1
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Vandelanotte S, De Meyer SF. Acute Ischemic Stroke Thrombus Composition. Neuroscience 2024; 550:11-20. [PMID: 38185279 DOI: 10.1016/j.neuroscience.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/09/2024]
Abstract
Ischemic stroke is caused by a thrombus blocking one or multiple arteries in the brain, resulting in irreversible damage in the associated brain tissue. The aim of therapy is to restore the blood flow as fast as possible. Two recanalization strategies are currently available: pharmacological thrombolysis using recombinant tissue plasminogen activator (rt-PA) and mechanical removal of the thrombus. Despite recent advancements, achieving efficient recanalization remains a challenge. The precise causes of therapy failure are not fully understood but thrombus composition is likely a key factor in successful recanalization. This review explores acute ischemic stroke thrombus composition, its recently identified components, and how it affects stroke treatment. It also discusses how new insights could enhance current recanalization strategies for ischemic stroke patients.
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Affiliation(s)
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium.
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2
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Cruts JMH, Giezen JA, van Gaalen K, Beurskens R, Ridwan Y, Dijkshoorn ML, van Beusekom HMM, Boodt N, van der Lugt A, de Vries JJ, de Maat MPM, Gijsen FJH, Cahalane RME. The association between human blood clot analogue computed tomography imaging, composition, contraction, and mechanical characteristics. PLoS One 2023; 18:e0293456. [PMID: 37956141 PMCID: PMC10642823 DOI: 10.1371/journal.pone.0293456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 10/05/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Clot composition, contraction, and mechanical properties are likely determinants of endovascular thrombectomy success. A pre-interventional estimation of these properties is hypothesized to aid in selecting the most suitable treatment for different types of thrombi. Here we determined the association between the aforementioned properties and computed tomography (CT) characteristics using human blood clot analogues. METHODS Clot analogues were prepared from the blood of 4 healthy human donors with 5 red blood cell (RBC) volume suspensions: 0%, 20%, 40%, 60% and 80% RBCs. Contraction was measured as the weight of the contracted clots as a percentage of the original suspension. The clots were imaged using CT with and without contrast to quantify clot density and density increase. Unconfined compression was performed to determine the high strain compressive stiffness. The RBC content was analysed using H&E staining. RESULTS The 5 RBC suspensions formed only two groups of clots, fibrin-rich (0% RBCs) and RBC-rich (>90% RBCs), as determined by histology. The density of the fibrin-rich clots was significantly lower (31-38HU) compared to the RBC-rich clots (72-89HU), and the density increase of the fibrin-rich clots was significantly higher (82-127HU) compared to the RBC-rich clots (3-17HU). The compressive stiffness of the fibrin-rich clots was higher (178-1624 kPa) than the stiffness of the RBC-rich clots (6-526 kPa). Additionally, the degree of clot contraction was higher for the fibrin-rich clots (89-96%) compared to the RBC-rich clots (11-77%). CONCLUSIONS CT imaging clearly reflects clot RBC content and seems to be related to the clot contraction and stiffness. CT imaging might be a useful tool in predicting the thrombus characteristics. However, future studies should confirm these findings by analysing clots with intermediate RBC and platelet content.
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Affiliation(s)
- Janneke M. H. Cruts
- Department of Biomedical Engineering, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jo-Anne Giezen
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - Kim van Gaalen
- Department of Biomedical Engineering, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Robert Beurskens
- Department of Biomedical Engineering, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yanto Ridwan
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Molecular Genetics, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Marcel L. Dijkshoorn
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Nikki Boodt
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Judith J. de Vries
- Department of Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Frank J. H. Gijsen
- Department of Biomedical Engineering, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Biomechanical Engineering, Delft University of Technology, Delft, the Netherlands
| | - Rachel M. E. Cahalane
- Department of Biomedical Engineering, Erasmus Medical Center, Rotterdam, the Netherlands
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3
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Lin L, Zhang H, Liu F, Chen C, Chen C, Bivard A, Parsons MW, Li G. Bridging Thrombolysis Before Endovascular Therapy in Stroke Patients With Faster Core Growth. Neurology 2023; 100:e2083-e2092. [PMID: 36963842 PMCID: PMC10186238 DOI: 10.1212/wnl.0000000000207154] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/20/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES It is still uncertain that going direct to endovascular thrombectomy (EVT) leads to equivalent outcomes as bridging IV thrombolysis (IVT) in acute ischemic patients. This study aimed to explore whether the rate of ischemic core growth influenced the patient outcomes after bridging IVT vs direct EVT. METHODS This was a retrospective cohort study based on the International Stroke Perfusion Imaging Registry (INSPIRE). It selected acute ischemic stroke patients receiving perfusion CT within 4.5 hours of stroke onset. Patients who went direct to EVT were compared with those who received bridging treatment of IVT before EVT. Ischemic core growth rate was estimated by the acute ischemic core volume on perfusion CT divided by the time from stroke onset to perfusion CT, based on the assumption of a linear growth pattern of ischemic core. Core growth rate was stratified into fast (>15 mL/h) and slow (≤15 mL/h), based on its interaction with bridging IVT in predicting the primary outcome. The primary outcome was modified Rankin scale of 0-2 at 3 months. The secondary outcomes included successful thrombectomy reperfusion defined by modified Thrombolysis in Cerebral Infarction score of 2b-3 and time from groin puncture to reperfusion. RESULTS Of the 1,221 EVT patients in the INSPIRE, 323 patients were selected, of which 82 patients received direct EVT and 241 patients received bridging IVT. Bridging IVT was associated with a higher rate of good clinical outcome among patients with fast core growth (39% vs 7% for direct EVT, odds ratio [OR] 8.75 [1.96-39.1], p = 0.005), but the difference was not notable for patients with slow core growth (55% vs 55% for direct EVT, OR 1.00 [0.53-1.87], p = 0.989). In patients with fast core growth, the bridging and direct EVT patients showed no difference in the reperfusion rate (80% vs 76%, p = 0.616). However, patients who received bridging IVT were more likely to achieve reperfusion earlier (the median groin to reperfusion time of 63.0 vs 94.0 minutes, p = 0.005). DISCUSSION Patients with fast core growth were more likely to benefit from bridging IVT. This is likely because prior IVT facilitates clot removal and thus reduces time to reperfusion.
