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Cahalane RME, Cruts JMH, van Beusekom HMM, de Maat MPM, Dijkshoorn M, van der Lugt A, Gijsen FJH. Contribution of Red Blood Cells and Platelets to Blood Clot Computed Tomography Imaging and Compressive Mechanical Characteristics. Ann Biomed Eng 2024; 52:2151-2161. [PMID: 38664333 PMCID: PMC11247058 DOI: 10.1007/s10439-024-03515-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 04/06/2024] [Indexed: 07/16/2024]
Abstract
Thrombus computed tomography (CT) imaging characteristics may correspond with thrombus mechanical properties and thus predict thrombectomy success. The impact of red blood cell (RBC) content on these properties (imaging and mechanics) has been widely studied. However, the additional effect of platelets has not been considered. The objective of the current study was to examine the individual and combined effects of blood clot RBC and platelet content on resultant CT imaging and mechanical characteristics. Human blood clot analogues were prepared from a combination of preselected RBC volumes and platelet concentrations to decouple their contributions. The resulting clot RBC content (%) and platelet content (%) were determined using Martius Scarlet Blue and CD42b staining, respectively. Non-contrast and contrast-enhanced CT (NCCT and CECT) scans were performed to measure the clot densities. CECT density increase was taken as a proxy for clinical perviousness. Unconfined compressive mechanics were analysed by performing 10 cycles of 80% strain. RBC content is the major determinant of clot NCCT density. However, additional consideration of the platelet content improves the association. CECT density increase is influenced by clot platelet and not RBC content. Platelet content is the dominant component driving clot stiffness, especially at high strains. Both RBC and platelet content contribute to the clot's viscoelastic and plastic compressive properties. The current in vitro results suggest that CT density is reflective of RBC content and subsequent clot viscoelasticity and plasticity, and that perviousness reflects the clot's platelet content and subsequent stiffness. However, these indications should be confirmed in a clinical stroke cohort.
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Affiliation(s)
- Rachel M E Cahalane
- Department of Biomedical Engineering, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Janneke M H Cruts
- Department of Biomedical Engineering, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | | | - Moniek P M de Maat
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marcel Dijkshoorn
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Frank J H Gijsen
- Department of Biomedical Engineering, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands.
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands.
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Anagnostakou V, Toth D, Bertalan G, Müller S, Reimann RR, Epshtein M, Madjidyar J, Thurner P, Schubert T, Wegener S, Kulcsar Z. Dynamic Perviousness Has Predictive Value for Clot Fibrin Content in Acute Ischemic Stroke. Diagnostics (Basel) 2024; 14:1387. [PMID: 39001277 PMCID: PMC11241263 DOI: 10.3390/diagnostics14131387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 07/16/2024] Open
Abstract
Dynamic perviousness is a novel imaging biomarker, with clot density measurements at multiple timepoints to allow longer contrast to thrombus interaction. We investigated the correlations between dynamic perviousness and clot composition in the setting of acute ischemic stroke. Thirty-nine patients with large vessel occlusion (LVO) undergoing mechanical thrombectomy (MT) were analyzed. Patients received a three-phase CT imaging pre-thrombectomy and histopathological analysis of retrieved clots. Clot densities for every phase and change in densities between phases were calculated, leading to four patterns of dynamic perviousness: no contrast uptake, early contrast uptake with and without washout and late uptake. Clots were categorized into three groups based on dominant histologic composition: red blood cell (RBC)-rich, fibrin/platelet-rich and mixed. Clot composition was correlated with dynamic perviousness using the Kruskal-Wallis test and Pearson's correlation analysis. The dynamic perviousness categories showed a significant difference between fibrin-rich clots when compared to RBC-rich plus mixed groups. The uptake without washout category had significantly fewer fibrin clots compared to the uptake with washout (p = 0.036), and nearly significantly fewer fibrin clots when compared to the no uptake category (p = 0.057). Contrast uptake with different patterns of contrast washout showed significant differences of the likelihood for fibrin-rich clots.
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Affiliation(s)
- Vania Anagnostakou
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland; (D.T.); (G.B.); (S.M.); (J.M.); (P.T.); (T.S.); (Z.K.)
