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Jayyusi F, AlBarakat MM, Al-Rousan HH, Alawajneh MM, Alkasabrah AR, Abujaber M, Aldabbas ME, Abuelsamen M, Alshgerat Y, Sayuri Y, Alhertani N, BaniAmer M, Shari I, Brašić JR. The Efficacy of Medical Interventions for Free-Floating Thrombus in Cerebrovascular Events: A Systematic Review. Brain Sci 2024; 14:801. [PMID: 39199493 PMCID: PMC11352359 DOI: 10.3390/brainsci14080801] [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: 07/19/2024] [Revised: 08/03/2024] [Accepted: 08/07/2024] [Indexed: 09/01/2024] Open
Abstract
Although free-floating thrombus (FFT) poses a significant risk of stroke or transient ischemic attack (TIA), optimal management strategies are uncertain. To determine the state-of-the-art of medical interventions for FFT, we conducted a systematic review of the efficacy of various medical interventions and factors influencing FFT resolution and recurrence. A comprehensive search of Embase, PubMed, and ScienceDirect identified 61 studies encompassing 179 patients with FFT-related stroke or TIA treated with anticoagulants, antiplatelets, or their combinations. Primary outcomes assessed were stroke recurrence and thrombus resolution. Statistical analyses (Fisher's exact test, chi-square test, Mann-Whitney test, and Kruskal-Wallis test) utilized significance set at p < 0.05. Over a median follow-up of 7 months, thrombus resolution occurred in 65% of patients, while 11.2% experienced recurrence, primarily as TIAs. Cardioembolism was significantly less common in resolved cases (p = 0.025). Combination therapy (antiplatelets, anticoagulants, and statins) significantly enhanced clot resolution (OR 11.4; 95% CI 1.436-91.91; p = 0.021) compared to monotherapies. Ulcerated plaque was a significant predictor of recurrence (OR 8.2; 95% CI 1.02-66.07; p = 0.048). These findings underscore the superiority of combination therapy in FFT management and highlight the need for targeted interventions in patients with ulcerated plaques to mitigate recurrence risk.
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Affiliation(s)
- Fairoz Jayyusi
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Majd M. AlBarakat
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Habib H. Al-Rousan
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Mohmmad M. Alawajneh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Abdel Rahman Alkasabrah
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Mo’tasem Abujaber
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Mohammed E. Aldabbas
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Mustafa Abuelsamen
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Yahya Alshgerat
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Yahia Sayuri
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Nazeeh Alhertani
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Mohammad BaniAmer
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - Issa Shari
- Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; (F.J.); (M.M.A.); (H.H.A.-R.); (M.M.A.); (A.R.A.); (M.A.); (M.E.A.); (M.A.); (Y.A.); (Y.S.); (N.A.); (M.B.).; (I.S.)
| | - James Robert Brašić
- Department of Psychiatry, New York City Health and Hospitals/Bellevue, New York, NY 10016, USA
- Department of Psychiatry, New York University Grossman School of Medicine, New York University Langone Health, New York, NY 10016, USA
- Section of High-Resolution Brain Positron Emission Tomography Imaging, Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Torres C, Lum C, Puac-Polanco P, Stotts G, Shamy MCF, Blacquiere D, Lun R, Dave P, Bharatha A, Menon BK, Thornhill R, Momoli F, Dowlatshahi D. Differentiating Carotid Free-Floating Thrombus From Atheromatous Plaque Using Intraluminal Filling Defect Length on CTA: A Validation Study. Neurology 2021; 97:e785-e793. [PMID: 34426550 DOI: 10.1212/wnl.0000000000012368] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/26/2021] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To validate a previously proposed filling defect length threshold of >3.8 mm on CT angiography (CTA) to discriminate between free-floating thrombus (FFT) and plaque of atheroma. METHODS This was a prospective multicenter observational study of 100 participants presenting with TIA/stroke symptoms and a carotid intraluminal filling defect on initial CTA. Follow-up CTA was obtained within 1 week and at weeks 2 and 4 if the intraluminal filling defect was unchanged in length. Resolution or decreased length was diagnostic of FFT, whereas its static appearance after 4 weeks was indicative of plaque. Diagnostic accuracy of FFT length was assessed by receiver operating characteristic analysis. RESULTS Ninety-five participants (mean [SD] age 68 [13] years, 61 men, 83 participants with FFT, 12 participants with a plaque) were evaluated. The >3.8-mm threshold had a sensitivity of 88% (73 of 83) (95% confidence interval [CI] 78%-94%) and specificity of 83% (10 of 12) (95% CI 51%-97%) (area under the curve 0.91, p < 0.001) for the diagnosis of FFT. The optimal length threshold was >3.64 mm with a sensitivity of 89% (74 of 83) (95% CI 80%-95%) and specificity of 83% (10 of 12) (95% CI 51%-97%). Adjusted logistic regression showed that every 1-mm increase in intraluminal filling defect length is associated with an increase in odds of FFT of 4.6 (95% CI 1.9-11.1, p = 0.01). CONCLUSION CTA enables accurate differentiation of FFT vs plaque using craniocaudal length thresholds. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT02405845. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that in patients with TIA/stroke symptoms, the presence of CTA-identified filling defects of lengths >3.8 mm accurately discriminates FFT from atheromatous plaque.