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Affiliation(s)
- Longting Lin
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Hao Zhang
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Feifeng Liu
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Chen Chen
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Chushuang Chen
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Andrew Bivard
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Mark W Parsons
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia.
| | - Gang Li
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia.
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4
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Ho-Tin-Noé B, Desilles JP, Mazighi M. Thrombus composition and thrombolysis resistance in stroke. Res Pract Thromb Haemost 2023; 7:100178. [PMID: 37538503 PMCID: PMC10394565 DOI: 10.1016/j.rpth.2023.100178] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/14/2023] [Accepted: 05/05/2023] [Indexed: 08/05/2023] Open
Abstract
A State of the Art lecture titled "Thrombus Composition and Thrombolysis Resistance in Stroke" was presented at the ISTH Congress in 2022. Intravenous thrombolysis (IVT) remains the only pharmacologic option to re-establish cerebral perfusion at the acute phase of ischemic stroke. IVT is based on the administration of recombinant tissue plasminogen activator with the objective of dissolving fibrin, the major fibrillar protein component of thrombi. Almost 30 years on from its introduction, although the clinical benefits of IVT have been clearly demonstrated, IVT still suffers from a relatively low efficacy, with a rate of successful early recanalization below 50% overall. Analyses of thrombectomy-recovered acute ischemic stroke (AIS) thrombi have shown that apart from occlusion site, thrombus length, and collateral status, AIS thrombus structure and composition are also important modulators of IVT efficacy. In this article, after a brief presentation of IVT principle and current knowledge on IVT resistance, we review recent findings on how compaction and structural alterations of fibrin together with nonfibrin thrombus components such as neutrophil extracellular traps and von Willebrand factor interfere with IVT in AIS. We further discuss how these new insights could soon result in the development of original adjuvant therapies for improved IVT in AIS. Finally, we summarize relevant new data presented during the 2022 ISTH Congress.
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Affiliation(s)
- Benoit Ho-Tin-Noé
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
| | - Jean-Philippe Desilles
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France
| | - Mikael Mazighi
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France
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5
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He Y, Xu J, Zhong W, Chen Z, Zhou Y, Li J, Luo Z, Lou M. Non-porous thrombi are less pervious and easier to be retrieved: implication from scanning electron microscopy study. J Neurointerv Surg 2023; 15:188-194. [PMID: 35347059 DOI: 10.1136/neurintsurg-2022-018689] [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: 01/14/2022] [Accepted: 03/10/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Scanning electron microscopy (SEM) studies found that the porosity of thrombi might vary among individuals. However, its relationship with the clinical presentation and efficacy of mechanical thrombectomy (MT) remains unknown. We aimed to characterize the ultrastructure of thrombi and explore its association with the complexity of MT and clot perviousness. METHODS SEM was used to observe the morphological features of different components of thrombi obtained from patients with anterior circulation large vessel occlusion undergoing MT and to determine the porosity of thrombi by semi-quantitative analysis. Non-porous thrombi were defined as thrombi with porosity <2%. Clot perviousness was also evaluated using thrombus attenuation increase on CT perfusion (TAIctp). We assessed the complexity of MT by attempts of retrieval >3 and procedural duration >60 min, defined as the time interval between groin puncture and recanalization. RESULTS A total of 49 thrombi were analyzed and 31 (63.3%) were classified as non-porous thrombi. The presence of non-porous thrombi was negatively associated with procedure >60 min (OR 0.152, 95% CI 0.031 to 0.734, p=0.019) and attempts >3 (OR 0.194, 95% CI 0.046 to 0.822, p=0.026) after adjustment. Additionally, receiver operating characteristic curve analysis indicated that TAIctp <17.9 Hounsfield units could predict the presence of non-porous thrombi with an area under the curve of 0.915. CONCLUSIONS Non-porous thrombi on SEM are easier to be retrieved during MT and could be identified as less pervious clots on CT images.