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA;
| | - Daniel Toth
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland; (D.T.); (G.B.); (S.M.); (J.M.); (P.T.); (T.S.); (Z.K.)
| | - Gergely Bertalan
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland; (D.T.); (G.B.); (S.M.); (J.M.); (P.T.); (T.S.); (Z.K.)
| | - Susanne Müller
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland; (D.T.); (G.B.); (S.M.); (J.M.); (P.T.); (T.S.); (Z.K.)
| | - Regina R. Reimann
- Institute of Neuropathology, University Hospital Zürich, Schmelzbergstrasse 12, 8091 Zürich, Switzerland;
| | - Mark Epshtein
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA;
| | - Jawid Madjidyar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland; (D.T.); (G.B.); (S.M.); (J.M.); (P.T.); (T.S.); (Z.K.)
| | - Patrick Thurner
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland; (D.T.); (G.B.); (S.M.); (J.M.); (P.T.); (T.S.); (Z.K.)
| | - Tilman Schubert
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland; (D.T.); (G.B.); (S.M.); (J.M.); (P.T.); (T.S.); (Z.K.)
| | - Susanne Wegener
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland;
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland; (D.T.); (G.B.); (S.M.); (J.M.); (P.T.); (T.S.); (Z.K.)
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3
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Vandelanotte S, Staessens S, François O, De Wilde M, Desender L, De Sloovere AS, Dewaele T, Tersteeg C, Vanhoorelbeke K, Vanacker P, Andersson T, De Meyer SF. Association between thrombus composition and first-pass recanalization after thrombectomy in acute ischemic stroke. J Thromb Haemost 2024:S1538-7836(24)00357-X. [PMID: 38897388 DOI: 10.1016/j.jtha.2024.05.034] [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: 04/10/2024] [Revised: 05/27/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Achieving first-pass recanalization (FPR) has become the primary procedural objective during thrombectomy in acute ischemic stroke patients as it correlates with the best clinical outcome. Understanding factors contributing to FPR failures is essential to enhance FPR success rates. As the central target of thrombectomy, the thrombus itself may be a significant factor influencing FPR. OBJECTIVES This study aimed to investigate the association between thrombus composition and FPR success rates. METHODS In total, thrombi from 267 ischemic stroke patients were collected in the AZ Groeninge Hospital (Kortrijk, Belgium). Thrombus composition was determined via detailed histologic analysis of red blood cells (RBCs), fibrin, von Willebrand factor, platelets, leukocytes, citrullinated histone 3 (marker for neutrophil extracellular traps), and intracellular and extracellular DNA. FPR was defined as obtaining a modified thrombolysis in cerebral infarction (mTICI) score of 2c/3 after the first pass. RESULTS An mTICI score of 2c/3 was obtained in 180 patients, which was achieved via a successful FPR procedure in 126 cases or after multiple passes in 54 cases. Interestingly, thrombi from FPR cases had a different composition from thrombi that needed multiple passes to obtain an mTICI score of 2c/3. FPR thrombi contained significantly more RBCs (P = .0264), less fibrin (P = .0196), and less extracellular DNA (P = .0457). CONCLUSION Our results indicate that thrombi characterized by lower RBC content, higher fibrin levels, and increased extracellular DNA are less likely to result in an FPR. These results are important to guide future research aiming at improving procedures or technologies to obtain FPR rates in RBC-poor thrombi.
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Affiliation(s)
| | - Senna Staessens
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium
| | | | - Maaike De Wilde
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium
| | - Linda Desender
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium
| | | | - Tom Dewaele
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Claudia Tersteeg
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium
| | | | - 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 Neuroradiology, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium.
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Toth DF, Bertalan G, Heinz P, Madjidyar J, Thurner P, Schubert T, Kulcsar Z. Dynamic Perviousness: A Novel Imaging Marker for Predicting Mechanical Thrombectomy Outcomes in Acute Ischemic Stroke. Diagnostics (Basel) 2024; 14:1197. [PMID: 38893723 PMCID: PMC11171946 DOI: 10.3390/diagnostics14111197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND The predictive value of thrombus standard perviousness (SP) in acute ischemic stroke (AIS) for the technical success rates of mechanical thrombectomy (MT) or functional outcomes is not yet conclusive. We investigated the relationship between dynamic perviousness (DP) and revascularization results using time-dependent enhancement curve types determined with computed tomography (CT). METHODS A retrospective analysis of 137 AIS patients was performed. DP was calculated as the thrombus attenuation increase (TAI) using three time points and categorized into four groups: (1) no enhancement (CNE); (2) late enhancement (CLE); (3) early enhancement with washout (CW); (4) early enhancement without washout (CNW). Associations with the technical success rate and functional outcomes were assessed. RESULTS Late enhancement (CLE) had approximately two times higher odds for successful MT as compared to clots with other enhancement dynamics. The odds ratios (logistic regression model with CNW as the reference) for the TICI III scores were 4.04 (p = 0.067), 1.82 (p = 0.3), and 1.69 (p = 0.4) for CLE, CW, and CNE, respectively. The NIHSS scores at discharge and mRS scores at three months showed regression coefficients (linear regression model with CNW as reference) of -3.05 (p = 0.10), -1.17 (p = 0.51), and -1.24 (p = 0.47); and -1.30 (p = 0.097), -0.85 (p = 0.25), and -0.15 (p = 0.83) for CLE, CW, and CNE, respectively. CONCLUSIONS Thrombi with late enhancement patterns showed a higher revascularization rate and better outcomes as compared to clots with early uptake or no washout.
