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Padmos RM, Arrarte Terreros N, Józsa TI, Závodszky G, Marquering HA, Majoie CBLM, Payne SJ, Hoekstra AG. Modelling collateral flow and thrombus permeability during acute ischaemic stroke. J R Soc Interface 2022; 19:20220649. [PMID: 36195117 PMCID: PMC9532024 DOI: 10.1098/rsif.2022.0649] [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: 11/05/2022] Open
Abstract
The presence of collaterals and high thrombus permeability are associated with good functional outcomes after an acute ischaemic stroke. We aim to understand the combined effect of the collaterals and thrombus permeability on cerebral blood flow during an acute ischaemic stroke. A cerebral blood flow model including the leptomeningeal collateral circulation is used to simulate cerebral blood flow during an acute ischaemic stroke. The collateral circulation is varied to capture the collateral scores: absent, poor, moderate and good. Measurements of the transit time, void fraction and thrombus length in acute ischaemic stroke patients are used to estimate thrombus permeability. Estimated thrombus permeability ranges between 10-7 and 10-4 mm2. Measured flow rates through the thrombus are small and the effect of a permeable thrombus on brain perfusion during stroke is small compared with the effect of collaterals. Our simulations suggest that the collaterals are a dominant factor in the resulting infarct volume after a stroke.
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Affiliation(s)
- Raymond M. Padmos
- Computational Science Laboratory, Informatics Institute, Faculty of Science, University of Amsterdam, Science Park 904, Amsterdam 1098, The Netherlands,Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Mekelweg 2, Delft 2628, The Netherlands
| | - Nerea Arrarte Terreros
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, The Netherlands,Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Tamás I. Józsa
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Parks Road, Oxford OX1 3PJ, UK,Department of Radiology and Nuclear Medicine, Amsterdam Neuroscience, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Gábor Závodszky
- Computational Science Laboratory, Informatics Institute, Faculty of Science, University of Amsterdam, Science Park 904, Amsterdam 1098, The Netherlands
| | - Henk A. Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, The Netherlands,Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Stephen J. Payne
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Parks Road, Oxford OX1 3PJ, UK,Institute of Applied Mechanics, National Taiwan University, Taiwan
| | - Alfons G. Hoekstra
- Computational Science Laboratory, Informatics Institute, Faculty of Science, University of Amsterdam, Science Park 904, Amsterdam 1098, The Netherlands
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Johnson S, Dwivedi A, Mirza M, McCarthy R, Gilvarry M. A Review of the Advancements in the in-vitro Modelling of Acute Ischemic Stroke and Its Treatment. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:879074. [PMID: 35756535 PMCID: PMC9214215 DOI: 10.3389/fmedt.2022.879074] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/29/2022] [Indexed: 11/13/2022] Open
Abstract
In-vitro neurovascular models of large vessel occlusions (LVOs) causing acute ischemic stroke (AIS) are used extensively for pre-clinical testing of new treatment devices. They enable physicians and engineers to examine device performance and the response of the occlusion to further advance design solutions for current unmet clinical needs. These models also enable physicians to train on basic skills, to try out new devices and new procedural approaches, and for the stroke team to practice workflows together in the comfort of a controlled environment in a non-clinical setting. Removal of the occlusive clot in its entirety is the primary goal of the endovascular treatment of LVOs via mechanical thrombectomy (MT) and the medical treatment via thrombolysis. In MT, recanalization after just one pass is associated with better clinical outcomes than procedures that take multiple passes to achieve the same level of recanalization, commonly known as first pass effect (FPE). To achieve this, physicians and engineers are continually investigating new devices and treatment approaches. To distinguish between treatment devices in the pre-clinical setting, test models must also be optimized and expanded become more nuanced and to represent challenging patient cohorts that could be improved through new technology or better techniques. The aim of this paper is to provide a perspective review of the recent advancements in the in-vitro modeling of stroke and to outline how these models need to advance further in future. This review provides an overview of the various in-vitro models used for the modeling of AIS and compares the advantages and limitations of each. In-vitro models remain an extremely useful tool in the evaluation and design of treatment devices, and great strides have been made to improve replication of physiological conditions. However, further advancement is still required to represent the expanding indications for thrombectomy and thrombolysis, and the generation of new thrombectomy devices, to ensure that smaller treatment effects are captured.