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Affiliation(s)
- Yaode He
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jinjin Xu
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Wansi Zhong
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Zhicai Chen
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Ying Zhou
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jiaping Li
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Zhongyu Luo
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Min Lou
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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6
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Dumitriu LaGrange D, Reymond P, Brina O, Zboray R, Neels A, Wanke I, Lövblad KO. Spatial heterogeneity of occlusive thrombus in acute ischemic stroke: A systematic review. J Neuroradiol 2023; 50:352-360. [PMID: 36649796 DOI: 10.1016/j.neurad.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 01/15/2023]
Abstract
Following the advent of mechanical thrombectomy, occlusive clots in ischemic stroke have been amply characterized using conventional histopathology. Many studies have investigated the compositional variability of thrombi and the consequences of thrombus composition on treatment response. More recent evidence has emerged about the spatial heterogeneity of the clot or the preferential distribution of its components and compact nature. Here we review this emerging body of evidence, discuss its potential clinical implications, and propose the development of adequate characterization techniques.
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Affiliation(s)
- Daniela Dumitriu LaGrange
- Neurodiagnostic and Neurointerventional Division, Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Philippe Reymond
- Neurodiagnostic and Neurointerventional Division, Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Olivier Brina
- Division of Diagnostic and Interventional Neuroradiology, HUG Geneva University Hospitals, Geneva, Switzerland
| | - Robert Zboray
- Center for X-Ray Analytics, Swiss Federal Laboratories for Materials Science and Technology (Empa), Dübendorf 8600, Switzerland
| | - Antonia Neels
- Center for X-Ray Analytics, Swiss Federal Laboratories for Materials Science and Technology (Empa), Dübendorf 8600, Switzerland
| | - Isabel Wanke
- Division of Neuroradiology, Klinik Hirslanden, Zurich, Switzerland; Swiss Neuroradiology Institute, Zurich, Switzerland; Division of Neuroradiology, University of Essen, Essen, Germany
| | - Karl-Olof Lövblad
- Division of Diagnostic and Interventional Neuroradiology, HUG Geneva University Hospitals, Geneva, Switzerland; Neurodiagnostic and Neurointerventional Division, Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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7
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Desilles JP, Di Meglio L, Delvoye F, Maïer B, Piotin M, Ho-Tin-Noé B, Mazighi M. Composition and Organization of Acute Ischemic Stroke Thrombus: A Wealth of Information for Future Thrombolytic Strategies. Front Neurol 2022; 13:870331. [PMID: 35873787 PMCID: PMC9298929 DOI: 10.3389/fneur.2022.870331] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/18/2022] [Indexed: 01/01/2023] Open
Abstract
During the last decade, significant progress has been made in understanding thrombus composition and organization in the setting of acute ischemic stroke (AIS). In particular, thrombus organization is now described as highly heterogeneous but with 2 preserved characteristics: the presence of (1) two distinct main types of areas in the core—red blood cell (RBC)-rich and platelet-rich areas in variable proportions in each thrombus—and (2) an external shell surrounding the core composed exclusively of platelet-rich areas. In contrast to RBC-rich areas, platelet-rich areas are highly complex and are mainly responsible for the thrombolysis resistance of these thrombi for the following reasons: the presence of platelet-derived fibrinolysis inhibitors in large amounts, modifications of the fibrin network structure resistant to the tissue plasminogen activator (tPA)-induced fibrinolysis, and the presence of non-fibrin extracellular components, such as von Willebrand factor (vWF) multimers and neutrophil extracellular traps. From these studies, new therapeutic avenues are in development to increase the fibrinolytic efficacy of intravenous (IV) tPA-based therapy or to target non-fibrin thrombus components, such as platelet aggregates, vWF multimers, or the extracellular DNA network.
