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Manisha KY, Poyuran R, Narasimhaiah D, Kumar Paramasivan N, Ramachandran H, Erat Sreedharan S, Er J, Kumar S, Vinoda Thulaseedharan J, Sylaja PN. Thrombus histology does not predict stroke etiological subtype but influences recanalization. J Clin Neurosci 2024; 124:54-59. [PMID: 38643652 DOI: 10.1016/j.jocn.2024.04.013] [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: 02/14/2024] [Revised: 03/13/2024] [Accepted: 04/12/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND There is conflicting data on whether clot retrieved from mechanical thrombectomy can predict stroke etiology or the success of recanalization. We aimed to analyse the relation between thrombus histology and stroke aetiology as well as recanalization. METHODOLOGY Histopathological analysis of clots retrieved from patients with acute ischemic stroke and large vessel occlusion was done. Quantification of the amount of fibrin, red blood cells(RBC), platelets and white blood cells (WBC) in the clots were done. The clinical, imaging data and recanalization parameters were collected. The correlation between clot composition and stroke etiology as well as recanalization were analysed. RESULTS Of the 77 patients, the mean age was 58. 67 ± 12.96 years. The stroke etiology were cardioembolism 44(57.1 %), large artery atherosclerosis 13(16.8 %), other determined aetiology 4(5.1 %) and undetermined in 16(20.7 %) patients. There was no significant correlation between the proportions of RBC-rich, platelet-rich and fibrin-rich thrombi and the stroke etiology. The susceptibility vessel sign was associated with RBC-rich clot(92.3 % vs 7.7 %, p = .03). All RBC-rich clots(100 %) had good recanalization(p = .05). Platelet-rich clots needed less number of passes(64.7 % vs 35.3 %, p = .006) and reduced groin puncture to recanalization time(87.9 % vs 12.1 %, p = .033). WBC-rich clots required lesser number of passes(57.5 % vs 42.5 %, P = .044). In multivariate analysis, WBC-rich clots (OR 0.230, CI 0.07-0.78, p = .018) showed an independent association with reduced recanalization attempts, while platelet-rich clots showed reduced recanalization time(OR 0.09, CI 0.01-0.63, p = .016). CONCLUSION There was no correlation between thrombus histology and the etiological stroke subtype. However, clot composition predicted the degree of recanalization and number of passes.
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Affiliation(s)
- K Y Manisha
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - Rajalakshmi Poyuran
- Department of Pathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - Deepthi Narasimhaiah
- Department of Pathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - Naveen Kumar Paramasivan
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Harikrishnan Ramachandran
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Sapna Erat Sreedharan
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - Jayadevan Er
- Department of Imaging Science and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - Santhosh Kumar
- Department of Imaging Science and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - Jissa Vinoda Thulaseedharan
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - P N Sylaja
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
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Zhang X, Fu X, Ren Z, Zhou X, Ma Q. Relationship between thrombus composition and prognosis in patients with acute ischemic stroke undergoing mechanical thrombectomy. J Clin Neurosci 2024; 126:46-51. [PMID: 38824803 DOI: 10.1016/j.jocn.2024.05.024] [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: 01/22/2024] [Revised: 05/11/2024] [Accepted: 05/21/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Mechanical thrombectomy has emerged as the primary endovascular treatment for acute ischemic stroke. Numerous studies have investigated the relationship between thrombus composition and factors such as pharmacological thrombolysis, stroke etiology, mechanical thrombectomy, and radiological imaging. However, limited research has explored the association between thrombus composition and clinical outcomes. METHODS This retrospective analysis examined the histopathological examination of thrombi retrieved from 50 patients with acute ischemic stroke between May 2020 and May 2023. The composition of the retrieved thrombi was assessed using HE staining to quantify the proportions of red blood cells, white blood cells, platelets, and fibrin. Based on the predominant composition of the thrombus, the patients were divided into two groups: erythrocyte-rich and fibrin-rich. Demographics, clinical characteristics, and clinical outcomes assessed by the National Institutes of Health Stroke Scale (NIHSS) score and modified Rankin Scale (mRS) scores were collected retrospectively. RESULT Of the 50 patients, 23 were classified in the erythrocyte-rich group, and 27 were classified in the fibrin-rich group. There were no significant differences between the two groups in terms of age, sex, stroke subtype, history of hypertension and diabetes, thrombus location, NIHSS scores, mRS scores on admission, the time interval from symptom onset to hospitalization and reperfusion, or the rate of successful reperfusion. However, erythrocyte-rich thrombi were associated with a shorter time interval from puncture to reperfusion. No significant differences were found in the red blood cell fraction and fibrin/platelet fraction between large artery atherosclerosis and cardioembolism. At the 90-day follow-up, patients with erythrocyte-rich thrombi exhibited lower NIHSS scores and more favorable functional outcomes (mRS scores of 0-2) compared to those with fibrin-rich thrombi. CONCLUSION Erythrocyte-rich thrombi were linked to shorter time intervals from puncture to reperfusion and favorable clinical outcomes in patients with acute ischemic stroke. The composition of the thrombus may influence the thrombectomy strategy for endovascular therapy.
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Affiliation(s)
- Xuyan Zhang
- Department of Neurology, Haining People's Hospital, Jiaxing, China
| | - Xinzheng Fu
- Department of Neurology, Haining People's Hospital, Jiaxing, China
| | - Zhouming Ren
- Department of Neurology, Haining People's Hospital, Jiaxing, China
| | - Xianghua Zhou
- Department of Pathology, Haining People's Hospital, Jiaxing, China
| | - Qianli Ma
- Department of Neurology, Haining People's Hospital, Jiaxing, China.
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Lin S, Chunxiao W, Li S, Guimei Z, Yaru Z, Weijie Z, Yiming Q, Ruolin Z, Lingjie M, Yan Z. Relationship between thrombus vWF and NETs with clinical severity and peripheral blood immunocytes' indicators in patients with acute ischemic stroke. Interv Neuroradiol 2024:15910199241258374. [PMID: 38807555 DOI: 10.1177/15910199241258374] [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: 05/30/2024] Open
Abstract
OBJECTIVE To investigate the association between von Willebrand factor (vWF) and neutrophil extracellular traps (NETs) in thrombus with clinical severity and peripheral blood immunocytes' indicators in patients with early-stage acute ischemic stroke (AIS). METHODS A retrospective study was conducted using the clinical data of 66 patients with AIS who underwent endovascular mechanical thrombectomy and had their thrombus samples collected. The concentrations of vWF and NETs in the thrombus samples were quantitatively assessed. Peripheral blood samples taken in the early stages of the disease were analyzed for total white blood cell counts (WBC), ratios of neutrophils (NEU%), lymphocytes (LYM%), eosinophils (EOS%), and monocytes (MONO%). The severity of clinical symptoms in these patients was evaluated using the modified Rankin Scale (mRS), Essen Stroke Risk Score (ESRS), Barthel Index (BI), and National Institute of Health Stroke Scale (NIHSS). RESULTS Higher vWF levels in thrombus were associated with lower NIHSS scores, while higher NETs levels were associated with higher initial NIHSS scores. In the early stages of AIS, WBC count and vWF levels were negatively correlated, as well as NEU%. LYM% was positively correlated with vWF level; however, it was negatively correlated with NETs. EOS% was positively correlated with vWF levels. CONCLUSION In the early stages of AIS, a higher peripheral WBC count and NEU%, combined with decreased EOS% and LYM%, were significantly correlated with a lower vWF level in the thrombus, potentially indicating more severe symptoms. Consequently, the timely administration of vWF-targeted medications is recommended for such patients. Reduced LYM% is indicative of elevated NETs levels and correlated with more severe clinical symptoms. Therefore, the prompt initiation of NETs-targeted medication is warranted for these patients.
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Affiliation(s)
- Shi Lin
- Cognitive Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Wei Chunxiao
- Cognitive Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Sun Li
- Cognitive Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Zhang Guimei
- Cognitive Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Zhang Yaru
- Department of Neurology and National Center for Neurological Diseases, Huashan Hospital, Shanghai, China
| | - Zhai Weijie
- Cognitive Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Qi Yiming
- Cognitive Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Zhou Ruolin
- Cognitive Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Meng Lingjie
- Cognitive Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Zhang Yan
- Cognitive Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
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Zhang L, Gao J, Liao Y, Lin J, Guan M, Huang S, Yang B, Cheng Z, Leng X, Qiao H, Huang L. Comparison of Outcomes between Stent Retriever Combined with Contact Aspiration and Contact Aspiration Alone in Patients without Hyperdense Artery Sign/Susceptibility Vessel Sign. J Vasc Interv Radiol 2024:S1051-0443(24)00330-0. [PMID: 38723863 DOI: 10.1016/j.jvir.2024.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 04/19/2024] [Accepted: 04/29/2024] [Indexed: 06/07/2024] Open
Abstract
PURPOSE To examine the relationship between hyperdense artery sign (HAS)/susceptibility vessel sign (SVS) and thrombus composition and evaluate the effect of HAS/SVS status on the association between first-line thrombectomy techniques and outcomes in patients with acute anterior circulation large vessel occlusion (LVO). MATERIALS AND METHODS From January 2018 to June 2021, 103 consecutive patients with acute anterior circulation LVO (75 [63.1%] men; median age, 66 years) who underwent thrombectomy and for whom the removed clot was available for histological analyses were retrospectively reviewed. The presence of HAS and SVS was assessed on unenhanced computed tomography (CT) and susceptibility-weighted imaging, respectively. Association of first-line thrombectomy techniques (stent retriever [SR] combined with contact aspiration [CA] vs CA alone) with outcomes was assessed according to HAS/SVS status. RESULTS Among the included patients, 55 (53.4%) were HAS/SVS-negative, and 69 (67.0%) underwent first-line SR + CA. Higher relative densities of fibrin/platelets (0.56 vs 0.51; P < .001) and lower relative densities of erythrocytes (0.32 vs 0.42; P < .001) were observed in HAS/SVS-negative patients compared with HAS/SVS-positive patients. First-line SR + CA was associated with reduced odds of distal embolization (adjusted odds ratio, 0.18; 95% CI, 0.04-0.83; P = .027) and a more favorable 90-day functional outcome (adjusted odds ratio, 5.29; 95% CI, 1.06-26.34; P = .042) in HAS/SVS-negative patients and a longer recanalization time (53 vs 25 minutes; P = .025) and higher risk of subarachnoid hemorrhage (24.2% vs 0%; P = .044) in HAS/SVS-positive patients. CONCLUSIONS Absence of HAS/SVS may indicate a higher density of fibrin/platelets in the thrombus, and first-line SR + CA yielded superior functional outcomes than CA alone in patients with acute LVO without HAS/SVS.