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Affiliation(s)
- Daniel F. Toth
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, 8091 Zürich, Switzerland (P.T.)
| | - Gergely Bertalan
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, 8091 Zürich, Switzerland (P.T.)
| | - Priska Heinz
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zürich, 8001 Zürich, Switzerland
| | - Jawid Madjidyar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, 8091 Zürich, Switzerland (P.T.)
| | - Patrick Thurner
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, 8091 Zürich, Switzerland (P.T.)
| | - Tilman Schubert
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, 8091 Zürich, Switzerland (P.T.)
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zürich, 8091 Zürich, Switzerland (P.T.)
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5
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Vandelanotte S, François O, Desender L, Staessens S, Vanhoorne A, Van Gool F, Tersteeg C, Vanhoorelbeke K, Vanacker P, Andersson T, De Meyer SF. R-tPA Resistance Is Specific for Platelet-Rich Stroke Thrombi and Can Be Overcome by Targeting Nonfibrin Components. Stroke 2024; 55:1181-1190. [PMID: 38525646 DOI: 10.1161/strokeaha.123.045880] [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: 11/29/2023] [Accepted: 02/15/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Resistance to r-tPA (recombinant tissue-type plasminogen activator) is a well-known but poorly understood phenomenon that hampers successful recanalization in patients with acute ischemic stroke. Using clinically relevant thrombi from patients with acute ischemic stroke, we investigated if and how thrombus composition impacts r-tPA-mediated lysis. In addition, we explored strategies to overcome r-tPA resistance. METHODS Thrombi were split into 2 parts, 1 of which was used for thrombolysis and the other for detailed histological analysis. Thrombolysis was performed in normal human plasma using r-tPA alone, using r-tPA in combination with DNase-1 or using r-tPA in combination with N,N'-diacetyl-l-cystine. Thrombus lysis was calculated as the percentage of residual thrombus weight compared with its initial weight and the degree of lysis was linked to thrombus composition determined via histology. RESULTS Interestingly, we found that the efficacy of r-tPA-mediated thrombolysis was strongly correlated with the composition of the thrombi. Thrombi containing high amounts of red blood cells and low amounts of DNA and von Willebrand Factor were efficiently degraded by r-tPA, whereas thrombi containing low amounts of red blood cells and higher amounts of DNA and von Willebrand Factor were resistant to r-tPA. Importantly, combination of r-tPA with DNase-1 or N,N'-diacetyl-l-cystine significantly and specifically improved the lysis of these r-tPA-resistant thrombi. CONCLUSIONS Using patient thrombus material, our results for the first time show that the composition of stroke thrombi largely determines their susceptibility to r-tPA-mediated thrombolysis. Red blood cell-poor thrombi have a specific resistance to r-tPA, which can be overcome by targeting nonfibrin components using DNase-1 or N,N'-diacetyl-l-cystine.
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Affiliation(s)
- Sarah Vandelanotte
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (S.V., L.D., S.S., C.T., K.V., S.F.D.M.)
| | - Olivier François
- Departments of Medical Imaging (O.F., F.V.G., T.A.), AZ Groeninge, Kortrijk, Belgium
| | - Linda Desender
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (S.V., L.D., S.S., C.T., K.V., S.F.D.M.)
| | - Senna Staessens
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (S.V., L.D., S.S., C.T., K.V., S.F.D.M.)
| | | | - Fréderick Van Gool
- Departments of Medical Imaging (O.F., F.V.G., T.A.), AZ Groeninge, Kortrijk, Belgium
| | - Claudia Tersteeg
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (S.V., L.D., S.S., C.T., K.V., S.F.D.M.)
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (S.V., L.D., S.S., C.T., K.V., S.F.D.M.)
| | - Peter Vanacker
- Neurology (A.V., P.V.), AZ Groeninge, Kortrijk, Belgium
- Department of Translational Neuroscience, University of Antwerp, Belgium (P.V.)
| | - Tommy Andersson
- Departments of Medical Imaging (O.F., F.V.G., T.A.), AZ Groeninge, Kortrijk, Belgium
- Department of Neuroradiology, Karolinska University Hospital, and Clinical Neuroscience Karolinska Institutet, Stockholm, Sweden (T.A.)
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium (S.V., L.D., S.S., C.T., K.V., S.F.D.M.)