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Affiliation(s)
- Jean-Philippe Desilles
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France.,Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France.,Université Paris Cité, Paris, France.,FHU Neurovasc, Paris, France
| | - Lucas Di Meglio
- Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France
| | - Francois Delvoye
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France.,University of Liège, Liege, Belgium
| | - Benjamin Maïer
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France.,Université Paris Cité, Paris, France.,FHU Neurovasc, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France.,Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France
| | - Benoît Ho-Tin-Noé
- Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France.,Université Paris Cité, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France.,Laboratory of Vascular Translational Science, U1148 INSERM, Paris, France.,Université Paris Cité, Paris, France.,FHU Neurovasc, Paris, France.,Department of Neurology, Hopital Lariboisère, APHP Nord, Paris, France
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8
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Agnieszka K, Bartosz H, Jacek K, Piotr P. Hemostasis Disturbances in Continuous-Flow Left Ventricular Assist Device (CF-LVAD) Patients—Rationale and Study Design. J Clin Med 2022; 11:jcm11133712. [PMID: 35806997 PMCID: PMC9267556 DOI: 10.3390/jcm11133712] [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: 05/17/2022] [Revised: 06/17/2022] [Accepted: 06/25/2022] [Indexed: 02/05/2023] Open
Abstract
Left ventricular assist devices are a treatment option for end-stage heart failure patients. Despite advancing technologies, bleeding and thromboembolic events strongly decrease the survival and the quality of life of these patients. Little is known about prognostic factors determining these adverse events in this group of patients. Therefore, we plan to investigate 90 consecutive left ventricular assist device (LVAD) patients and study in vitro fibrin clot properties (clot lysis time, clot permeability, fibrin ultrastructure using a scanning electron microscope) and the calibrated automated thrombogram in addition to the von Willebrand factor antigen, fibrinogen, D-dimer, prothrombin time/international normalized ratio (PT/INR), and activated partial thromboplastin time (APTT) to identify prognostic factors of adverse outcomes during the course of therapy. We plan to assess the hemostasis system at four different time points, i.e., before LVAD implantation, 3–4 months after LVAD implantation, 6–12 months after LVAD implantation, and at the end of the study (at 5 years or at the time of the adverse event). Adverse outcomes were defined as bleeding events (bleeding in general or in the following subtypes: severe bleeding, fatal bleeding, gastrointestinal bleeding, intracranial bleeding), thromboembolic events (stroke or transient ischemic attack, pump thrombosis, including thrombosis within the pump or its inflow or outflow conduits, arterial peripheral thromboembolism), and death.
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Affiliation(s)
- Kuczaj Agnieszka
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland;
- Correspondence:
| | - Hudzik Bartosz
- Third Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland;
- Department of Cardiovascular Disease Prevention in Bytom, Faculty of Public Health in Bytom, Medical University of Silesia, 40-055 Katowice, Poland
| | - Kaczmarski Jacek
- Haemostasis Laboratory, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland;
| | - Przybyłowski Piotr
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland;
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9
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Mereuta OM, Abbasi M, Arturo Larco JL, Dai D, Liu Y, Arul S, Kadirvel R, Hanel RA, Yoo AJ, Almekhlafi MA, Layton KF, Delgado Almandoz JE, Kvamme P, Mendes Pereira V, Jahromi BS, Nogueira RG, Gounis MJ, Patel B, Aghaebrahim A, Sauvageau E, Bhuva P, Soomro J, Demchuk AM, Thacker IC, Kayan Y, Copelan A, Nazari P, Cantrell DR, Haussen DC, Al-Bayati AR, Mohammaden M, Pisani L, Rodrigues GM, Puri AS, Entwistle J, Meves A, Savastano L, Cloft HJ, Nimjee SM, McBane Ii RD, Kallmes DF, Brinjikji W. Correlation of von Willebrand factor and platelets with acute ischemic stroke etiology and revascularization outcome: an immunohistochemical study. J Neurointerv Surg 2022; 15:488-494. [PMID: 35595407 DOI: 10.1136/neurintsurg-2022-018645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/01/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Platelets and von Willebrand factor (vWF) are key components of acute ischemic stroke (AIS) emboli. We aimed to investigate the CD42b (platelets)/vWF expression, its association with stroke etiology and the impact these components may have on the clinical/procedural parameters. METHODS CD42b/vWF immunostaining was performed on 288 emboli collected as part of the multicenter STRIP Registry. CD42b/VWF expression and distribution were evaluated. Student's t-test and χ2 test were performed as appropriate. RESULTS The mean CD42b and VWF content in clots was 44.3% and 21.9%, respectively. There was a positive correlation between platelets and vWF (r=0.64, p<0.001**). We found a significantly higher vWF level in the other determined etiology (p=0.016*) and cryptogenic (p=0.049*) groups compared with cardioembolic etiology. No significant difference in CD42b content was found across the etiology subtypes. CD42b/vWF patterns were significantly associated with stroke etiology (p=0.006*). The peripheral pattern was predominant in atherosclerotic clots (36.4%) while the clustering (patchy) pattern was significantly associated with cardioembolic and cryptogenic origin (66.7% and 49.8%, respectively). The clots corresponding to other determined etiology showed mainly a diffuse pattern (28.1%). Two types of platelets were distinguished within the CD42b-positive clusters in all emboli: vWF-positive platelets were observed at the center, surrounded by vWF-negative platelets. Thrombolysis correlated with a high platelet content (p=0.03*). vWF-poor and peripheral CD42b/vWF pattern correlated with first pass effect (p=0.03* and p=0.04*, respectively). CONCLUSIONS The vWF level and CD42b/vWF distribution pattern in emboli were correlated with AIS etiology and revascularization outcome. Platelet content was associated with response to thrombolysis.
