achieved. High rates of clot fragmentation and failure to remove the clot resulting in poor neurological outcomes suggest that in order to further advance the field of stroke intervention we must turn our attention towards understanding the science of clot. Accurately identifying the composition of the occlusive clot prior to intervention could significantly influence the success of the revascularization strategy used to treat them. Numerous features of thromboemboli could be studied and characterized, including quantitative histomorphometry and diagnostic imaging characteristics. Each of these features might logically predict superior thrombectomy outcomes with one device or another. This article aims to review the current literature on histopathological composition of acute ischemic stroke clots, with a particular focus on the correlation between clot composition and diagnostic imaging, stroke etiology and revascularization outcomes.
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Affiliation(s)
- Seán Fitzgerald
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- CÚRAM-Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Oana M Mereuta
- CÚRAM-Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Karen M Doyle
- CÚRAM-Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Daying Dai
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA -
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
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33
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Fitzgerald ST, Wang S, Dai D, Douglas A, Kadirvel R, Gounis MJ, Chueh J, Puri AS, Layton KF, Thacker IC, Hanel RA, Sauvageau E, Aghaebrahim A, Almekhlafi MA, Demchuk AM, Nogueira RG, Pereira VM, Kvamme P, Kayan Y, Delgado Almandoz JE, Yoo AJ, Kallmes DF, Doyle KM, Brinjikji W. Platelet-rich clots as identified by Martius Scarlet Blue staining are isodense on NCCT. J Neurointerv Surg 2019; 11:1145-1149. [PMID: 30952688 DOI: 10.1136/neurintsurg-2018-014637] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/28/2019] [Accepted: 03/03/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Current studies on clot characterization in acute ischemic stroke focus on fibrin and red blood cell composition. Few studies have examined platelet composition in acute ischemic stroke clots. We characterize clot composition using the Martius Scarlet Blue stain and assess associations between platelet density and CT density. MATERIALS AND METHOD Histopathological analysis of the clots collected as part of the multi-institutional STRIP registry was performed using Martius Scarlet Blue stain and the composition of the clots was quantified using Orbit Image Analysis (www.orbit.bio) machine learning software. Prior to endovascular treatment, each patient underwent non-contrast CT (NCCT) and the CT density of each clot was measured. Correlations between clot components and clinical information were assessed using the χ2 test. RESULTS Eighty-five patients were included in the study. The mean platelet density of the clots was 15.7% (2.5-72.5%). There was a significant correlation between platelet-rich clots and the absence of hyperdensity on NCCT, (ρ=0.321, p=0.003*, n=85). Similarly, there was a significant inverse correlation between the percentage of platelets and the mean Hounsfield Units on NCCT (ρ=-0.243, p=0.025*, n=85). CONCLUSION Martius Scarlet Blue stain can identify patients who have platelet-rich clots. Platelet-rich clots are isodense on NCCT.
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Affiliation(s)
- Sean T Fitzgerald
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,CÚRAM - Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Shunli Wang
- Department of Pathology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Daying Dai
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew Douglas
- CÚRAM - Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.,Department of Physiology, National University of Ireland Galway, Galway, Ireland
| | | | - Matthew J Gounis
- Department of Radiology, University of Massachusetts, Worcester, Massachusetts, USA
| | - Juyu Chueh
- Department of Radiology, University of Massachusetts, Worcester, Massachusetts, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts, Worcester, Massachusetts, USA
| | - Kennith F Layton
- Department of Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Ike C Thacker
- Department of Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Ricardo A Hanel
- Stroke & Cerebrovascular Center, Lyerly Neurosurgery/Baptist Neurological Center, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Stroke & Cerebrovascular Center, Lyerly Neurosurgery/Baptist Neurological Center, Jacksonville, Florida, USA
| | - Amin Aghaebrahim
- Stroke & Cerebrovascular Center, Lyerly Neurosurgery/Baptist Neurological Center, Jacksonville, Florida, USA
| | | | - Andrew M Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Raul G Nogueira
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Emory University, Atlanta, Georgia, USA
| | - Vitor M Pereira
- Joint Department of Medical Imaging, Neuroradiology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Peter Kvamme
- Department of Radiology, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Yasha Kayan
- NeuroInterventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Josser E Delgado Almandoz
- NeuroInterventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Albert J Yoo
- Department of Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Karen M Doyle
- CÚRAM - Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.,Department of Physiology, National University of Ireland Galway, Galway, Ireland
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34
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Brinjikji W, Duffy S, Burrows A, Hacke W, Liebeskind D, Majoie CBLM, Dippel DWJ, Siddiqui AH, Khatri P, Baxter B, Nogeuira R, Gounis M, Jovin T, Kallmes DF. Correlation of imaging and histopathology of thrombi in acute ischemic stroke with etiology and outcome: a systematic review. J Neurointerv Surg 2017; 9:529-534. [PMID: 27166383 PMCID: PMC6697418 DOI: 10.1136/neurintsurg-2016-012391] [Citation(s) in RCA: 195] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 04/15/2016] [Accepted: 04/22/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Studying the imaging and histopathologic characteristics of thrombi in ischemic stroke could provide insights into stroke etiology and ideal treatment strategies. We conducted a systematic review of imaging and histologic characteristics of thrombi in acute ischemic stroke. MATERIALS AND METHODS We identified all studies published between January 2005 and December 2015 that reported findings related to histologic and/or imaging characteristics of thrombi in acute ischemic stroke secondary to large vessel occlusion. The five outcomes examined in this study were (1) association between histologic composition of thrombi and stroke etiology; (2) association between histologic composition of thrombi and angiographic outcomes; (3) association between thrombi imaging and histologic characteristics; (4) association between thrombi imaging characteristics and angiographic outcomes; and (5) association between imaging characteristics of thrombi and stroke etiology. A meta-analysis was performed using a random effects model. RESULTS There was no significant difference in the proportion of red blood cell (RBC)-rich thrombi between cardioembolic and large artery atherosclerosis etiologies (OR 1.62, 95% CI 0.1 to 28.0, p=0.63). Patients with a hyperdense artery sign had a higher odds of having RBC-rich thrombi than those without a hyperdense artery sign (OR 9.0, 95% CI 2.6 to 31.2, p<0.01). Patients with a good angiographic outcome had a mean thrombus Hounsfield unit (HU) of 55.1±3.1 compared with a mean HU of 48.4±1.9 for patients with a poor angiographic outcome (mean standard difference 6.5, 95% CI 2.7 to 10.2, p<0.001). There was no association between imaging characteristics and stroke etiology (OR 1.13, 95% CI 0.32 to 4.00, p=0.85). CONCLUSIONS The hyperdense artery sign is associated with RBC-rich thrombi and improved recanalization rates. However, there was no association between the histopathological characteristics of thrombi and stroke etiology and angiographic outcomes.
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Affiliation(s)
| | - Sharon Duffy
- Department of Engineering, Galway-Mayo Institute of Technology, Galway, Ireland
| | - Anthony Burrows
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - David Liebeskind
- Department of Neurology, University of California, Los Angeles, California, USA
| | - Charles B L M Majoie
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Adnan H Siddiqui
- Department of Neurosurgery, University of Buffalo, Buffalo, New York, USA
| | - Pooja Khatri
- Department of Neurology, University of Cincinatti, Cincinatti, Ohio, USA
| | - Blaise Baxter
- Department of Radiology, University of Tennessee Medical Center, Chatanooga, Tennessee, USA
| | - Raul Nogeuira
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Matt Gounis
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts, USA
| | - Tudor Jovin
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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