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Nogueira RG, Pinheiro A, Brinjikji W, Abbasi M, Al-Bayati AR, Mohammaden MH, Souza Viana L, Ferreira F, Abdelhamid H, Bhatt NR, Kvamme P, Layton KF, Delgado Almandoz JE, Hanel RA, Mendes Pereira V, Almekhlafi MA, Yoo AJ, Jahromi BS, Gounis MJ, Patel B, Arturo Larco JL, Fitzgerald S, Mereuta OM, Doyle K, Savastano LE, Cloft HJ, Thacker IC, Kayan Y, Copelan A, Aghaebrahim A, Sauvageau E, Demchuk AM, Bhuva P, Soomro J, Nazari P, Cantrell DR, Puri AS, Entwistle J, Polley EC, Frankel MR, Kallmes DF, Haussen DC. Clot composition and recanalization outcomes in mechanical thrombectomy. J Neurointerv Surg 2024; 16:466-470. [PMID: 37419694 DOI: 10.1136/jnis-2023-020117] [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: 02/06/2023] [Accepted: 05/24/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) has become standard for large vessel occlusions, but rates of complete recanalization are suboptimal. Previous reports correlated radiographic signs with clot composition and a better response to specific techniques. Therefore, understanding clot composition may allow improved outcomes. METHODS Clinical, imaging, and clot data from patients enrolled in the STRIP Registry from September 2016 to September 2020 were analyzed. Samples were fixed in 10% phosphate-buffered formalin and stained with hematoxylin-eosin and Martius Scarlett Blue. Percent composition, richness, and gross appearance were evaluated. Outcome measures included the rate of first-pass effect (FPE, modified Thrombolysis in Cerebral Infarction 2c/3) and the number of passes. RESULTS A total of 1430 patients of mean±SD age 68.4±13.5 years (median (IQR) baseline National Institutes of Health Stroke Scale score 17.2 (10.5-23), IV-tPA use 36%, stent-retrievers (SR) 27%, contact aspiration (CA) 27%, combined SR+CA 43%) were included. The median (IQR) number of passes was 1 (1-2). FPE was achieved in 39.3% of the cases. There was no association between percent histological composition or clot richness and FPE in the overall population. However, the combined technique resulted in lower FPE rates for red blood cell (RBC)-rich (P<0.0001), platelet-rich (P=0.003), and mixed (P<0.0001) clots. Fibrin-rich and platelet-rich clots required a higher number of passes than RBC-rich and mixed clots (median 2 and 1.5 vs 1, respectively; P=0.02). CA showed a trend towards a higher number of passes with fibrin-rich clots (2 vs 1; P=0.12). By gross appearance, mixed/heterogeneous clots had lower FPE rates than red and white clots. CONCLUSIONS Despite the lack of correlation between clot histology and FPE, our study adds to the growing evidence supporting the notion that clot composition influences recanalization treatment strategy outcomes.
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Affiliation(s)
| | | | | | - Mehdi Abbasi
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | | | | | - Nirav R Bhatt
- UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
| | - Peter Kvamme
- Radiology, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Kennith F Layton
- NeuroInterventional Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Ricardo A Hanel
- Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Mohammed A Almekhlafi
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Babak S Jahromi
- Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Biraj Patel
- Radiology, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
- Radiology, Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | | | | | - Oana Madalina Mereuta
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
- CÚRAM-SFI Research Centre for Medical Devices and Physiology Department, National University of Ireland Galway, Galway, Ireland
| | - Karen Doyle
- Physiology, CURAM, National University of Ireland Galway, Galway, Ireland
| | | | | | - Ike C Thacker
- NeuroInterventional Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Yasha Kayan
- Interventional Neuroradiology, Abbot Northwestern Hospital, 55435, Minnesota, USA
| | - Alexander Copelan
- NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Health System, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Andrew M Demchuk
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- University of Calgary, Calgary, Alberta, Canada
| | - Parita Bhuva
- Neuroendovascular Surgery, Texas Stroke Institute, Plano, Texas, USA
| | - Jazba Soomro
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Pouya Nazari
- Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Neurosurgery and Radiology, Northwestern University, Chicago, Illinois, USA
| | | | - Ajit S Puri
- Radiology, University of Massachusetts, Worcester, Massachusetts, USA
| | - John Entwistle
- Radiology, Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | | | - Michael R Frankel
- Department of Neurology, Emory University Atlanta, Atlanta, Georgia, USA
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | | | - Diogo C Haussen
- Neurology and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