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Affiliation(s)
| | - Mehdi Abbasi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jorge L Arturo Larco
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Daying Dai
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yang Liu
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhosh Arul
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ricardo A Hanel
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Albert J Yoo
- Department of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Mohammed A Almekhlafi
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kennith F Layton
- Department of Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Josser E Delgado Almandoz
- Department of NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Peter Kvamme
- Department of Radiology, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Vitor Mendes Pereira
- Departments of Medical Imaging and Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Babak S Jahromi
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Matthew J Gounis
- Department of Radiology, University of Massachusetts Medical School, New England Center for Stroke Research, Worcester, Massachusetts, USA
| | - Biraj Patel
- Departments of Radiology and Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Amin Aghaebrahim
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Parita Bhuva
- Department of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Jazba Soomro
- Department of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Andrew M Demchuk
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ike C Thacker
- Department of Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Yasha Kayan
- Department of NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Alexander Copelan
- Department of NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Pouya Nazari
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Donald Robert Cantrell
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Mahmoud Mohammaden
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Leonardo Pisani
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Gabriel Martins Rodrigues
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, New England Center for Stroke Research, Worcester, Massachusetts, USA
| | - John Entwistle
- Departments of Radiology and Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Alexander Meves
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Luis Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Harry J Cloft
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shahid M Nimjee
- Department of Neurological Surgery, Ohio State University, Columbus, Ohio, USA
| | - Robert D McBane Ii
- Gonda Vascular Center, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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10
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Rossi R, Molina S, Mereuta OM, Douglas A, Fitzgerald S, Tierney C, Pandit A, Brennan P, Power S, O'Hare A, Gilvarry M, McCarthy R, Magoufis G, Tsivgoulis G, Nagy A, Vadász Á, Jood K, Redfors P, Nordanstig A, Ceder E, Dunker D, Carlqvist J, Psychogios K, Szikora I, Tatlisumak T, Rentzos A, Thornton J, Doyle KM. Does prior administration of rtPA influence acute ischemic stroke clot composition? Findings from the analysis of clots retrieved with mechanical thrombectomy from the RESTORE registry. J Neurol 2022; 269:1913-1920. [PMID: 34415423 PMCID: PMC8940807 DOI: 10.1007/s00415-021-10758-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/29/2021] [Accepted: 08/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE There is still much debate whether bridging-therapy [intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT)] might be beneficial compared to MT alone. We investigated the effect of IVT on size and histological composition of the clots retrieved from patients undergoing bridging-therapy or MT alone. METHODS We collected mechanically extracted thrombi from 1000 acute ischemic stroke (AIS) patients included in RESTORE registry. Patients were grouped according to the administration (or not) of IVT before thrombectomy. Gross photos of each clot were taken and Extracted Clot Area (ECA) was measured using ImageJ software. Martius Scarlett Blue stain was used to characterize the main histological clot components [red blood cells (RBCs), fibrin (FIB), platelets/other (PTL)] and Orbit Image Analysis was used for quantification. Additionally, we calculated the area of each main component by multiplying the component percent by ECA. Chi-squared and Kruskal-Wallis tests were used for statistical analysis. RESULTS 451 patients (45%) were treated with bridging-therapy while 549 (55%) underwent MT alone. When considering only percent histological composition, we did not find any difference in RBC% (P = 0.895), FIB% (P = 0.458) and PTL% (P = 0.905). However, bridging-therapy clots were significantly smaller than MT-alone clots [32.7 (14.8-64.9) versus 36.8 (20.1-79.8) mm2, N = 1000, H1 = 7.679, P = 0.006*]. A further analysis expressing components per clot area showed that clots retrieved from bridging-therapy cases contained less RBCs [13.25 (4.29-32.06) versus 14.97 (4.93-39.80) mm2, H1 = 3.637, P = 0.056] and significantly less fibrin [9.10 (4.62-17.98) versus 10.54 (5.57-22.48) mm2, H1 = 7.920, P = 0.005*] and platelets/other [5.04 (2.26-11.32) versus 6.54 (2.94-13.79) mm2, H1 = 9.380, P = 0.002*] than MT-alone clots. CONCLUSIONS Our results suggest that previous IVT administration significantly reduces thrombus size, proportionally releasing all the main histological components.
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Affiliation(s)
- Rosanna Rossi
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland Galway, University Road, Galway, Ireland
- CÚRAM-SFI Research Centre in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Sara Molina
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland Galway, University Road, Galway, Ireland
- CÚRAM-SFI Research Centre in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Oana Madalina Mereuta
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland Galway, University Road, Galway, Ireland
- CÚRAM-SFI Research Centre in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Andrew Douglas
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland Galway, University Road, Galway, Ireland
- CÚRAM-SFI Research Centre in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Seán Fitzgerald
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland Galway, University Road, Galway, Ireland
| | - Ciara Tierney
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland Galway, University Road, Galway, Ireland
- CÚRAM-SFI Research Centre in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Abhay Pandit
- CÚRAM-SFI Research Centre in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Paul Brennan
- Department of Radiology, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Sarah Power
- Department of Radiology, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Alan O'Hare
- Department of Radiology, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | | | | | | | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece
| | - András Nagy
- Department of Neurointerventions, National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Ágnes Vadász
- Department of Neurointerventions, National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Petra Redfors
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Annika Nordanstig
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Erik Ceder
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Dennis Dunker
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Jeanette Carlqvist
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | | | - István Szikora
- Department of Neurointerventions, National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Turgut Tatlisumak
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Alexandros Rentzos
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - John Thornton
- Department of Radiology, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Karen M Doyle
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland Galway, University Road, Galway, Ireland.