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Affiliation(s)
- Liang Zhang
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Jia'li Gao
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Yu Liao
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, China; Department of Pathology, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Jia'xing Lin
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Min Guan
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Sheng'ming Huang
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Bing Yang
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Zhong'yuan Cheng
- Medical Imaging Center, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Xin'yi Leng
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hong'yu Qiao
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Li'an Huang
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, China.
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Wang H, Ma J, Li X, Peng Y, Wang M. FDA compound library screening Baicalin upregulates TREM2 for the treatment of cerebral ischemia-reperfusion injury. Eur J Pharmacol 2024; 969:176427. [PMID: 38428662 DOI: 10.1016/j.ejphar.2024.176427] [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: 11/26/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/03/2024]
Abstract
Acute ischemic stroke (AIS) is a leading cause of global incidence and mortality rates. Oxidative stress and inflammation are key factors in the pathogenesis of AIS neuroinjury. Therefore, it is necessary to develop drugs that target neuroinflammation and oxidative stress in AIS. The Triggering Receptor Expressed on Myeloid Cells 2 (TREM2), primarily expressed on microglial cell membranes, plays a critical role in reducing inflammation and oxidative stress in AIS. In this study, we employed a high-throughput screening (HTS) strategy to evaluate 2625 compounds from the (Food and Drug Administration) FDA library in vitro to identify compounds that upregulate the TREM2 receptor on microglia. Through this screening, we identified Baicalin as a potential drug for AIS treatment. Baicalin, a flavonoid compound extracted and isolated from the root of Scutellaria baicalensis, demonstrated promising results. Next, we established an in vivo mouse model of cerebral ischemia-reperfusion injury (MCAO/R) and an in vitro microglia cell of oxygen-glucose deprivation reperfusion (OGD/R) to investigate the role of Baicalin in inflammation injury, oxidative stress, and neuronal apoptosis. Our results showed that baicalin effectively inhibited microglia activation, reactive oxygen species (ROS) production, and inflammatory responses in vitro. Additionally, baicalin suppressed neuronal cell apoptosis. In the in vivo experiments, baicalin not only improved neurological functional deficits and reduced infarct volume but also inhibited microglia activation and inflammatory responses. Overall, our findings demonstrate the efficacy of Baicalin in treating MCAO/R by upregulating TREM2 to reduce inflammatory responses and inhibit neuronal apoptosis.
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Affiliation(s)
- Hongxia Wang
- Department of Neurology, Lanzhou University Second Hospital, Cuiying Biomedical Research Center of Lanzhou University Second Hospital, Lanzhou, 730030, China
| | - Jialiang Ma
- Department of Neurology, Lanzhou University Second Hospital, Cuiying Biomedical Research Center of Lanzhou University Second Hospital, Lanzhou, 730030, China
| | - Xiaoling Li
- Department of Neurology, Lanzhou University Second Hospital, Cuiying Biomedical Research Center of Lanzhou University Second Hospital, Lanzhou, 730030, China
| | - Yanhui Peng
- Department of Neurology, The Sixth Affiliated Hospital of Xinjiang Medical University, Ürümqi 830000, China
| | - Manxia Wang
- Department of Neurology, Lanzhou University Second Hospital, Cuiying Biomedical Research Center of Lanzhou University Second Hospital, Lanzhou, 730030, China.
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Martins PN, Nogueira RG, Tarek MA, Dolia JN, Sheth SA, Ortega-Gutierrez S, Salazar-Marioni S, Iyyangar A, Galecio-Castillo M, Rodriguez-Calienes A, Pabaney A, Grossberg JA, Haussen DC. Early technique switch following failed passes during mechanical thrombectomy for ischemic stroke: should the approach change and when? J Neurointerv Surg 2024:jnis-2024-021545. [PMID: 38479798 DOI: 10.1136/jnis-2024-021545] [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: 01/26/2024] [Accepted: 03/02/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Fast and complete reperfusion in endovascular therapy (EVT) for ischemic stroke leads to superior clinical outcomes. The effect of changing the technical approach following initially unsuccessful passes remains undetermined. OBJECTIVE To evaluate the association between early changes to the EVT approach and reperfusion. METHODS Multicenter retrospective analysis of prospectively collected data for patients who underwent EVT for intracranial internal carotid artery, middle cerebral artery (M1/M2), or basilar artery occlusions. Changes in EVT technique after one or two failed passes with stent retriever (SR), contact aspiration (CA), or a combined technique (CT) were compared with repeating the previous strategy. The primary outcome was complete/near-complete reperfusion, defined as an expanded Thrombolysis in Cerebral Infarction (eTICI) of 2c-3, following the second and third passes. RESULTS Among 2968 included patients, median age was 66 years and 52% were men. Changing from SR to CA on the second or third pass was not observed to influence the rates of eTICI 2c-3, whereas changing from SR to CT after two failed passes was associated with higher chances of eTICI 2c-3 (OR=5.3, 95% CI 1.9 to 14.6). Changing from CA to CT was associated with higher eTICI 2c-3 chances after one (OR=2.9, 95% CI 1.6 to 5.5) or two (OR=2.7, 95% CI 1.0 to 7.4) failed CA passes, while switching to SR was not significantly associated with reperfusion. Following one or two failed CT passes, switching to SR was not associated with different reperfusion rates, but changing to CA after two failed CT passes was associated with lower chances of eTICI 2c-3 (OR=0.3, 95% CI 0.1 to 0.9). Rates of functional independence were similar. CONCLUSIONS Early changes in EVT strategies were associated with higher reperfusion and should be contemplated following failed attempts with stand-alone CA or SR.
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Affiliation(s)
- Pedro N Martins
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
- UPMC, Pittsburgh, Pennsylvania, USA
| | - Mohamed A Tarek
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Jaydevsinh N Dolia
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Sunil A Sheth
- Department of Neurology, University of Texas Health Science Center, Houston, Texas, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Ananya Iyyangar
- Department of Neurology, University of Texas Health Science Center, Houston, Texas, USA
| | - Milagros Galecio-Castillo
- Department of Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Aaron Rodriguez-Calienes
- Department of Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Cientifica del Sur Facultad de Ciencias de la Salud, Lima, Peru
| | - Aqueel Pabaney
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Jonathan A Grossberg
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Grady Memorial Hospital, Atlanta, Georgia, USA
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Sahin C, Giraud A, Jabrah D, Patil S, Messina P, Bozsak F, Darcourt J, Sacchetti F, Januel AC, Bellanger G, Pagola J, Juega J, Imamura H, Ohta T, Spelle L, Chalumeau V, Mircic U, Stanarčević P, Vukašinović I, Ribo M, Sakai N, Cognard C, Doyle K. Electrical impedance measurements can identify red blood cell-rich content in acute ischemic stroke clots ex vivo associated with first-pass successful recanalization. Res Pract Thromb Haemost 2024; 8:102373. [PMID: 38617048 PMCID: PMC11015511 DOI: 10.1016/j.rpth.2024.102373] [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: 02/22/2024] [Accepted: 03/07/2024] [Indexed: 04/16/2024] Open
Abstract
Background Electrochemical impedance spectroscopy can determine characteristics such as cell density, size, and shape. The development of an electrical impedance-based medical device to estimate acute ischemic stroke (AIS) clot characteristics could improve stroke patient outcomes by informing clinical decision making. Objectives To assess how well electrical impedance combined with machine learning identified red blood cell (RBC)-rich composition of AIS clots ex vivo, which is associated with a successfully modified first-pass effect. Methods A total of 253 clots from 231 patients who underwent thrombectomy in 5 hospitals in France, Japan, Serbia, and Spain between February 2021 and October 2023 were analyzed in the Clotbase International Registry. Electrical impedance measurements were taken following clot retrieval by thrombectomy, followed by Martius Scarlet Blue staining. The clot components were quantified via Orbit Image Analysis, and RBC percentages were correlated with the RBC estimations made by the electrical impedance machine learning model. Results Quantification by Martius Scarlet Blue staining identified RBCs as the major component in clots (RBCs, 37.6%; white blood cells, 5.7%; fibrin, 25.5%; platelets/other, 30.3%; and collagen, 1%). The impedance-based RBC estimation correlated well with the RBC content determined by histology, with a slope of 0.9 and Spearman's correlation of r = 0.7. Clots removed in 1 pass were significantly richer in RBCs and clots with successful recanalization in 1 pass (modified first-pass effect) were richer in RBCs as assessed using histology and impedance signature. Conclusion Electrical impedance estimations of RBC content in AIS clots are consistent with histologic findings and may have potential for clinically relevant parameters.