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Bertalan G, Duparc R, Krepuska M, Toth D, Madjidyar J, Thurner P, Schubert T, Kulcsar Z. Dynamic Perviousness Predicts Revascularization Success in Acute Ischemic Stroke. Diagnostics (Basel) 2024; 14:535. [PMID: 38473007 DOI: 10.3390/diagnostics14050535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND The predictive value of thrombus perviousness in acute ischemic stroke (AIS), as measured by computed tomography (CT), has been intensively studied with conflicting results. In this study, we investigate the predictive potential of the novel concept of dynamic perviousness using three-dimensional (3D) volumetric evaluation of occlusive thrombi. METHODS The full thrombus volume in 65 patients with a hyperdense artery sign on non-contrast CT (NCCT), who underwent mechanical thrombectomy (MT), was segmented. Perviousness maps were computed voxel-wise for the entire thrombus volume as thrombus attenuation increase (TAI) between NCCT and CT angiography (CTA) as well as between CTA and late venous phase CT (CTV). Perviousness was analyzed for its association with NIHSS at admission, Thrombolysis In Cerebral Infarction (TICI) score, and number of MT passes. RESULTS The mean late-uptake TAI of thrombi with NIHSS scores greater than 21 at admission was approximately 100% higher than for lower scored NIHSS (p between 0.05 and 0.005). Concerning revascularization results, thrombi requiring less than four MT passes had ca. 80% higher group mean late-uptake TAI than clots requiring four or more passes (p = 0.03), and thrombi with TICI score III had ca. 95% higher group mean late-uptake TAI than thrombi with TICI II (p = 0.03). Standard perviousness showed no significant correlation with MT results. CONCLUSION Standard thrombus perviousness of 3D clot volume is not associated with revascularization results in AIS. In contrast, dynamic perviousness assessed with a voxel-wise characterization of 3D thrombi volume may be a better predictor of MT outcomes than standard perviousness.
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Affiliation(s)
- Gergely Bertalan
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Roxane Duparc
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Miklos Krepuska
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Daniel Toth
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Jawid Madjidyar
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Patrick Thurner
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Tilman Schubert
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
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Schartz D, Akkipeddi SMK, Rahmani R, Ellens N, Houk C, Kohli GS, Worley L, Welle K, Bhalla T, Mattingly T, Morrell C, Bender MT. Ischemic Stroke Thrombus Perviousness Is Associated with Distinguishable Proteomic Features and Susceptibility to ADAMTS13-Augmented Thrombolysis. AJNR Am J Neuroradiol 2023; 45:22-29. [PMID: 38123915 PMCID: PMC10756583 DOI: 10.3174/ajnr.a8069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/20/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND PURPOSE Perviousness is the differential attenuation on CT of an intracranial arterial occlusive thrombus before and after IV contrast administration. While perviousness/permeability has been shown to be related to various clinical outcomes and reflects histopathologic composition, it remains unclear whether perviousness is also associated with differences in proteomic composition. MATERIALS AND METHODS Retrieved clots from 59 patients were evaluated with quantitative mass spectrometry. Proteomic differences between high-perviousness (≥11 HU) and low-perviousness (<11 HU) clots were investigated. Perviousness as a continuous variable was also correlated with protein abundance. Last, an ex vivo lysis assay was performed to investigate the differential susceptibility to tPA, deoxyribonuclease, and ADAMTS13 thrombolysis as a function of perviousness. RESULTS In total, 2790 distinct proteins were identified. Thrombus perviousness was associated with distinct proteomic features, including depletion of the macrophage marker CD14 (P = .039, z = 1.176) and hemoglobin subunit ζ (P = .046, z = 1.68) in pervious clots. Additionally, proteins involved in platelet cytoskeleton remodeling (tropomyosin α-3-chain) and granule secretion/aggregation (synaptotagmin-like protein 4/FC region receptor II-a) were associated with increasing perviousness (P < .006), among numerous other proteins. Monocyte/macrophage-associated proteins (apoptosis-associated specklike protein containing a CARD/SAMHD1) were also depleted in pervious emboli (P < .002). Ex vivo lysis indicated that pervious clots were more susceptible to ADAMTS13-augmented tPA thrombolysis compared with impervious clots (P < .05), though without differences in deoxyribonuclease digestion. CONCLUSIONS Thrombus perviousness is associated with complex proteomic features, including differential abundance of platelet-related proteins in highly permeable clots with monocyte/macrophage depletion. This association may help to explain why highly pervious thrombi were also found more susceptible to ADAMTS13-augmented thrombolysis.