- CÚRAM-SFI Research Centre in Medical Devices, National University of Ireland Galway, Galway, Ireland.
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11
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Zeng C, Chen Z, Yang H, Fan Y, Fei L, Chen X, Zhang M. Advanced high resolution three-dimensional imaging to visualize the cerebral neurovascular network in stroke. Int J Biol Sci 2022; 18:552-571. [PMID: 35002509 PMCID: PMC8741851 DOI: 10.7150/ijbs.64373] [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: 07/01/2021] [Accepted: 10/28/2021] [Indexed: 11/05/2022] Open
Abstract
As an important method to accurately and timely diagnose stroke and study physiological characteristics and pathological mechanism in it, imaging technology has gone through more than a century of iteration. The interaction of cells densely packed in the brain is three-dimensional (3D), but the flat images brought by traditional visualization methods show only a few cells and ignore connections outside the slices. The increased resolution allows for a more microscopic and underlying view. Today's intuitive 3D imagings of micron or even nanometer scale are showing its essentiality in stroke. In recent years, 3D imaging technology has gained rapid development. With the overhaul of imaging mediums and the innovation of imaging mode, the resolution has been significantly improved, endowing researchers with the capability of holistic observation of a large volume, real-time monitoring of tiny voxels, and quantitative measurement of spatial parameters. In this review, we will summarize the current methods of high-resolution 3D imaging applied in stroke.
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Affiliation(s)
- Chudai Zeng
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China, 410008.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China, 410008
| | - Zhuohui Chen
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China, 410008.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China, 410008
| | - Haojun Yang
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China, 410008.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China, 410008
| | - Yishu Fan
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China, 410008.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China, 410008
| | - Lujing Fei
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China, 410008.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China, 410008
| | - Xinghang Chen
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China, 410008.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China, 410008
| | - Mengqi Zhang
- Department of Neurology, Xiangya Hospital of Central South University, Changsha, Hunan, China, 410008.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China, 410008
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12
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Aliena-Valero A, Baixauli-Martín J, Torregrosa G, Tembl JI, Salom JB. Clot Composition Analysis as a Diagnostic Tool to Gain Insight into Ischemic Stroke Etiology: A Systematic Review. J Stroke 2021; 23:327-342. [PMID: 34649378 PMCID: PMC8521257 DOI: 10.5853/jos.2021.02306] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/24/2021] [Accepted: 09/02/2021] [Indexed: 12/22/2022] Open
Abstract
Mechanical thrombectomy renders the occluding clot available for analysis. Insights into thrombus composition could help establish the stroke cause. We aimed to investigate the value of clot composition analysis as a complementary diagnostic tool in determining the etiology of large vessel occlusion (LVO) ischemic strokes (International Prospective Register of Systematic Reviews [PROSPERO] registration # CRD42020199436). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we ran searches on Medline (using the PubMed interface) and Web of Science for studies reporting analyses of thrombi retrieved from LVO stroke patients subjected to mechanical thrombectomy (January 1, 2006 to September 21, 2020). The PubMed search was updated weekly up to February 22, 2021. Reference lists of included studies and relevant reviews were hand-searched. From 1,714 identified studies, 134 eligible studies (97 cohort studies, 31 case reports, and six case series) were included in the qualitative synthesis. Physical, histopathological, biological, and microbiological analyses provided information about the gross appearance, mechanical properties, structure, and composition of the thrombi. There were non-unanimous associations of thrombus size, structure, and composition (mainly proportions of fibrin and blood formed elements) with the Trial of Org 10172 in Acute Stroke Treatment (TOAST) etiology and underlying pathologies, and similarities between cryptogenic thrombi and those of known TOAST etiology. Individual thrombus analysis contributed to the diagnosis, mainly in atypical cases. Although cohort studies report an abundance of quantitative rates of main thrombus components, a definite clot signature for accurate diagnosis of stroke etiology is still lacking. Nevertheless, the qualitative examination of the embolus remains an invaluable tool for diagnosing individual cases, particularly regarding atypical stroke causes.
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Affiliation(s)
- Alicia Aliena-Valero
- Joint Cerebrovascular Research Unit, La Fe Health Research Institute, University of Valencia, Valencia, Spain
| | | | - Germán Torregrosa
- Joint Cerebrovascular Research Unit, La Fe Health Research Institute, University of Valencia, Valencia, Spain
| | - José I. Tembl
- Stroke Unit, Neurology Service, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Juan B. Salom
- Joint Cerebrovascular Research Unit, La Fe Health Research Institute, University of Valencia, Valencia, Spain
- Department of Physiology, University of Valencia, Valencia, Spain
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13
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Brinjikji W, Madalina Mereuta O, Dai D, Kallmes DF, Savastano L, Liu Y, Nimjee SM, Nogueira RG, Abbasi M, Kadirvel R. Mechanisms of fibrinolysis resistance and potential targets for thrombolysis in acute ischaemic stroke: lessons from retrieved stroke emboli. Stroke Vasc Neurol 2021; 6:658-667. [PMID: 34312319 PMCID: PMC8717785 DOI: 10.1136/svn-2021-001032] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/30/2021] [Indexed: 11/30/2022] Open
Abstract
There has been growing interest and insight into the histological composition of retrieved stroke emboli. One of the main focuses of the stroke clot analysis literature has been the implications of clot composition on mechanical thrombectomy procedures. However, the holy grail of clot analysis may not be in the field of clot–device interaction, but rather, in understanding mechanisms of fibrinolysis resistance. The mechanisms underlying the low response to fibrinolytic therapy, even with the newer, more powerful agents, remain poorly understood. While factors such as embolus size, location and collateral status influence alteplase delivery and recanalisation rates; compositional analyses focused on histological and ultrastructural characteristics offer unique insights into mechanisms of alteplase resistance. In this review, we strive to provide comprehensive review of current knowledge on clot composition and ultrastructural analyses that help explain resistance to fibrinolysis.