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Affiliation(s)
- Cansu Sahin
- Department of Physiology, University of Galway, Galway, Ireland
- Centre for Research in Medical Devices (CÚRAM)- Science Foundation Ireland (SFI), University of Galway, Galway, Ireland
| | | | - Duaa Jabrah
- Department of Physiology, University of Galway, Galway, Ireland
| | - Smita Patil
- Department of Physiology, University of Galway, Galway, Ireland
- Centre for Research in Medical Devices (CÚRAM)- Science Foundation Ireland (SFI), University of Galway, Galway, Ireland
| | | | | | - Jean Darcourt
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Universitaire (CHU) de Toulouse, Toulouse, France
| | - Federico Sacchetti
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Universitaire (CHU) de Toulouse, Toulouse, France
| | - Anne-Christine Januel
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Universitaire (CHU) de Toulouse, Toulouse, France
| | - Guillaume Bellanger
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Universitaire (CHU) de Toulouse, Toulouse, France
| | - Jorge Pagola
- Department of Neurology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Jesus Juega
- Department of Neurology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Laurent Spelle
- Department of Interventional Neuroradiology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Vanessa Chalumeau
- Department of Interventional Neuroradiology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Uros Mircic
- Department of Neuroradiology, Centre for Radiology and Magnetic Resonance Imaging (MRI), University Clinical Center of Serbia, Belgrade, Serbia
| | | | - Ivan Vukašinović
- Department of Neuroradiology, Centre for Radiology and Magnetic Resonance Imaging (MRI), University Clinical Center of Serbia, Belgrade, Serbia
| | - Marc Ribo
- Department of Neurology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Universitaire (CHU) de Toulouse, Toulouse, France
| | - Karen Doyle
- Department of Physiology, University of Galway, Galway, Ireland
- Centre for Research in Medical Devices (CÚRAM)- Science Foundation Ireland (SFI), University of Galway, Galway, Ireland
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Vandelanotte S, De Meyer SF. Acute Ischemic Stroke Thrombus Composition. Neuroscience 2024:S0306-4522(23)00551-1. [PMID: 38185279 DOI: 10.1016/j.neuroscience.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/09/2024]
Abstract
Ischemic stroke is caused by a thrombus blocking one or multiple arteries in the brain, resulting in irreversible damage in the associated brain tissue. The aim of therapy is to restore the blood flow as fast as possible. Two recanalization strategies are currently available: pharmacological thrombolysis using recombinant tissue plasminogen activator (rt-PA) and mechanical removal of the thrombus. Despite recent advancements, achieving efficient recanalization remains a challenge. The precise causes of therapy failure are not fully understood but thrombus composition is likely a key factor in successful recanalization. This review explores acute ischemic stroke thrombus composition, its recently identified components, and how it affects stroke treatment. It also discusses how new insights could enhance current recanalization strategies for ischemic stroke patients.
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Affiliation(s)
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium.
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Li Y, Shu Y, Yu K, Ni R, Chu L. Analysis and Regulatory Mechanisms of Platelet-Related Genes in Patients with Ischemic Stroke. Cell Mol Neurobiol 2024; 44:15. [PMID: 38175286 DOI: 10.1007/s10571-023-01433-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/26/2023] [Indexed: 01/05/2024]
Abstract
It was found that ischemic stroke (IS) was associated with abnormal platelet activity and thrombosis. However, the potential significance of platelet-related genes (PRGs) in IS still needs to be more thorough. This study extracted IS-related transcriptome datasets from the Gene Expression Omnibus (GEO) database. The target genes were obtained by intersecting the differentially expressed genes (DEGs), the module genes related to IS, and PRGs, where the key genes of IS were screened by two machine learning algorithms. The key genes-based diagnostic model was constructed. Gene set enrichment analysis (GSEA) and the immune microenvironment analyses were analyzed targeting key genes in IS. The co-expression, TF-mRNA, and competitive endogenous RNAs (ceRNA) regulatory networks were constructed to reveal the potential regulation of key genes. Potential drugs targeting key genes were predicted as well. Totals of eight target genes were obtained and were associated with immune-related functions. Four platelet-related key genes were acquired, which were related to immunity and energy metabolism. The abnormal expressions of DOCK8, GIMAP5, ICOS were determined by the quantitative real-time polymerase chain reaction (qRT-PCR), and the significant correlations among these key genes were identified. Notably, hsa-miR-17-3p, hsa-miR-3158-3p, hsa-miR-423-3p, and hsa-miR-193a-8p could regulate all key genes at the same time. In addition, Caffeine, Carboplatin, and Vopratelimab were the targeted drugs of these key genes. This study identified four platelet-related key genes of IS, which might help to deepen the understanding of the role of platelet-related genes in the molecular mechanism of IS.
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Affiliation(s)
- Yuan Li
- Department of Neurology, Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Yuanlu Shu
- Department of Neurology, Guizhou Medical University, Guiyang, 550004, China
| | - Kun Yu
- Department of Neurology, Guizhou Medical University, Guiyang, 550004, China
| | - Ruihan Ni
- Department of Neurology, Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Lan Chu
- Department of Neurology, Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China.
- Department of Neurology, Guizhou Medical University, Guiyang, 550004, China.
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10
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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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11
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Bilgin C, Dai D, Johnson C, Mereuta OM, Kallmes DF, Brinjikji W, Kadirvel R. Quality assessment of histopathological stainings on prolonged formalin fixed thrombus tissues retrieved by mechanical thrombectomy. Front Neurol 2023; 14:1223947. [PMID: 38152640 PMCID: PMC10751908 DOI: 10.3389/fneur.2023.1223947] [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: 05/16/2023] [Accepted: 11/03/2023] [Indexed: 12/29/2023] Open
Abstract
Background Formalin-fixed retrieved clots from mechanical thrombectomy (MT) are now routinely studied using both conventional histopathologic techniques and immunohistochemistry (IHC). However, the effects of prolonged formalin fixation on the histological results of clot analysis remain unknown. The objective of this study was to investigate the effects of prolonged formalin fixation on quality of histopathologic stainings of thrombus tissues retrieved by MT. Methods As part of the multicenter EXCELLENT registry, a total of 80 clots extracted by MT from acute ischemic stroke patients were randomly selected from the tissue database and assigned into four groups according to 10% neutral buffered formalin (NBF) fixation duration (1-30, 30-60, 60-90, and 90+ days, up to 2 years). Samples underwent processing and sectioning. Two serial sections for each case were stained with hematoxylin and eosin (H&E), Martius Scarlet Blue (MSB), and IHC for CD42b (platelet marker). An expert pathologist, who was blinded to tissue fixation duration and patient clinical data, assessed the quality of each stain including stainability, sensitivity, specificity, and consistency of stainings. Results No significant issues were encountered during tissue processing and sectioning. On H&E stain, 97.5% (78/80) of slides showed good-quality staining, demonstrating clear histological properties of the thrombus tissue as red blood cells (RBC) stained in red, fibrin/platelet stained in pink, and nuclei stained in blue with intranuclear detail. The same histological features were also successfully demonstrated on MSB for all 80 samples. One of the 80 samples (1.2%) showed that RBC lost stainability on H&E due to tissue autolysis. Clear positive signal of platelet staining was expressed in 98.8% of the samples (79/80) with minimal background staining on IHC. There was no significant difference in staining quality across different formalin fixation groups. Conclusion A good quality of histopathological staining is achievable for the thrombus tissue fixed in 10% neutral buffered formalin for up to 2 years. The findings are limited to the thrombus tissue retrieved by MT and specific fixation and staining protocols used in the study. To apply these results to other tissue or experimental setups, further studies and validations would be necessary. Clinical trial registration This study was conducted as part of the EXCELLENT study: www.clinicaltrials.gov, unique identifier: NCT03685578.
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Affiliation(s)
- Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Daying Dai
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Collin Johnson
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Oana M. Mereuta
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - David F. Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
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12
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Li Y, Xiang W, Xue H, Meng T, Zhang T, Zhang J, Wang J, Zhao J, Wang B. The impact of platelet indices on ischemic stroke: a Mendelian randomization study and mediation analysis. Front Neurol 2023; 14:1302008. [PMID: 38145119 PMCID: PMC10741650 DOI: 10.3389/fneur.2023.1302008] [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: 09/25/2023] [Accepted: 11/22/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction Platelet indices (PIs) are hematological parameters that indicate the number, morphology, and activation of platelets. Although some clinical trials suggest an association between PIs and the risk of stroke, the lack of robust evidence is attributed to confounding effects and reverse causation. Objective This study aimed to evaluate the association between PIs and stroke risk through Mendelian randomization (MR) while exploring the mediating effect of blood pressure in this association. Methods We identified genetic variants associated with PIs, including platelet count (PLT), platelet distribution width (PDW), mean platelet volume (MPV), and platelet crit (PCT), in the UK Biobank (n = 350,474). Relevant genome-wide association studies were utilized to gather summary statistics pertaining to the traits of interest. We primarily used the inverse-variance weighted analysis to obtain estimates for individual causal power. Result We observed a positive correlation between genetically predicted increases in PCT levels with the stroke onset [PCT: OR (95%CI) = 1.113(1.047, 1.183), p < 0.001]. However, no significant causal relationship was found between PLT, PDW, and MPV and the risk of stroke [PLT: OR (95%CI) = 1.037(0.979, 1.098), p = 0.221; PDW: OR (95%CI) = 0.973(0.923, 1.024), p = 0.294; MPV: OR (95%CI) = 0.990(0.945, 1.038), p = 0.675]. Multivariable MR analyses and mediation analysis found that the proportion mediated by systolic blood pressure (SBP) is 23.71% [95%CI (10.85-33.31%)] and the proportion mediated by diastolic blood pressure (DBP) is 28.09% [95%CI (12.92-39.63%)]. Conclusion This large MR study presents evidence for the potential causal relationship between the PCT level and the risk of ischemic stroke, which might be mediated by blood pressure.