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Affiliation(s)
- Derrek Schartz
- From the Department of Imaging Sciences (D.S., L.W.), University of Rochester Medical Center, Rochester, New York
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Sajal Medha K Akkipeddi
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Redi Rahmani
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Nathaniel Ellens
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Clifton Houk
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Gurkirat Singh Kohli
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Logan Worley
- From the Department of Imaging Sciences (D.S., L.W.), University of Rochester Medical Center, Rochester, New York
| | - Kevin Welle
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Tarun Bhalla
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Thomas Mattingly
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Craig Morrell
- Aab Cardiovascular Research Institute (C.M.), University of Rochester Medical Center, Rochester, New York
| | - Matthew T Bender
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
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Kim YD, Kwon I, Park Y, Lee H, Lee IH, Lim IH, Hong SH, Lee HS, Nam HS, Heo JH. Association of clot ultrastructure with clot perviousness in stroke patients. Sci Rep 2023; 13:14568. [PMID: 37666907 PMCID: PMC10477321 DOI: 10.1038/s41598-023-41383-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/25/2023] [Indexed: 09/06/2023] Open
Abstract
Clot perviousness on computerized tomography (CT) is predictive of response to reperfusion therapy. This study aimed to determine the association of clot perviousness with ultrastructural features of clot in stroke patients undergoing endovascular thrombectomy. We quantitatively analyzed the ultrastructural components identified using scanning electron microscopy. The clot components were determined in the inner portions of the clots. Clot perviousness was assessed as thrombus attenuation increase (TAI) using noncontrast CT and CT angiography. We compared the association between the identified ultrastructural components and clot perviousness. The proportion of pores consisted of 3.5% on scanning electron microscopy images. The proportion of porosity in the inner portion was 2.5%. Among the ultrastructural components, polyhedrocytes were most commonly observed. The mean TAI was 9.3 ± 10.0 (median 5.6, interquartile range 1.1-14.3) Hounsfield units. TAI correlated positively with inner porosity (r = 0.422, p = 0.020). Among the ultrastructural clot components, TAI was independently associated with polyhedrocytes (B = - 0.134, SE = 0.051, p = 0.008). Clot perviousness is associated with porosity and the proportion of polyhdrocytes of clots.
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Affiliation(s)
- Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - Il Kwon
- Integrative Research Institute for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, South Korea
| | - Youngseon Park
- Integrative Research Institute for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyungwoo Lee
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - Il Hyung Lee
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - In Hwan Lim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - Soon-Ho Hong
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Department of Research Affairs, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, South Korea.
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Jiang J, Gu H, Li M, Hua Y, Wang S, Dai L, Li Y. The Value of Dual-Energy Computed Tomography Angiography-Derived Parameters in the Evaluation of Clot Composition. Acad Radiol 2023; 30:1866-1873. [PMID: 36587997 DOI: 10.1016/j.acra.2022.12.023] [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: 10/11/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES We aimed to assess the value of dual-energy computed tomography angiography (DE-CTA) derived parameters as a quantitative biomarker of thrombus composition in acute ischemic stroke (AIS). METHODS AIS patients who underwent DE-CTA before thrombectomy between August 2016 and September 2022 were included in this study. We assessed the relative proportion of red blood cells (RBCs) and the fibrin/platelet ratio (F/P) of the retrieved clots and categorized the clots as RBC-dominant (RBCs > F/P) or F/P-dominant (F/P > RBCs). The thrombus based parameters were measured on polyenergetic images (PEI), virtual monoenergetic (VM), virtual non-contrast (VNC), iodine concentration (IC), and effective atomic number (Zeff) images respectively, and the slope of the spectral Hounsfield unit curve (λHU) was calculated. These parameters were compared in the DE-CTA images of RBC- and F/P-dominant thrombi. The diagnostic performance of the parameters was analyzed using the ROC curve. Correlations between thrombus composition and DE-CTA-derived parameters were assessed. RESULTS The retrieved clots in 54 of 88 patients (61.36%) were RBC-dominant. The RBC-dominant thrombi showed significantly higher VNC values and lower IC, λHU, and Zeff values than the F/P-dominant thrombi (p < 0.05). The CT density measured on IC images showed the largest AUC value (AUC, 0.94; sensitivity, 77.78%; specificity, 100.00%). The Spearman rank-order correlation coefficient values showed that CT density measured on IC images of the thrombus showed the strongest association with the proportion of RBCs (r = -0.64, p < 0.001) and F/P (r = 0.65, p < 0.001). CONCLUSIONS DE-CTA-derived parameters, especially the CT density measured on IC images, could be associated with thrombus composition and allow for personalized thrombectomy strategies.
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Affiliation(s)
- Jingxuan Jiang
- Department of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China; Department of Radiology, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Hongmei Gu
- Department of Radiology, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Minda Li
- Department of Radiology, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Ye Hua
- Department of Radiology, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Sijia Wang
- Department of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Lisong Dai
- Department of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Yuehua Li
- Department of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China.