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Affiliation(s)
- Waleed Brinjikji
- Radiology, Mayo Clinic, Rochester, Minnesota, USA .,Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Daying Dai
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Yang Liu
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shahid M Nimjee
- Neurosurgery, Ohio State University Medical Center, Columbus, Ohio, USA
| | - Raul G Nogueira
- Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mehdi Abbasi
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
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14
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Mereuta OM, Abbasi M, Fitzgerald S, Dai D, Kadirvel R, Hanel RA, Yoo AJ, Almekhlafi MA, Layton KF, Delgado Almandoz JE, Kvamme P, Mendes Pereira V, Jahromi BS, Nogueira RG, Gounis MJ, Patel B, Aghaebrahim A, Sauvageau E, Bhuva P, Soomro J, Demchuk AM, Thacker IC, Kayan Y, Copelan A, Nazari P, Cantrell DR, Haussen DC, Al-Bayati AR, Mohammaden M, Pisani L, Rodrigues GM, Puri AS, Entwistle J, Meves A, Arturo Larco JL, Savastano L, Cloft HJ, Kallmes DF, Doyle KM, Brinjikji W. Histological evaluation of acute ischemic stroke thrombi may indicate the occurrence of vessel wall injury during mechanical thrombectomy. J Neurointerv Surg 2021; 14:356-361. [PMID: 33975922 PMCID: PMC8581068 DOI: 10.1136/neurintsurg-2021-017310] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/26/2021] [Accepted: 04/06/2021] [Indexed: 11/12/2022]
Abstract
Background Several animal studies have demonstrated that mechanical thrombectomy (MT) for acute ischemic stroke (AIS) may cause vessel wall injury (VWI). However, the histological changes in human cerebral arteries following MT are difficult to determine. Objective To investigate the occurrence of VWI during MT by histological and immunohistochemical evaluation of AIS clots. Methods As part of the multicenter STRIP registry, 277 clots from 237 patients were analyzed using Martius Scarlett Blue stain and immunohistochemistry for CD34 (endothelial cells) and smooth muscle actin (smooth muscle cells). Results MT devices used were aspiration catheters (100 cases), stentriever (101 cases), and both (36 cases). VWI was found in 33/277 clots (12%). There was no significant correlation between VWI and MT device. The degree of damage varied from grade I (mild intimal damage, 24 clots), to grade II (relevant intimal and subintimal damage, 3 clots), and III (severe injury, 6 clots). VWI clots contained significantly more erythrocytes (p=0.006*) and less platelets/other (p=0.005*) than non-VWI clots suggesting soft thrombus material. Thrombolysis correlated with a lower rate of VWI (p=0.04*). VWI cases showed a significantly higher number of passes (2 [1–4] vs 1 [1–3], p=0.028*) and poorer recanalization outcome (p=0.01*) than cases without VWI. Conclusions Histological markers of VWI were present in 12% of AIS thrombi, suggesting that VWI might be related to MT. VWI was associated with soft thrombus consistency, higher number of passes and poorer revascularization outcome. There was no significant correlation between VWI and MT device.