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Affiliation(s)
- Yang Li
- Department of Neurology, Inner Mongolia Institute of Cerebrovascular Diseases, Baotou Center Hospital, Baotou, Inner Mongolia, China
| | - Wenping Xiang
- Department of Neurology, Inner Mongolia Institute of Cerebrovascular Diseases, Baotou Center Hospital, Baotou, Inner Mongolia, China
| | - Hui Xue
- Department of Neurology, Inner Mongolia Institute of Cerebrovascular Diseases, Baotou Center Hospital, Baotou, Inner Mongolia, China
| | - Tianyu Meng
- Graduate School, Chongqing Medical University, Chongqing, China
| | - Tianyou Zhang
- Department of Neurology, Inner Mongolia Institute of Cerebrovascular Diseases, Baotou Center Hospital, Baotou, Inner Mongolia, China
| | - Jinfeng Zhang
- Department of Neurology, Inner Mongolia Institute of Cerebrovascular Diseases, Baotou Center Hospital, Baotou, Inner Mongolia, China
| | - Jingbo Wang
- Department of Neurology, Inner Mongolia Institute of Cerebrovascular Diseases, Baotou Center Hospital, Baotou, Inner Mongolia, China
| | - Jili Zhao
- Graduate School, Baotou Medical College, Baotou, Inner Mongolia, China
| | - Baojun Wang
- Department of Neurology, Inner Mongolia Institute of Cerebrovascular Diseases, Baotou Center Hospital, Baotou, Inner Mongolia, China
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13
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Overmars LM, van Solinge WW, Ruijter HMD, van der Worp HB, Van Es B, Hulsbergen-Veelken CAR, Biessels GJ, Exalto LG, Haitjema S. Sexual dimorphism in peripheral blood cell characteristics linked to recanalization success of endovascular thrombectomy in acute ischemic stroke. J Thromb Thrombolysis 2023; 56:614-625. [PMID: 37596427 PMCID: PMC10550865 DOI: 10.1007/s11239-023-02881-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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 08/20/2023]
Abstract
Endovascular thrombectomy (EVT) success to treat acute ischemic stroke varies with factors like stroke etiology and clot composition, which can differ between sexes. We studied if sex-specific blood cell characteristics (BCCs) are related to recanalization success. We analyzed electronic health records of 333 EVT patients from a single intervention center, and extracted 71 BCCs from the Sapphire flow cytometry analyzer. Through Sparse Partial Least Squares Discriminant Analysis, incorporating cross-validation and stability selection, we identified BCCs associated with successful recanalization (TICI 3) in both sexes. Stroke etiology was considered, while controlling for cardiovascular risk factors. Of the patients, successful recanalization was achieved in 51% of women and 49% of men. 21 of the 71 BCCs showed significant differences between sexes (pFDR-corrected < 0.05). The female-focused recanalization model had lower error rates than both combined [t(192.4) = 5.9, p < 0.001] and male-only models [t(182.6) = - 15.6, p < 0.001]. In women, successful recanalization and cardioembolism were associated with a higher number of reticulocytes, while unsuccessful recanalization and large artery atherosclerosis (LAA) as cause of stroke were associated with a higher mean corpuscular hemoglobin concentration. In men, unsuccessful recanalization and LAA as cause of stroke were associated with a higher coefficient of variance of lymphocyte complexity of the intracellular structure. Sex-specific BCCs related to recanalization success varied and were linked to stroke etiology. This enhanced understanding may facilitate personalized treatment for acute ischemic stroke.
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Affiliation(s)
- L Malin Overmars
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center, Utrecht University, Utrecht, The Netherlands.
| | - Wouter W van Solinge
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Hester M den Ruijter
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Bram Van Es
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Geert Jan Biessels
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Lieza G Exalto
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Saskia Haitjema
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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14
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Zhang L, Li J, Yang B, Li W, Wang X, Zou M, Song H, Shi L, Duan Y. The risk and outcome of malignant brain edema in post-mechanical thrombectomy: acute ischemic stroke by anterior circulation occlusion. Eur J Med Res 2023; 28:435. [PMID: 37833809 PMCID: PMC10571427 DOI: 10.1186/s40001-023-01414-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND AND PURPOSE Malignant brain edema (MBE) occurring after mechanical thrombectomy (MT) in acute ischemic stroke (AIS) could lead to severe disability and mortality. We aimed to investigate the incidence, predictors, and clinical outcomes of MBE in patients with AIS after MT. METHODS The clinical and imaging data of 155 patients with AIS of anterior circulation after MT were studied. Standard non-contrast CT was used to evaluate baseline imaging characteristics at admission. Clinical outcomes were measured using the 90-day modified Rankin Scale (mRS) score. Based on the follow-up CT scans performed within 72 h after MT, the patients were classified into MBE and non-MBE group. MBE was defined as a midline shift of ≥ 5 mm with signs of local brain swelling. Univariate and multivariate regression analyses were used to analyze the relationship between MBE and clinical outcomes and identify the predictors that correlate with MBE. RESULTS MBE was observed in 19.4% of the patients who underwent MT and was associated with a lower rate of favorable 90-day clinical outcomes. Significant differences were observed in both MBE and non-MBE groups: baseline Alberta Stroke Program Early CT (ASPECT) score, hyperdense middle cerebral artery sign (HMCAS), baseline signs of early infarct, angiographic favorable collaterals, number of retrieval attempts, and revascularization rate. Multivariate analysis indicated that low baseline ASPECT score, absent HMCAS, angiographic poor collaterals, more retrieval attempt count, and poor revascularization independently influenced the occurrence of MBE in AIS patients with anterior circulation after MT. CONCLUSION MBE was associated with a lower rate of favorable 90-day clinical outcomes. Low baseline ASPECT score, absent HMCAS, angiographic poor collaterals, more retrieval attempt count and poor revascularization were independently associated with MBE after MT.
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Affiliation(s)
- Luojin Zhang
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China
- Department of Radiology, Shanxi Fenyang Hospital, Shanxi, China
| | - Jinze Li
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China
- Northern Theater Command Postgraduate Training Base of Jinzhou Medical University General Hospital, Shenyang, China
| | - Benqiang Yang
- Department of Radiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Wei Li
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xinrui Wang
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China
| | - Mingyu Zou
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China
| | - Hongyan Song
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China
| | - Lin Shi
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China
| | - Yang Duan
- Center for Neuroimaging, Department of Radiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang, China.
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15
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Brinjikji W, Kallmes DF, Virmani R, de Meyer SF, Yoo AJ, Humphries W, Zaidat OO, Teleb MS, Jones JG, Siddiqui AH, Andersson T, Nogueira RG, Gil SM, Douglas A, Rossi R, Rentzos A, Ceder E, Carlqvist J, Dunker D, Jood K, Tatlisumak T, Doyle KM. Endotheliitis and cytokine storm as a mechanism of clot formation in COVID-19 ischemic stroke patients: A histopathologic study of retrieved clots. Interv Neuroradiol 2023:15910199231185804. [PMID: 37769315 DOI: 10.1177/15910199231185804] [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: 09/30/2023] Open
Abstract
BACKGROUND Studies during the COVID-19 pandemic have demonstrated an association between COVID-19 virus infection and the development of acute ischemic stroke, particularly large vessel occlusion (LVO). Studying the characteristics and immunohistochemistry of retrieved stroke emboli during mechanical thrombectomy for LVO may offer insights into the pathogenesis of LVO in COVID-19 patients. We examined retrieved COVID-19 emboli from the STRIP, EXCELLENT, and RESTORE registries and compared their characteristics to a control group. METHODS We identified COVID-positive LVO patients from the STRIP, RESTORE, and EXCELLENT studies who underwent mechanical thrombectomy. These patients were matched to a control group controlling for stroke etiology based on Trial of Org 10172 in Acute Stroke Treatment criteria. All clots were stained with Martius Scarlet Blue (MSB) along with immunohistochemistry for interleukin-6 (IL-6), C-reactive protein (CRP), von Willebrand factor (vWF), CD66b, fibrinogen, and citrullinated Histone H3. Clot composition was compared between groups. RESULTS Nineteen COVID-19-positive patients and 38 controls were included. COVID-19-positive patients had a significantly higher percentage of CRP and vWF. There was no difference in IL-6, fibrin, CD66b, or citrullinated Histone H3 between groups. Based on MSB staining, there was no statistically significant difference regarding the percentage of red blood cells, white blood cells, fibrin, and platelets. CONCLUSIONS Our study found higher concentrations of CRP and vWF in retrieved clots of COVID-19-positive stroke patients compared to COVID-19-negative controls. These findings support the potential role of systemic inflammation as indicated by elevated CRP and endothelial injury as indicated by elevated vWF as precipitating factors in thrombus development in these patients.