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A nomogram for predicting thrombus composition in stroke patients with large vessel occlusion: combination of thrombus density and perviousness with clinical features. Neuroradiology 2023; 65:371-380. [PMID: 36064806 DOI: 10.1007/s00234-022-03046-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/24/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To establish a nomogram incorporating pretreatment imaging parameters and clinical characteristics for predicting the thrombus composition of acute ischemic stroke (AIS) with large vessel occlusion (LVO). METHODS We retrospectively enrolled patients with occlusion of the Middle Cerebral Artery (MCA) who underwent Mechanical Thrombectomy (MT). Retrieved thrombi were stained with Hematoxylin and Eosin (H&E) and Martius Scarlet Blue (MSB). Thrombi are assigned to the Fibrin-rich or RBC-rich group based on the relative fractions of Red Blood Cells (RBC), fibrin, and platelet. The independent risk factors for Fibrin-rich clots were determined via univariate and multivariate logistic regression analysis and were then integrated to establish a nomogram. RESULTS In total, 98 patients were included in this study. Patients with fibrin-rich clots had worse functional outcome [modified Rankin scale (mRS) 0-2, 34.7% vs 63.2%, p = 0.005], longer procedure time (76.8 min vs 50.8 min, p = 0.001), and increased maneuvers of MT (1.84 vs 1.46, p = 0.703) than those with RBC-rich clots. The independent risk factors for Fibrin-rich clots were lower perviousness measured by Non-Contrast Computer Tomography (NCCT) and CT Angiography (CTA), lower thrombus relative attenuation on NCCT, elevated Platelet-WBC ratio (PWR) of admission peripheral blood, and previous antithrombotic medication. The nomogram showed good discrimination with an area under the Receiver Operating Characteristic (ROC) curve (AUC) of 0.852 (95% CI: 0.778-0.926). The calibration curve and decision curve analysis also displayed satisfactory accuracy and clinical utility. CONCLUSION This study has developed and internally validated an easy-to-use nomogram which can help predict clot composition and optimize therapeutic strategies for thrombectomy.
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Clot Morphology in Acute Ischemic Stroke Decision Making. Int J Mol Sci 2022; 23:ijms232012373. [PMID: 36293230 PMCID: PMC9604475 DOI: 10.3390/ijms232012373] [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] [Received: 09/11/2022] [Revised: 10/09/2022] [Accepted: 10/13/2022] [Indexed: 11/17/2022] Open
Abstract
Stroke is a leading cause of death and disability in the world, and the provision of reperfusion therapy and endovascular therapy, in particular, have revolutionized the treatment of patients with stroke and opened opportunities to look at brain clots retrieved after the procedure. The use of histopathology and molecular profiling of clots is of growing research and clinical interest. However, its clinical implications and incorporation within stroke workflows remain suboptimal. Recent studies have indicated that the study of brain clots may inform the mechanism of stroke and hence guide treatment decision-making in select groups of patients, especially patients without a defined cause or known mechanism. This article provides a comprehensive overview of various clot histopathological examinations in acute stroke-care settings, their clinical utility, and existing gaps and opportunities for further research. We also provide targeted recommendations to improve clot analysis workflow, hence standardizing its incorporation into clinical practice.
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Huang J, Killingsworth MC, Bhaskar SMM. Is Composition of Brain Clot Retrieved by Mechanical Thrombectomy Associated with Stroke Aetiology and Clinical Outcomes in Acute Ischemic Stroke?—A Systematic Review and Meta-Analysis. Neurol Int 2022; 14:748-770. [PMID: 36278687 PMCID: PMC9589969 DOI: 10.3390/neurolint14040063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 12/29/2022] Open
Abstract
Background: Brain clots retrieved following endovascular thrombectomy in acute ischemic stroke patients may offer unique opportunities to characterise stroke aetiology and aid stroke decision-making in select groups of patients. However, the evidence around the putative association of clot morphology with stroke aetiology is limited and remains inconclusive. This study aims to perform a systematic review and meta-analysis to delineate the association of brain clot composition with stroke aetiology and post-reperfusion outcomes in patients receiving endovascular thrombectomy. Methods: The authors conducted a systematic literature review and meta-analysis by extracting data from several research databases (MEDLINE/PubMed, Cochrane, and Google Scholar) published since 2010. We used appropriate key search terms to identify clinical studies concerning stroke thrombus composition, aetiology, and clinical outcomes, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: The authors identified 30 articles reporting on the relationship between stroke thrombus composition or morphology and aetiology, imaging, or clinical outcomes, of which 21 were included in the meta-analysis. The study found that strokes of cardioembolic origin (SMD = 0.388; 95% CI, 0.032–0.745) and cryptogenic origin (SMD = 0.468; 95% CI, 0.172–0.765) had significantly higher fibrin content than strokes of non-cardioembolic origin. Large artery atherosclerosis strokes had significantly lower fibrin content than cardioembolic (SMD = 0.552; 95% CI, 0.099–1.004) or cryptogenic (SMD = 0.455; 95% CI, 0.137–0.774) strokes. Greater red blood cell content was also significantly associated with a thrombolysis in cerebral infarction score of 2b–3 (SMD = 0.450; 95% CI, 0.177–0.722), and a positive hyperdense middle cerebral artery sign (SMD = 0.827; 95% CI, 0.472–1.183). No significant associations were found between red blood cell, platelet, or white blood cell content and aetiology, or between clot composition and bridging thrombolysis. Conclusions: This meta-analysis found that fibrin composition is significantly higher in strokes of cardioembolic and cryptogenic origin, and that red blood cell content is positively associated with the hyperdense middle cerebral artery sign and better reperfusion outcomes. Important advances to stroke clinical workup can be derived from these findings, in which many aspects of stroke workflow remain to be optimised. As data are still limited in terms of the association of various thrombus components with stroke aetiology as well as a standardised method of analysis, further studies are required to validate these findings to guide their use in clinical decision-making.