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Affiliation(s)
- Oana Madalina Mereuta
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA .,CÚRAM - SFI Research Centre for Medical Devices and Department of Physiology, National University of Ireland Galway, Galway, Ireland
| | - Mehdi Abbasi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Seán Fitzgerald
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,CÚRAM - SFI Research Centre for Medical Devices and Department of Physiology, National University of Ireland Galway, Galway, Ireland
| | - Daying Dai
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ram Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ricardo A Hanel
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Albert J Yoo
- Department of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Mohammed A Almekhlafi
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kennith F Layton
- Department of Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Josser E Delgado Almandoz
- Department of NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Peter Kvamme
- Department of Radiology, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Vitor Mendes Pereira
- Departments of Medical Imaging and Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Babak S Jahromi
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Raul G Nogueira
- Department of Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA.,Emory University, Atlanta, Georgia, USA
| | - Matthew J Gounis
- Department of Radiology, University of Massachusetts Medical School, New England Center for Stroke Research, Worcester, Massachusetts, USA
| | - Biraj Patel
- Departments of Radiology and Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Amin Aghaebrahim
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Parita Bhuva
- Department of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Jazba Soomro
- Department of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Andrew M Demchuk
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ike C Thacker
- Department of Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Yasha Kayan
- Department of NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Alexander Copelan
- Department of NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Pouya Nazari
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Donald Robert Cantrell
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Diogo C Haussen
- Department of Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA.,Emory University, Atlanta, Georgia, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA.,Emory University, Atlanta, Georgia, USA
| | - Mahmoud Mohammaden
- Department of Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA.,Emory University, Atlanta, Georgia, USA
| | - Leonardo Pisani
- Department of Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA.,Emory University, Atlanta, Georgia, USA
| | - Gabriel Martins Rodrigues
- Department of Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA.,Emory University, Atlanta, Georgia, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, New England Center for Stroke Research, Worcester, Massachusetts, USA
| | - John Entwistle
- Departments of Radiology and Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Alexander Meves
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jorge L Arturo Larco
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Luis Savastano
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Harry J Cloft
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Karen M Doyle
- CÚRAM - SFI Research Centre for Medical Devices and Department of Physiology, National University of Ireland Galway, Galway, Ireland
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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15
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Brinjikji W, Nogueira RG, Kvamme P, Layton KF, Delgado Almandoz JE, Hanel RA, Mendes Pereira V, Almekhlafi MA, Yoo AJ, Jahromi BS, Gounis MJ, Patel B, Abbasi M, Fitzgerald S, Mereuta OM, Dai D, Kadirvel R, Doyle K, Savastano L, Cloft HJ, Haussen DC, Al-Bayati AR, Mohammaden MH, Pisani L, Rodrigues GM, 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, Kallmes DF. Association between clot composition and stroke origin in mechanical thrombectomy patients: analysis of the Stroke Thromboembolism Registry of Imaging and Pathology. J Neurointerv Surg 2021; 13:594-598. [PMID: 33722963 DOI: 10.1136/neurintsurg-2020-017167] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 02/06/2021] [Accepted: 02/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND We retrospectively evaluated the composition of retrieved clots from ischemic stroke patients to study the association between histological composition and stroke etiology METHODS: Consecutive patients enrolled in the Stroke Thromboembolism Registry of Imaging and Pathology (STRIP) were included in this study. All patients underwent mechanical thrombectomy and retrieved clots were sent to a central core lab for processing. Histological analysis was performed using martius scarlet blue (MSB) staining, and quantification for red blood cells (RBCs), white blood cells (WBCs), fibrin and platelets was performed using Orbit Image Software. A Wilcoxon test was used for continuous variables and χ2 test for categorical variables. RESULTS 1350 patients were included in this study. The overall rate of Thrombolysis In Cerebral Infarction (TICI) 2c/3 was 68%. 501 patients received tissue plasminogen activator (tPA) (37%). 267 patients (20%) had a large artery atherosclerosis (LAA) source, 662 (49%) a cardioembolic (CE) source, 301 (22%) were cryptogenic, and the remainder had other identifiable sources including hypercoagulable state or dissection. LAA thrombi had a higher mean RBC density (46±23% vs 42±22%, p=0.01) and a lower platelet density (24±18% vs 27±18%, p=0.03) than CE thrombi. Clots from dissection patients had the highest mean RBC density (50±24%) while clots from patients with a hypercoagulable state had the lowest mean RBC density (26±21%). CONCLUSIONS Our study found statistically significant but clinically insignificant differences between clots of CE and LAA etiologies. Future studies should emphasize molecular, proteomic and immunohistochemical characteristics to determine links between clot composition and etiology.
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Affiliation(s)
- Waleed Brinjikji
- Radiology, Mayo Clinic, Rochester, Minnesota, USA .,Neurosurgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Raul G Nogueira
- Neurology, Emory University School of Medicine, Atlanta, Georgia, 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
| | | | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Babak S Jahromi
- Neurosurgery and Radiology, Northwestern University, Chicago, Illinois, USA
| | - Matthew J Gounis
- Radiology, New England Center for Stroke Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Biraj Patel
- Radiology, Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Mehdi Abbasi
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Seán Fitzgerald
- CÚRAM-SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland.,Physiology Department, National University of Ireland Galway, Galway, Ireland
| | - Oana Madalina Mereuta
- CÚRAM-SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland.,Physiology Department, National University of Ireland Galway, Galway, Ireland
| | - Daying Dai
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Karen Doyle
- CÚRAM-SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland.,Physiology Department, National University of Ireland Galway, Galway, Ireland
| | - Luis Savastano
- Neurosurgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | | | - Diogo C Haussen
- Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | | | - Leonardo Pisani
- Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Ike C Thacker
- NeuroInterventional Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Yasha Kayan
- Interventional Neuroradiology, Abbot Northwestern Hospital, 55435, Minnesota, USA
| | - Alexander Copelan
- Interventional Neuroradiology, Abbot Northwestern Hospital, 55435, Minnesota, USA
| | - Amin Aghaebrahim
- Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Andrew M Demchuk
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Parita Bhuva
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Jazba Soomro
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Pouya Nazari
- 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
| | - Eric C Polley
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, MN, USA
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