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Affiliation(s)
| | | | - Renu Virmani
- Department of Pathology, CVPath Institute, Gaithersburg, MD, USA
| | - Simon F de Meyer
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, TX, USA
| | | | - Osama O Zaidat
- Department of Neuroscience, Mercy Health St Vincent Medical Center, Toledo, OH, USA
| | - Mohamed S Teleb
- Neurointerventional Surgery, Stroke, and Neurocritical Care, Banner Health, Mesa, AZ, USA
| | - Jesse G Jones
- Department of Neurosurgery, University of Alabama, Birmingham, AL, USA
| | - Adnan H Siddiqui
- Departments of Neurosurgery and Radiology, State University of New York at Buffalo, New York, NY, USA
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Raul G Nogueira
- Department of Neurology and Neurosurgery, University of Pittsburgh Medical Center, UPMC Stroke Institute, Pittsburgh, PA, USA
| | - Sara Molina Gil
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland, Galway, Ireland
- CÚRAM-SFI Research Centre for 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, Ireland
- CÚRAM-SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Rosanna Rossi
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland, Galway, Ireland
- CÚRAM-SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Alexander Rentzos
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Erik Ceder
- 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
| | - Dennis Dunker
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Jood
- Department of Clinical Neurosciences, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Turgut Tatlisumak
- Department of Clinical Neurosciences, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Karen M Doyle
- Department of Physiology and Galway Neuroscience Centre, School of Medicine, National University of Ireland, Galway, Ireland
- CÚRAM-SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland
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16
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Juega J, Li J, Palacio-Garcia C, Rodriguez M, Tiberi R, Piñana C, Rodriguez-Luna D, Requena M, García-Tornel Á, Rodriguez-Villatoro N, Rubiera M, Muchada M, Olivé-Gadea M, Rizzo F, Hernandez D, Dios-Lascuevas M, Hernandez-Perez M, Dorado L, Quesada H, Cardona P, De La Torre C, Gallur L, Camacho J, Ramon-Y-Cajal S, Tomasello A, Ribó M, Molina CA, Pagola J. Granulocytes-Rich Thrombi in Cerebral Large Vessel Occlusion Are Associated with Increased Stiffness and Poorer Revascularization Outcomes. Neurotherapeutics 2023; 20:1167-1176. [PMID: 37212981 PMCID: PMC10457261 DOI: 10.1007/s13311-023-01385-1] [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] [Accepted: 04/24/2023] [Indexed: 05/23/2023] Open
Abstract
We aim to identify a profile of intracranial thrombus resistant to recanalization by mechanical thrombectomy (MT) in acute stroke treatment. The first extracted clot of each MT was analyzed by flow cytometry obtaining the composition of the main leukocyte populations: granulocytes, monocytes, and lymphocytes. Demographics, reperfusion treatment, and grade of recanalization were registered. MT failure (MTF) was defined as final thrombolysis in cerebral infarction score IIa or lower and/or need of permanent intracranial stenting as a rescue therapy. To explore the relationship between stiffness of intracranial clots and cellular composition, unconfined compression tests were performed in other cohorts of cases. Thrombi obtained in 225 patients were analyzed. MTF were observed in 30 cases (13%). MTF was associated with atherosclerosis etiology (33.3% vs. 15.9%; p = 0.021) and higher number of passes (3 vs. 2; p < 0.001). Clot analysis of MTF showed higher percentage of granulocytes [82.46 vs. 68.90% p < 0.001] and lower percentage of monocytes [9.18% vs.17.34%, p < 0.001] in comparison to successful MT cases. The proportion of clot granulocytes (aOR 1.07; 95% CI 1.01-1.14) remained an independent marker of MTF. Among thirty-eight clots mechanically tested, there was a positive correlation between granulocyte proportion and thrombi stiffness (Pearson's r = 0.35, p = 0.032), with a median clot stiffness of 30.2 (IQR, 18.9-42.7) kPa. Granulocytes-rich thrombi are harder to capture by mechanical thrombectomy due to increased stiffness, so a proportion of intracranial granulocytes might be useful to guide personalized endovascular procedures in acute stroke treatment.
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Affiliation(s)
- Jesús Juega
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Jiahui Li
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | | | - Maite Rodriguez
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Riccardo Tiberi
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Carlos Piñana
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - David Rodriguez-Luna
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Álvaro García-Tornel
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Noelia Rodriguez-Villatoro
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Marian Muchada
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Federica Rizzo
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - David Hernandez
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marta Dios-Lascuevas
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Laura Dorado
- Department of Neurology, Germans Trias I Pujol University Hospital, Badalona, Spain
| | - Helena Quesada
- Department of Neurology, Bellvitge University Hospital, Hospitalet de Llobregat, Spain
| | - Pere Cardona
- Department of Neurology, Bellvitge University Hospital, Hospitalet de Llobregat, Spain
| | - Carolina De La Torre
- Proteomics Unit, Josep Carreras Leukaemia Research Institute (IJC), Badalona, Spain
| | - Laura Gallur
- Hematology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jessica Camacho
- Department of Pathology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Alejandro Tomasello
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain.
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
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17
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Huo X, Sun D, Chen W, Han H, Abdalkader M, Puetz V, Yi T, Wang H, Liu R, Tong X, Jia B, Ma N, Gao F, Mo D, Yan B, Mitchell PJ, Leung TW, Yavagal DR, Albers GW, Costalat V, Fiehler J, Zaidat OO, Jovin TG, Liebeskind DS, Nguyen TN, Miao Z. Endovascular Treatment for Acute Large Vessel Occlusion Due to Underlying Intracranial Atherosclerotic Disease. Semin Neurol 2023; 43:337-344. [PMID: 37549690 DOI: 10.1055/s-0043-1771207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Intracranial atherosclerotic disease (ICAD) is one of the most common causes of acute ischemic stroke worldwide. Patients with acute large vessel occlusion due to underlying ICAD (ICAD-LVO) often do not achieve successful recanalization when undergoing mechanical thrombectomy (MT) alone, requiring rescue treatment, including intra-arterial thrombolysis, balloon angioplasty, and stenting. Therefore, early detection of ICAD-LVO before the procedure is important to enable physicians to select the optimal treatment strategy for ICAD-LVO to improve clinical outcomes. Early diagnosis of ICAD-LVO is challenging in the absence of consensus diagnostic criteria on noninvasive imaging and early digital subtraction angiography. In this review, we summarize the clinical and diagnostic criteria, prediction of ICAD-LVO prior to the procedure, and EVT strategy of ICAD-LVO and provide recommendations according to the current literature.
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Affiliation(s)
- Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hongxing Han
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | | | - Volker Puetz
- Department of Neurology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hao Wang
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Raynald Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre, Melbourne, Australia
| | - Peter J Mitchell
- Department of Radiology, Melbourne Brain Centre, Melbourne, Australia
| | - Thomas W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Dileep R Yavagal
- Departments of Neurology and Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Güi-de-Chauliac, CHU de Montpellier, Montpellier, France
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Osama O Zaidat
- Department of Neuroscience, Mercy Saint Vincent Medical Center, Toledo, Ohio
| | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital, Camden, New Jersey
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, California
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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18
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Darcourt J, Brinjikji W, François O, Giraud A, Johnson CR, Patil S, Staessens S, Kadirvel R, Mohammaden MH, Pisani L, Rodrigues GM, Cancelliere NM, Pereira VM, Bozsak F, Doyle K, De Meyer SF, Messina P, Kallmes D, Cognard C, Nogueira RG. Identifying ex vivo acute ischemic stroke thrombus composition using electrochemical impedance spectroscopy. Interv Neuroradiol 2023:15910199231175377. [PMID: 37192738 DOI: 10.1177/15910199231175377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Intra-procedural characterization of stroke thromboemboli might guide mechanical thrombectomy (MT) device choice to improve recanalization rates. Electrochemical impedance spectroscopy (EIS) has been used to characterize various biological tissues in real time but has not been used in thrombus. OBJECTIVE To perform a feasibility study of EIS analysis of thrombi retrieved by MT to evaluate: (1) the ability of EIS and machine learning to predict red blood cell (RBC) percentage content of thrombi and (2) to classify the thrombi as "RBC-rich" or "RBC-poor" based on a range of cutoff values of RBC. METHODS ClotbasePilot was a multicentric, international, prospective feasibility study. Retrieved thrombi underwent histological analysis to identify proportions of RBC and other components. EIS results were analyzed with machine learning. Linear regression was used to evaluate the correlation between the histology and EIS. Sensitivity and specificity of the model to classify the thrombus as RBC-rich or RBC-poor were also evaluated. RESULTS Among 514 MT,179 thrombi were included for EIS and histological analysis. The mean composition in RBC of the thrombi was 36% ± 24. Good correlation between the impedance-based prediction and histology was achieved (slope of 0.9, R2 = 0.53, Pearson coefficient = 0.72). Depending on the chosen cutoff, ranging from 20 to 60% of RBC, the calculated sensitivity for classification of thrombi ranged from 77 to 85% and the specificity from 72 to 88%. CONCLUSION Combination of EIS and machine learning can reliably predict the RBC composition of retrieved ex vivo AIS thrombi and then classify them into groups according to their RBC composition with good sensitivity and specificity.