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Affiliation(s)
- Sarah Johnson
- Cerenovus (Johnson & Johnson), Galway Neuro Technology Centre, Galway, Ireland
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Measuring the effect of thrombosis, thrombus maturation and thrombolysis on clot mechanical properties in an in-vitro model. J Biomech 2021; 129:110731. [PMID: 34601216 DOI: 10.1016/j.jbiomech.2021.110731] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/23/2021] [Accepted: 07/25/2021] [Indexed: 01/05/2023]
Abstract
Changes in acute ischemic stroke thrombi structure and composition may result in significant differences in treatment responsiveness. Ischemic stroke patients are often treated with a thrombolytic agent to dissolve thrombi, however these patients may subsequently undergo mechanical thrombectomy to remove the occlusive clot. We set out to determine if rt-PA thrombolysis treatment of blood clots changes their mechanical properties, which in turn may impact mechanical thrombectomy. Using a design-of-experiment approach, ovine clot analogues were prepared with varying composition and further exposed to different levels of compaction force to simulate the effect of arterial blood pressure. Finally, clots were treated with three r-tPA doses for different durations. Clot mass and mechanical behaviour was analysed to assess changes due to (i) Platelet driven contraction (ii) Compaction force and (iii) Thrombolysis. Clots that were exposed to r-tPA for longer duration showed significant reduction in clot mass (p < 0.001). Exposure time to r-tPA (p < 0.001) was shown to be an independent predictor of lower clot stiffness. A decrease in energy dissipation ratio during mechanical compression was associated with longer exposure time in r-tPA (p = 0.001) and a higher platelet concentration ratio (p = 0.018). The dose of r-tPA was not a significant factor in reducing clot mass or changing mechanical properties of the clots. Fibrinolysis reduces clot stiffness which may explain increased distal clot migration observed in patients treated with r-tPA and should be considered as a potential clot modification factor before mechanical thrombectomy.
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Padmos RM, Terreros NA, Józsa TI, Závodszky G, Marquering HA, Majoie CBLM, Hoekstra AG. Modelling the leptomeningeal collateral circulation during acute ischaemic stroke. Med Eng Phys 2021; 91:1-11. [PMID: 34074460 DOI: 10.1016/j.medengphy.2021.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/26/2021] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Abstract
A novel model of the leptomeningeal collateral circulation is created by combining data from multiple sources with statistical scaling laws. The extent of the collateral circulation is varied by defining a collateral vessel probability. Blood flow and pressure are simulated using a one-dimensional steady state blood flow model. The leptomeningeal collateral vessels provide significant flow during a stroke. The pressure drop over an occlusion predicted by the model ranges between 60 and 85 mmHg depending on the extent of the collateral circulation. The linear transport of contrast material was simulated in the circulatory network. The time delay of peak contrast over an occlusion is 3.3 s in the model, and 2.1 s (IQR 0.8-4.0 s) when measured in dynamic CTA data of acute ischaemic stroke patients. Modelling the leptomeningeal collateral circulation could lead to better estimates of infarct volume and patient outcome.
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Affiliation(s)
- Raymond M Padmos
- Computational Science Laboratory, Informatics Institute, Faculty of Science, University of Amsterdam, Science Park 904, Amsterdam 1098 XH, the Netherlands.
| | - Nerea Arrarte Terreros
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands; Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Tamás I Józsa
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Parks Road, Oxford OX1 3PJ, UK
| | - Gábor Závodszky
- Computational Science Laboratory, Informatics Institute, Faculty of Science, University of Amsterdam, Science Park 904, Amsterdam 1098 XH, the Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands; Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Alfons G Hoekstra
- Computational Science Laboratory, Informatics Institute, Faculty of Science, University of Amsterdam, Science Park 904, Amsterdam 1098 XH, the Netherlands
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Tahir RA, Affan M, Marin H, Haider SA, Alsrouji OK, Ahmad A, Chebl AB, Katramados A, Van Harn M, Kole M. Quantification of pial collateral pressure in acute large vessel occlusion stroke: basic concept with patient outcomes. Neuroradiology 2021; 63:1313-1323. [PMID: 33507337 DOI: 10.1007/s00234-021-02641-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/06/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Pial collateral perfusion to the ischemic penumbra plays a critical role in determining patient outcomes in acute stroke. We aimed to assess the validity and reliability of an intra-procedural technique for measuring and quantifying the pial collateral pressure (QPCP) to ischemic brain tissue during acute stroke secondary to LVO. QPCP measurements were correlated with standard computed tomography angiography (CTA) and digital subtraction angiography imaging assessments of pial collateral perfusion and outcomes after mechanical endovascular revascularization (MER). METHODS This prospective cohort study included 60 consecutive patients with middle cerebral artery (MCA)-M1 and proximal M2 occlusions. QPCP measurements were obtained during MER. The validity of QPCP measurements was evaluated using four widely accepted collateral grading scales. QPCP measurements were also analyzed as a predictor of patient outcomes utilizing National Institute of Health Stroke Scale reduction at 24 h and modified Rankin Scale (mRS) scores at 30 days. RESULTS QPCP measurements and QPCP ratio (QPCP/systemic mean arterial blood pressure) showed a statistically significant association with single-phase pretreatment CTA Maas and American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology binary grading scales. Patient outcomes demonstrated for every 10-unit increase in QPCP, the odds of mRS 0-2 at 30 days increased by 76% (p = 0.019). CONCLUSION QPCP measurements related best with the pretreatment CTA Maas collateral grading scale but were more strongly associated with patient outcomes than any of the four widely accepted collateral grading scales. Greater QPCP was significantly associated with better overall patient outcomes as defined by mRS at 30 days.