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Affiliation(s)
- Joanna Huang
- Global Health Neurology Lab, Sydney, NSW 2000, Australia
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW 2170, Australia
- UNSW Medicine and Health, University of New South Wales (UNSW), South Western Sydney Clinical Campuses, Sydney, NSW 2170, Australia
| | - Murray C. Killingsworth
- UNSW Medicine and Health, University of New South Wales (UNSW), South Western Sydney Clinical Campuses, Sydney, NSW 2170, Australia
- Department of Anatomical Pathology, NSW Health Pathology, Correlative Microscopy Facility, Ingham Institute for Applied Medical Research and Western Sydney University (WSU), Liverpool, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney, NSW 2000, Australia
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Liverpool Hospital & South West Sydney Local Health District (SWSLHD), Department of Neurology & Neurophysiology, Sydney, NSW 2170, Australia
- Ingham Institute for Applied Medical Research, Stroke & Neurology Research Group, Sydney, NSW 2170, Australia
- Clinical Sciences Building, 1 Elizabeth St., Liverpool Hospital, Liverpool, NSW 2170, Australia
- Correspondence: ; Tel.:+61-(02)-8738-9179; Fax: +61-(02)-8738-3648
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Quantitative thrombus characteristics on thin-slice computed tomography improve prediction of thrombus histopathology: results of the MR CLEAN Registry. Eur Radiol 2022; 32:7811-7823. [PMID: 35501573 PMCID: PMC9668956 DOI: 10.1007/s00330-022-08762-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Thrombus computed tomography (CT) characteristics might be used to assess histopathologic thrombus composition in patients treated with endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). We aimed to assess the variability in thrombus composition that could be predicted with combined thrombus CT characteristics. METHODS Thrombi of patients enrolled in the MR CLEAN Registry between March 2014 and June 2016 were histologically analyzed with hematoxylin-eosin staining and quantified for percentages of red blood cells (RBCs) and fibrin/platelets. We estimated the association between general qualitative characteristics (hyperdense artery sign [HAS], occlusion location, clot burden score [CBS]) and thrombus composition with linear regression, and quantified RBC variability that could be explained with individual and combined characteristics with R2. For patients with available thin-slice (≤ 2.5 mm) imaging, we performed similar analyses for general and quantitative characteristics (HAS, occlusion location, CBS, [relative] thrombus density, thrombus length, perviousness, distance from ICA-terminus). RESULTS In 332 included patients, the presence of HAS (aβ 7.8 [95% CI 3.9-11.7]) and shift towards a more proximal occlusion location (aβ 3.9 [95% CI 0.6-7.1]) were independently associated with increased RBC and decreased fibrin/platelet content. With general characteristics, 12% of RBC variability could be explained; HAS was the strongest predictor. In 94 patients with available thin-slice imaging, 30% of RBC variability could be explained; thrombus density and thrombus length were the strongest predictors. CONCLUSIONS Quantitative thrombus CT characteristics on thin-slice admission CT improve prediction of thrombus composition and might be used to further guide clinical decision-making in patients treated with EVT for AIS in the future. KEY POINTS • With hyperdense artery sign and occlusion location, 12% of variability in thrombus RBC content can be explained. • With hyperdense artery sign, occlusion location, and quantitative thrombus characteristics on thin-slice (≤ 2.5 mm) non-contrast CT and CTA, 30% of variability in thrombus RBC content can be explained. • Absolute thrombus density and thrombus length were the strongest predictors for thrombus composition.
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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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