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Affiliation(s)
- Jean Darcourt
- Department of Neuroradiology, University Hospital of Toulouse, Toulouse, France
- INSERM I2MC (Institut des Maladies Cardiovasculaires et Métaboliques) UMR 1048, Toulouse University Hospital, Toulouse, France
| | - Waleed Brinjikji
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, USA
- Neurosurgery, Mayo Clinic Rochester, Rochester, MN, USA
| | | | | | - Collin R Johnson
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, USA
- Neurosurgery, Mayo Clinic Rochester, Rochester, MN, USA
| | - Smita Patil
- Department of Physiology, Galway Neuroscience Centre, National University of Ireland Galway, Galway, Ireland
- CÚRAM - SFI Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Senna Staessens
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Belgium
| | - Ramanathan Kadirvel
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, USA
- Neurosurgery, Mayo Clinic Rochester, Rochester, MN, USA
| | - Mahmoud H Mohammaden
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, GA, USA
| | - Leonardo Pisani
- Department of Neurology, Grady Memorial Hospital and Emory University, Atlanta, GA, USA
| | | | - Nicole M Cancelliere
- Department of Neurosurgery, Department of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Vitor Mendes Pereira
- Department of Neurosurgery, Department of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | | | - Karen Doyle
- Department of Physiology, Galway Neuroscience Centre, National University of Ireland Galway, Galway, Ireland
- CÚRAM - SFI Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Belgium
| | | | - David Kallmes
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, USA
- Neurosurgery, Mayo Clinic Rochester, Rochester, MN, USA
| | - Christophe Cognard
- Department of Neuroradiology, University Hospital of Toulouse, Toulouse, France
- INSERM I2MC (Institut des Maladies Cardiovasculaires et Métaboliques) UMR 1048, Toulouse University Hospital, Toulouse, France
| | - Raul G Nogueira
- Department of Neurology and Neurosurgery, University of Pittsburg Medical Center, UPMC Stroke Institute, Pittsburg, PA, USA
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19
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Barakzie A, Jansen AG, ten Cate H, de Maat MP. Coagulation biomarkers for ischemic stroke. Res Pract Thromb Haemost 2023; 7:100160. [PMID: 37274178 PMCID: PMC10236221 DOI: 10.1016/j.rpth.2023.100160] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/24/2023] [Accepted: 03/25/2023] [Indexed: 06/06/2023] Open
Abstract
A State of the Art lecture titled "coagulation biomarkers for ischemic stroke" was presented at the International Society on Thrombosis and Haemostasis (ISTH) Congress in 2022. Ischemic stroke (IS) is a common disease with major morbidity and mortality. It is a challenge to determine which patients are at risk for IS or have poor clinical outcome after IS. An imbalance of coagulation markers may contribute to the progression and prognosis of IS. Therefore, we now discuss studies on the association of selected coagulation biomarkers from the hemostasis, inflammation, and immunothrombosis systems with the risk of IS, stroke severity at the acute phase, and clinical outcome after treatment. We report on coagulation biomarker-induced risk of IS, stroke severity, and outcomes following IS derived from prospective population studies, case-control studies, and acute-phase IS studies. We found indications that many coagulation and inflammation biomarkers are associated with IS, but it is early to conclude that any of these biomarkers can be applied in a therapeutic setting to predict patients at risk of IS, stroke severity at the acute phase, and clinical outcome after treatment. The strongest evidence for a role in IS was found for beta-thromboglobulin, von Willebrand factor, factor VIII, fibrinogen, thrombin-activatable fibrinolysis inhibitor, D-dimer, and neutrophil extracellular traps, and therefore, they are promising candidates. Further research and validation in large-size populations using well-defined study designs are warranted. Finally, we provide a selection of recent data relevant to this subject that was presented at the 2022 ISTH Congress.
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Affiliation(s)
- Aarazo Barakzie
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A.J. Gerard Jansen
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hugo ten Cate
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, The Netherlands
- Thrombosis Expertise Center and Department of Internal Medicine, Maastricht University Medical Centre, The Netherlands
| | - Moniek P.M. de Maat
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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20
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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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21
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Vantyghem S, Staessens S, Francois O, De Meyer SF, Vanacker P. Mechanical thrombectomy for acute ischemic stroke revealing a cardiac myxoma: histological and immunohistochemical study to determine myxomatous emboli. Acta Neurol Belg 2023:10.1007/s13760-023-02254-6. [PMID: 37040065 DOI: 10.1007/s13760-023-02254-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 03/25/2023] [Indexed: 04/12/2023]
Affiliation(s)
- Soetkin Vantyghem
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
- Department of Neurology, Groeninge Hospital, Kortrijk, Belgium
| | - Senna Staessens
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak, Kortrijk, Belgium
| | | | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak, Kortrijk, Belgium
| | - Peter Vanacker
- Department of Neurology, Groeninge Hospital, Kortrijk, Belgium.
- NeuroVascular Center and Stroke Unit Antwerp, Department of Neurology, Antwerp University Hospital, Wilrijkstraat 10, Edegem, 2650, Antwerp, Belgium.
- Research Group on Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, Wilrijk, 2910, Antwerp, Belgium.
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22
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Costamagna G, Bonato S, Corti S, Meneri M. Advancing Stroke Research on Cerebral Thrombi with Omic Technologies. Int J Mol Sci 2023; 24:ijms24043419. [PMID: 36834829 PMCID: PMC9961481 DOI: 10.3390/ijms24043419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/05/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023] Open
Abstract
Cerebrovascular diseases represent a leading cause of disability, morbidity, and death worldwide. In the last decade, the advances in endovascular procedures have not only improved acute ischemic stroke care but also conceded a thorough analysis of patients' thrombi. Although early anatomopathological and immunohistochemical analyses have provided valuable insights into thrombus composition and its correlation with radiological features, response to reperfusion therapies, and stroke etiology, these results have been inconclusive so far. Recent studies applied single- or multi-omic approaches-such as proteomics, metabolomics, transcriptomics, or a combination of these-to investigate clot composition and stroke mechanisms, showing high predictive power. Particularly, one pilot studies showed that combined deep phenotyping of stroke thrombi may be superior to classic clinical predictors in defining stroke mechanisms. Small sample sizes, varying methodologies, and lack of adjustments for potential confounders still represent roadblocks to generalizing these findings. However, these techniques hold the potential to better investigate stroke-related thrombogenesis and select secondary prevention strategies, and to prompt the discovery of novel biomarkers and therapeutic targets. In this review, we summarize the most recent findings, overview current strengths and limitations, and present future perspectives in the field.
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Affiliation(s)
- Gianluca Costamagna
- Dino Ferrari Centre, Neuroscience Section, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Via Francesco Sforza 35, 20122 Milan, Italy
- Stroke Unit, Neurology Unit, Neuroscience and Mental Health Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence:
| | - Sara Bonato
- Stroke Unit, Neurology Unit, Neuroscience and Mental Health Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Stefania Corti
- Dino Ferrari Centre, Neuroscience Section, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Via Francesco Sforza 35, 20122 Milan, Italy
- Stroke Unit, Neurology Unit, Neuroscience and Mental Health Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Megi Meneri
- Dino Ferrari Centre, Neuroscience Section, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Via Francesco Sforza 35, 20122 Milan, Italy
- Stroke Unit, Neurology Unit, Neuroscience and Mental Health Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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23
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Narwal A, Whyte CS, Mutch NJ. Location, location, location: Fibrin, cells, and fibrinolytic factors in thrombi. Front Cardiovasc Med 2023; 9:1070502. [PMID: 36741833 PMCID: PMC9889369 DOI: 10.3389/fcvm.2022.1070502] [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: 10/14/2022] [Accepted: 12/16/2022] [Indexed: 01/20/2023] Open
Abstract
Thrombi are heterogenous in nature with composition and structure being dictated by the site of formation, initiating stimuli, shear stress, and cellular influences. Arterial thrombi are historically associated with high platelet content and more tightly packed fibrin, reflecting the shear stress in these vessels. In contrast, venous thrombi are generally erythrocyte and fibrin-rich with reduced platelet contribution. However, these conventional views on the composition of thrombi in divergent vascular beds have shifted in recent years, largely due to recent advances in thromboectomy and high-resolution imaging. Interestingly, the distribution of fibrinolytic proteins within thrombi is directly influenced by the cellular composition and vascular bed. This in turn influences the susceptibility of thrombi to proteolytic degradation. Our current knowledge of thrombus composition and its impact on resistance to thrombolytic therapy and success of thrombectomy is advancing, but nonetheless in its infancy. We require a deeper understanding of thrombus architecture and the downstream influence on fibrinolytic susceptibility. Ultimately, this will aid in a stratified and targeted approach to tailored antithrombotic strategies in patients with various thromboembolic diseases.