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Affiliation(s)
- Carlos Torres
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada.
| | - Cheemun Lum
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Paulo Puac-Polanco
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Grant Stotts
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Michel Christopher Frank Shamy
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Dylan Blacquiere
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Ronda Lun
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Prasham Dave
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Aditya Bharatha
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Bijoy K Menon
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Rebecca Thornhill
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Franco Momoli
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
| | - Dar Dowlatshahi
- From the Division of Neuroradiology (C.T., P.P.-P.), Department of Radiology, Division of Neurology (G.S., M.C.F.S., D.B., R.L., P.D., D.D.), Department of Medicine, Division of Medical Physics (R.T.), Department of Radiology, and School of Epidemiology and Public Health (F.M.), University of Ottawa; Neuroscience Program (C.T., G.S., M.C.F.S., D.B., D.D.), The Ottawa Hospital Research Institute; Division of Neuroradiology (A.B.), Department of Medical Imaging, St. Michael's Hospital, University of Toronto, Ontario; and Departments of Clinical Neurosciences, Radiology, and Community Health Sciences (B.K.M.), University of Calgary, Foothills Medical Centre, Alberta, Canada
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Thornhill RE, Lum C, Jaberi A, Stefanski P, Torres CH, Momoli F, Petrcich W, Dowlatshahi D. Can shape analysis differentiate free-floating internal carotid artery thrombus from atherosclerotic plaque in patients evaluated with CTA for stroke or transient ischemic attack? Acad Radiol 2014; 21:345-54. [PMID: 24507422 DOI: 10.1016/j.acra.2013.11.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/22/2013] [Accepted: 11/08/2013] [Indexed: 11/16/2022]
Abstract
RATIONALE AND OBJECTIVES Patients presenting with transient ischemic attack or stroke may have symptom-related lesions on acute computed tomography angiography (CTA) such as free-floating intraluminal thrombus (FFT). It is difficult to distinguish FFT from carotid plaque, but the distinction is critical as management differs. By contouring the shape of these vascular lesions ("virtual endarterectomy"), advanced morphometric analysis can be performed. The objective of our study is to determine whether quantitative shape analysis can accurately differentiate FFT from atherosclerotic plaque. MATERIALS AND METHODS We collected 23 consecutive cases of suspected carotid FFT seen on CTA (13 men, 65 ± 10 years; 10 women, 65.5 ± 8.8 years). True-positive FFT cases (FFT+) were defined as filling defects resolving with anticoagulant therapy versus false-positives (FFT-), which remained unchanged. Lesion volumes were extracted from CTA images and quantitative shape descriptors were computed. The five most discriminative features were used to construct receiver operator characteristic (ROC) curves and to generate three machine-learning classifiers. Average classification accuracy was determined by cross-validation. RESULTS Follow-up imaging confirmed sixteen FFT+ and seven FFT- cases. Five shape descriptors delineated FFT+ from FFT- cases. The logistic regression model produced from combining all five shape features demonstrated a sensitivity of 87.5% and a specificity of 71.4% with an area under the ROC curve = 0.85 ± 0.09. Average accuracy for each classifier ranged from 65.2%-76.4%. CONCLUSIONS We identified five quantitative shape descriptors of carotid FFT. This shape "signature" shows potential for supplementing conventional lesion characterization in cases of suspected FFT.
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Affiliation(s)
- Rebecca E Thornhill
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada; Department of Medical Imaging, The Ottawa Hospital, 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada; Clinical Epidemiology Program/Methods Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Cheemun Lum
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada; Department of Medical Imaging, The Ottawa Hospital, 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada; Clinical Epidemiology Program/Methods Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Arash Jaberi
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada; Department of Medical Imaging, The Ottawa Hospital, 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada
| | - Pawel Stefanski
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada; Department of Medical Imaging, The Ottawa Hospital, 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada
| | - Carlos H Torres
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada; Department of Medical Imaging, The Ottawa Hospital, 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada; Clinical Epidemiology Program/Methods Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Franco Momoli
- Clinical Epidemiology Program/Methods Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - William Petrcich
- Clinical Epidemiology Program/Methods Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Clinical Epidemiology Program/Methods Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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