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Affiliation(s)
- Rizwan A Tahir
- Department of Neurosurgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA
| | - Muhammad Affan
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA
| | - Horia Marin
- Department of Neurosurgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA
- Department of Radiology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA
| | - Sameah A Haider
- Department of Neurosurgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA
| | - Owais Khadem Alsrouji
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA
| | - Ayesha Ahmad
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA
| | - Alex Bou Chebl
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA
| | - Angelos Katramados
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA
| | - Meredith Van Harn
- Department of Public Health Sciences, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA
| | - Max Kole
- Department of Neurosurgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
- Department of Radiology, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
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Arrarte Terreros N, Tolhuisen ML, Bennink E, de Jong HW, Beenen LF, Majoie CB, van Bavel E, Marquering HA. From perviousness to permeability, modelling and measuring intra-thrombus flow in acute ischemic stroke. J Biomech 2020; 111:110001. [DOI: 10.1016/j.jbiomech.2020.110001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 08/13/2020] [Accepted: 08/14/2020] [Indexed: 10/23/2022]
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Intra-arterial pulse wave analysis during thrombectomy for the assessment of collateral status - A feasibility study. PLoS One 2019; 14:e0210572. [PMID: 30629721 PMCID: PMC6328207 DOI: 10.1371/journal.pone.0210572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 12/26/2018] [Indexed: 11/30/2022] Open
Abstract
Purpose Knowledge of the collateralization of an occluded vessel is important for the risk-benefit analysis of difficult revascularization maneuvers during mechanical thrombectomy. If the territory behind a clot is well perfused, one could desist from performing a risky thrombectomy maneuver. The arterial pulse pressure curve may serve as an indicator for the collateralization of an occluded target vessel. We investigated the feasibility of arterial pulse measurements with a standard microcatheter. Methods We measured the intra-arterial blood pressure proximal and distal to the clot in 40 thrombectomy maneuvers in a porcine stroke model. We used a microcatheter (Trevo Pro 18, Stryker, Kalamazoo, CA, USA), a pressure transducer (MEMSCAP SP844), an AdInstruments Powerlab 16/35 workstation, and LabChart 8 Software (AdInstruments, Dunedin, New Zealand). Results Median arterial blood pressure proximal and distal to the clot was 96.0 mmHg (IQR, 23.8 mmHg) and 47.5 mmHg (IQR, 43.5 mmHg), respectively (p < .001). The median difference between systolic maximum and diastolic minimum proximal and distal to the clot decreased significantly from 1.8 mmHg (IQR, 3.6 mmHg) to 0.0 mmHg (IQR, 0.5 mmHg) (p < .001). There was loss of the curve in 26 of 40 cases and loss of pressure in 23 of 40 cases (p = .008). There was no significant correlation between vessel diameter and either loss of the pulse pressure curve (p = .20) or overall pressure loss (p = .31). Conclusion It is possible to measure the pulse pressure proximal and distal to the clot with a standard microcatheter used during mechanical thrombectomy.