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24
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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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25
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Gao J, Yao M, Chang D, Liu J. mTOR (Mammalian Target of Rapamycin): Hitting the Bull's Eye for Enhancing Neurogenesis After Cerebral Ischemia? Stroke 2023; 54:279-285. [PMID: 36321454 DOI: 10.1161/strokeaha.122.040376] [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: 12/24/2022]
Abstract
Ischemic stroke remains a leading cause of morbidity and disability around the world. The sequelae of serious neurological damage are irreversible due to body's own limited repair capacity. However, endogenous neurogenesis induced by cerebral ischemia plays a critical role in the repair and regeneration of impaired neural cells after ischemic brain injury. mTOR (mammalian target of rapamycin) kinase has been suggested to regulate neural stem cells ability to self-renew and differentiate into proliferative daughter cells, thus leading to improved cell growth, proliferation, and survival. In this review, we summarized the current evidence to support that mTOR signaling pathways may enhance neurogenesis, angiogenesis, and synaptic plasticity following cerebral ischemia, which could highlight the potential of mTOR to be a viable therapeutic target for the treatment of ischemic brain injury.
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Affiliation(s)
- Jiale Gao
- Beijing Key Laboratory of Pharmacology of Chinese Materia Medica, Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, China (J.G., M.Y., J.L.)
| | - Mingjiang Yao
- Beijing Key Laboratory of Pharmacology of Chinese Materia Medica, Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, China (J.G., M.Y., J.L.)
| | - Dennis Chang
- NICM Health Research Institute, Western Sydney University, Penrith, Australia (D.C.)
| | - Jianxun Liu
- Beijing Key Laboratory of Pharmacology of Chinese Materia Medica, Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, China (J.G., M.Y., J.L.)
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26
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Miller C, Konduri P, Bridio S, Luraghi G, Arrarte Terreros N, Boodt N, Samuels N, Rodriguez Matas JF, Migliavacca F, Lingsma H, van der Lugt A, Roos Y, Dippel D, Marquering H, Majoie C, Hoekstra A. In silico thrombectomy trials for acute ischemic stroke. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 228:107244. [PMID: 36434958 DOI: 10.1016/j.cmpb.2022.107244] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/11/2022] [Accepted: 11/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND OBJECTIVE In silico trials aim to speed up the introduction of new devices in clinical practice by testing device design and performance in different patient scenarios and improving patient stratification for optimizing clinical trials. In this paper, we demonstrate an in silico trial framework for thrombectomy treatment of acute ischemic stroke and apply this framework to compare treatment outcomes in different subpopulations and with different thrombectomy stent-retriever devices. We employ a novel surrogate thrombectomy model to evaluate the thrombectomy success in the in silico trial. METHODS The surrogate thrombectomy model, built using data from a fine-grained finite-element model, is a device-specific binary classifier (logistic regression), to estimate the probability of successful recanalization, the outcome of interest. We incorporate this surrogate model within our previously developed in silico trial framework and demonstrate its use with three examples of in silico clinical trials. The first trial is a validation trial for the surrogate thrombectomy model. We then present two exploratory trials: one evaluating the performance of a commercially available device based on the fibrin composition in the occluding thrombus and one comparing the performance of two commercially available stent retrievers. RESULTS The Validation Trial showed the surrogate thrombectomy model was able to reproduce a similar recanalization rate as the real-life MR CLEAN trial (p=0.6). Results from the first exploratory trial showed that the chance of successful thrombectomy increases with higher blood cell concentrations in the thrombi, which is in line with observations from clinical data. The second exploratory trial showed improved recanalization success with a newer stent retriever device; however, these results require further investigation as the surrogate model for the newer stent retriever device has not yet been validated. CONCLUSIONS In this novel study, we have shown that in silico trials have the potential to help inform medical device developers on the performance of a new device and may also be used to select populations of interest for a clinical trial. This would reduce the time and costs involved in device development and traditional clinical trials.
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Affiliation(s)
- Claire Miller
- Computational Science Laboratory, Informatics Institute, Faculty of Science, University of Amsterdam, Amsterdam 1098 XH, the Netherlands
| | - Praneeta Konduri
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam 1105 AZ, the Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam 1105 AZ, the Netherlands
| | - Sara Bridio
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Milan 20133, Italy
| | - Giulia Luraghi
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Milan 20133, Italy
| | - Nerea Arrarte Terreros
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam 1105 AZ, the Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam 1105 AZ, the Netherlands
| | - Nikki Boodt
- Department of Radiology, Neurology, and Public Health, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam 3015 CE, the Netherlands
| | - Noor Samuels
- Department of Radiology, Neurology, and Public Health, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam 3015 CE, the Netherlands
| | - Jose F Rodriguez Matas
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Milan 20133, Italy
| | - Francesco Migliavacca
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Milan 20133, Italy
| | - Hester Lingsma
- Department of Public Health, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam 3015 CE, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam 3015 CE, the Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam 1105 AZ, the Netherlands
| | - Diederik Dippel
- Department of Neurology, Amsterdam UMC, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam 3015 CE, the Netherlands
| | - Henk Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam 1105 AZ, the Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam 1105 AZ, the Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam 1105 AZ, the Netherlands
| | - Alfons Hoekstra
- Computational Science Laboratory, Informatics Institute, Faculty of Science, University of Amsterdam, Amsterdam 1098 XH, the Netherlands.
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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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28
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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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29
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Hu J, He W, Zheng B, Huang F, Lv K, Liao J, Chen Z, Jiang H, Wang K, Wang H, Lei Y, Liao J, Sang H, Liu S, Luo W, Sun R, Yang J, Huang J, Song J, Li F, Zi W, Long C, Yang Q. Hyperdense Artery Sign and Clinical Outcomes After Endovascular Treatment in Acute Basilar Artery Occlusion. Front Neurol 2022; 13:830705. [PMID: 35547375 PMCID: PMC9081764 DOI: 10.3389/fneur.2022.830705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background This study aimed to investigate the association between the hyperdense basilar artery sign (HBAS) on non-enhanced computed tomography (CT) and clinical outcomes in patients with acute basilar artery occlusion (BAO) who underwent endovascular treatment (EVT). Methods Eligible patients who underwent EVT due to acute BAO between January 2014 and May 2019 were divided into two groups based on HBAS. HBAS was assessed by two neuroradiologists using five grades on nonenhanced CT. The primary outcome was a favorable functional outcome (defined as a modified Rankin Scale [mRS] of 0-3) at 90 days. Secondary outcomes included successful recanalization and mortality within 90 days. Results Among 829 patients with BAO as assessed with CT angiography, magnetic resonance angiography, or digital subtraction angiography, 643 patients were treated with EVT. Of these, 51.32% (330/643) had HBAS. Patients with HBAS were older and had more severe neurological deficits and a higher frequency of atrial fibrillation than those without HBAS. There was no significant difference in favorable outcome (adjusted odds ratio [aOR]: 1.354, 95% confidence interval [CI]: 0.906-2.024; p = 0.14), successful recanalization (aOR: 0.926, 95% CI: 0.616--1.393; p = 0.71), and mortality (aOR: 1.193, 95% CI: 0.839-1.695; p = 0.33) between patients with or without HBAS. Subgroup analysis showed that the HBAS predicted a favorable outcome in patients aged <60 years (aOR: 2.574, 95% CI: 1.234-5.368; p = 0.01) and patients with vertebral artery-V4 segment occlusion (aOR: 3.738, 95% CI: 1.212-11.530; p = 0.02). In patients with HBAS, the baseline National Institutes of Health Stroke Scale (NIHSS) score, posterior circulation-Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS), and stent retriever were associated with successful recanalization. Conclusions Our study did not find a significant association between HBAS and favorable outcomes and successful recanalization in patients with BAO who underwent EVT. Moreover, large prospective studies are warranted to further investigate this relationship.
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Affiliation(s)
- Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wencheng He
- Department of Neurology, Guiping People's Hospital, Guiping, China
| | - Bo Zheng
- Department of Neurology, Yaan Peoples's Hospital, Yaan, China
| | - Fang Huang
- Department of Neurology, People's Hospital of Yuxi City, Yuxi, China
| | - Kefeng Lv
- Department of Neurology, Dongguan People's Hospital of Southern Medical University, Dongguan, China
| | - Jiasheng Liao
- Department of Neurology, Suining No.1 People's Hospital, Suining, China
| | - Zhao Chen
- Department of Neurology, Yaan Peoples's Hospital, Yaan, China
| | - He Jiang
- Department of Neurology, The First People's Hospital of Neijiang, Neijiang, China
| | - Kuiyun Wang
- Department of Neurology, The Jintang First People's Hospital, Jintang, China
| | - Hongjun Wang
- Department of Neurology, Fengdu People's Hospital, Fengdu, China
| | - Yang Lei
- Department of Neurology, Wulong District People's Hospital, Chongqing, China
| | - Jiachuan Liao
- Department of Neurology, Santai County People's Hospital of North Sichuan Medical College, Santai, China
| | - Hongfei Sang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weidong Luo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Ruidi Sun
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chen Long
- Department of Emergency, Xiangtan Central Hospital, Chongqing, China
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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30
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Endres M, Moro MA, Nolte CH, Dames C, Buckwalter MS, Meisel A. Immune Pathways in Etiology, Acute Phase, and Chronic Sequelae of Ischemic Stroke. Circ Res 2022; 130:1167-1186. [PMID: 35420915 DOI: 10.1161/circresaha.121.319994] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Inflammation and immune mechanisms are crucially involved in the pathophysiology of the development, acute damage cascades, and chronic course after ischemic stroke. Atherosclerosis is an inflammatory disease, and, in addition to classical risk factors, maladaptive immune mechanisms lead to an increased risk of stroke. Accordingly, individuals with signs of inflammation or corresponding biomarkers have an increased risk of stroke. Anti-inflammatory drugs, such as IL (interleukin)-1β blockers, methotrexate, or colchicine, represent attractive treatment strategies to prevent vascular events and stroke. Lately, the COVID-19 pandemic shows a clear association between SARS-CoV2 infections and increased risk of cerebrovascular events. Furthermore, mechanisms of both innate and adaptive immune systems influence cerebral damage cascades after ischemic stroke. Neutrophils, monocytes, and microglia, as well as T and B lymphocytes each play complex interdependent roles that synergize to remove dead tissue but also can cause bystander injury to intact brain cells and generate maladaptive chronic inflammation. Chronic systemic inflammation and comorbid infections may unfavorably influence both outcome after stroke and recurrence risk for further stroke. In addition, stroke triggers specific immune depression, which in turn can promote infections. Recent research is now increasingly addressing the question of the extent to which immune mechanisms may influence long-term outcome after stroke and, in particular, cause specific complications such as poststroke dementia or even poststroke depression.