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Nikoubashman O, Nikoubashman A, Büsen M, Wiesmann M. Necessary Catheter Diameters for Mechanical Thrombectomy with ADAPT. AJNR Am J Neuroradiol 2017; 38:2277-2281. [PMID: 29025728 DOI: 10.3174/ajnr.a5401] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/07/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Large-bore catheters allow mechanical thrombectomy in ischemic stroke by engaging and retrieving clots without additional devices (direct aspiration first-pass technique [ADAPT]). The purpose of this study was to establish a model for minimal catheter diameters needed for ADAPT. MATERIALS AND METHODS We established a theoretic model for the calculation of minimal catheter diameters needed for ADAPT. We then verified its validity in 28 ADAPT maneuvers in a porcine in vivo model. To account for different mechanical thrombectomy techniques, we factored in ADAPT with/without a hypothetic 0.021-inch microcatheter or 0.014-inch microwire inside the lumen of the aspiration catheter and aspiration with a 60-mL syringe versus an aspiration pump. RESULTS According to our calculations, catheters with an inner diameter of >0.040 inch and >0.064 inch, respectively, are needed to be effective in the middle cerebral artery (2.5-mm diameter) or in the internal carotid artery (4 mm) in an average patient. There was a significant correlation between predicted and actual thrombectomy results (P = .010). Our theoretic model had a positive and negative predictive value of 78% and 79%, respectively. Sensitivity and specificity were 88% and 64%, respectively. CONCLUSIONS Our theoretic model allows estimating the minimal catheter diameters needed for successful mechanical thrombectomy with ADAPT, as demonstrated by the good agreement with our animal experiments. Our model will be helpful to interventionalists in avoiding selecting catheters that are likely too small to be effective.
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Affiliation(s)
- O Nikoubashman
- From the Department of Diagnostic and Interventional Neuroradiology (O.N., M.W.), University Hospital, RWTH Aachen University, Aachen, Germany
| | - A Nikoubashman
- Institute of Physics (A.N.), Johannes Gutenberg University Mainz, Mainz, Germany
| | - M Büsen
- Institute of Applied Medical Engineering (M.B.), RWTH Aachen University, Aachen, Germany
| | - M Wiesmann
- From the Department of Diagnostic and Interventional Neuroradiology (O.N., M.W.), University Hospital, RWTH Aachen University, Aachen, Germany
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Leng X, Scalzo F, Ip HL, Johnson M, Fong AK, Fan FSY, Chen X, Soo YOY, Miao Z, Liu L, Feldmann E, Leung TWH, Liebeskind DS, Wong KS. Computational fluid dynamics modeling of symptomatic intracranial atherosclerosis may predict risk of stroke recurrence. PLoS One 2014; 9:e97531. [PMID: 24818753 PMCID: PMC4018340 DOI: 10.1371/journal.pone.0097531] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 04/21/2014] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Patients with symptomatic intracranial atherosclerosis (ICAS) of ≥ 70% luminal stenosis are at high risk of stroke recurrence. We aimed to evaluate the relationships between hemodynamics of ICAS revealed by computational fluid dynamics (CFD) models and risk of stroke recurrence in this patient subset. METHODS Patients with a symptomatic ICAS lesion of 70-99% luminal stenosis were screened and enrolled in this study. CFD models were reconstructed based on baseline computed tomographic angiography (CTA) source images, to reveal hemodynamics of the qualifying symptomatic ICAS lesions. Change of pressures across a lesion was represented by the ratio of post- and pre-stenotic pressures. Change of shear strain rates (SSR) across a lesion was represented by the ratio of SSRs at the stenotic throat and proximal normal vessel segment, similar for the change of flow velocities. Patients were followed up for 1 year. RESULTS Overall, 32 patients (median age 65; 59.4% males) were recruited. The median pressure, SSR and velocity ratios for the ICAS lesions were 0.40 (-2.46-0.79), 4.5 (2.2-20.6), and 7.4 (5.2-12.5), respectively. SSR ratio (hazard ratio [HR] 1.027; 95% confidence interval [CI], 1.004-1.051; P = 0.023) and velocity ratio (HR 1.029; 95% CI, 1.002-1.056; P = 0.035) were significantly related to recurrent territorial ischemic stroke within 1 year by univariate Cox regression, respectively with the c-statistics of 0.776 (95% CI, 0.594-0.903; P = 0.014) and 0.776 (95% CI, 0.594-0.903; P = 0.002) in receiver operating characteristic analysis. CONCLUSIONS Hemodynamics of ICAS on CFD models reconstructed from routinely obtained CTA images may predict subsequent stroke recurrence in patients with a symptomatic ICAS lesion of 70-99% luminal stenosis.
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Affiliation(s)
- Xinyi Leng
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Fabien Scalzo
- UCLA Stroke Center, Los Angeles, California, United States of America
| | - Hing Lung Ip
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Mark Johnson
- UCLA Stroke Center, Los Angeles, California, United States of America
| | - Albert K. Fong
- UCLA Stroke Center, Los Angeles, California, United States of America
| | - Florence S. Y. Fan
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Xiangyan Chen
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Yannie O. Y. Soo
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Zhongrong Miao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Edward Feldmann
- Department of Neurology, Tufts University, Boston, Massachusetts, United States of America
| | - Thomas W. H. Leung
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | | | - Ka Sing Wong
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- * E-mail:
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