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Affiliation(s)
- Matthias Endres
- Klinik für Neurologie mit Experimenteller Neurologie (M.E., C.H.N., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Center for Stroke Research Berlin (M.E., C.H.N., C.D., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Excellence Cluster NeuroCure (M.E.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,German Center for Neurodegenerative Diseases, Partner Site Berlin, Germany (M.E.).,German Centre for Cardiovascular Research, Partner Site Berlin, Germany (M.E., C.H.N.)
| | - Maria A Moro
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (M.A.M.).,Departamento de Farmacología yToxicología, Unidad de Investigación Neurovascular, Universidad Complutense de Madrid, Madrid, Spain (M.A.M.).,Instituto Universitario de Investigación en Neuroquímica, UCM, Madrid, Spain (M.A.M.).,Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain (M.A.M.)
| | - Christian H Nolte
- Klinik für Neurologie mit Experimenteller Neurologie (M.E., C.H.N., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Center for Stroke Research Berlin (M.E., C.H.N., C.D., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,German Centre for Cardiovascular Research, Partner Site Berlin, Germany (M.E., C.H.N.)
| | - Claudia Dames
- Center for Stroke Research Berlin (M.E., C.H.N., C.D., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Institute for Medical Immunology (C.D.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (M.S.B.).,Wu Tsai Neurosciences Institute, Stanford University, CA (M.S.B.)
| | - Andreas Meisel
- Klinik für Neurologie mit Experimenteller Neurologie (M.E., C.H.N., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,Center for Stroke Research Berlin (M.E., C.H.N., C.D., A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,NeuroCure Clinical Research Center (A.M.), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
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Ikenberg B, Boeckh-Behrens T, Maegerlein C, Härtl J, Hernandez Petzsche M, Zimmer C, Wunderlich S, Berndt M. Ischemic Stroke of Suspected Cardioembolic Origin Despite Anticoagulation: Does Thrombus Analysis Help to Clarify Etiology? Front Neurol 2022; 13:824792. [PMID: 35359653 PMCID: PMC8961689 DOI: 10.3389/fneur.2022.824792] [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: 11/29/2021] [Accepted: 01/25/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Despite sufficient oral anticoagulation (OAC) to prevent cardioembolism, some patients suffer from cerebral ischemic strokes of suspected cardioembolic origin. Reasons for that are not clarified yet. In certain cases, the suspected cardioembolic origin of stroke is questioned. This study aimed to understand the thrombi origin and pathophysiology in patients suffering from stroke despite OAC by the analysis of histologic thrombus composition and imaging characteristics. Materials and Methods On two distinct cohorts, we retrospectively analyzed histologic (n = 92) and imaging features (n = 64), i.e., thrombus perviousness in admission CT imaging, of cerebral thrombi retrieved by the endovascular treatment for a large vessel occlusion of the anterior circulation. In each group, patients with non-cardioembolic strokes and suspected cardioembolic strokes with or without anticoagulation were compared. Results Fibrin/platelet content of suspected cardioembolic thrombi (mean/SD 57.2% ± 13) is higher than in non-cardioembolic thrombi (48.9% ± 17; p = 0.01). In suspected cardioembolic thrombi, the fibrin/platelet content does not differ in the subgroups of patients with (57.3% ± 13) and without prior OAC treatment (56.6% ±13; p = 0.8), both with higher values than non-cardioembolic thrombi. Thrombus perviousness (ε) of suspected cardioembolic OAC thrombi (mean/SD: 0.09 ± 0.06) differs significantly from non-cardioembolic thrombi (0.02 ± 0.02; p < 0.001). Further, ε is higher in suspected cardioembolic thrombi with OAC than in cardioembolic thrombi without OAC (0.06 ± 0.03; p = 0.04) and with insufficient OAC (0.04 ± 0.02; p = 0.07). Conclusion Thrombi of the suspected cardioembolic origin of patients with prior OAC do not differ in their histologic composition from those without prior OAC, but both differ from non-cardioembolic thrombi. These histologic results make a non-cardioembolic etiology for strokes despite prior OAC rather unlikely but favor other reasons for these ischemic events. Perviousness assessment reinforces the histologic findings, with additional information about the OAC thrombi, which present with higher perviousness. This suggests that OAC would not affect the relative histologic thrombus composition but may alter the microstructure, as reflected by perviousness.
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Affiliation(s)
- Benno Ikenberg
- Department of Neurology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- *Correspondence: Benno Ikenberg
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Johanna Härtl
- Department of Neurology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Moritz Hernandez Petzsche
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Silke Wunderlich
- Department of Neurology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maria Berndt
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Sanchez ZAC, Vijayananda V, Virassammy DM, Rosenfeld L, Ramasubramanian AK. The interaction of vortical flows with red cells in venous valve mimics. BIOMICROFLUIDICS 2022; 16:024103. [PMID: 35282036 PMCID: PMC8896891 DOI: 10.1063/5.0078337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/08/2022] [Indexed: 06/14/2023]
Abstract
The motion of cells orthogonal to the direction of main flow is of importance in natural and engineered systems. The lateral movement of red blood cells (RBCs) distal to sudden expansion is considered to influence the formation and progression of thrombosis in venous valves, aortic aneurysms, and blood-circulating devices and is also a determining parameter for cell separation applications in flow-focusing microfluidic devices. Although it is known that the unique geometry of venous valves alters the blood flow patterns and cell distribution in venous valve sinuses, the interactions between fluid flow and RBCs have not been elucidated. Here, using a dilute cell suspension in an in vitro microfluidic model of a venous valve, we quantified the spatial distribution of RBCs by microscopy and image analysis, and using micro-particle image velocimetry and 3D computational fluid dynamics simulations, we analyzed the complex flow patterns. The results show that the local hematocrit in the valve pockets is spatially heterogeneous and is significantly different from the feed hematocrit. Above a threshold shear rate, the inertial separation of streamlines and lift forces contribute to an uneven distribution of RBCs in the vortices, the entrapment of RBCs in the vortices, and non-monotonic wall shear stresses in the valve pockets. Our experimental and computational characterization provides insights into the complex interactions between fluid flow, RBC distribution, and wall shear rates in venous valve mimics, which is of relevance to understanding the pathophysiology of thrombosis and improving cell separation efficiency.
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Genchi A, Semerano A, Schwarz G, Dell'Acqua B, Gullotta GS, Sampaolo M, Boeri E, Quattrini A, Sanvito F, Diamanti S, Bergamaschi A, Grassi S, Podini P, Panni P, Michelozzi C, Simionato F, Scomazzoni F, Remida P, Valvassori L, Falini A, Ferrarese C, Michel P, Saliou G, Hajdu S, Beretta S, Roveri L, Filippi M, Strambo D, Martino G, Bacigaluppi M. Neutrophils predominate the immune signature of cerebral thrombi in COVID-19 stroke patients. Acta Neuropathol Commun 2022; 10:14. [PMID: 35105380 PMCID: PMC8805426 DOI: 10.1186/s40478-022-01313-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/08/2022] [Indexed: 02/07/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is associated with an increased risk of thrombotic events. Ischemic stroke in COVID-19 patients entails high severity and mortality rates. Here we aimed to analyze cerebral thrombi of COVID-19 patients with large vessel occlusion (LVO) acute ischemic stroke to expose molecular evidence for SARS-CoV-2 in the thrombus and to unravel any peculiar immune-thrombotic features. We conducted a systematic pathological analysis of cerebral thrombi retrieved by endovascular thrombectomy in patients with LVO stroke infected with COVID-19 (n = 7 patients) and non-covid LVO controls (n = 23). In thrombi of COVID-19 patients, the SARS-CoV-2 docking receptor ACE2 was mainly expressed in monocytes/macrophages and showed higher expression levels compared to controls. Using polymerase chain reaction and sequencing, we detected SARS-CoV-2 Clade20A, in the thrombus of one COVID-19 patient. Comparing thrombus composition of COVID-19 and control patients, we noted no overt differences in terms of red blood cells, fibrin, neutrophil extracellular traps (NETs), von Willebrand Factor (vWF), platelets and complement complex C5b-9. However, thrombi of COVID-19 patients showed increased neutrophil density (MPO+ cells) and a three-fold higher Neutrophil-to-Lymphocyte Ratio (tNLR). In the ROC analysis both neutrophils and tNLR had a good discriminative ability to differentiate thrombi of COVID-19 patients from controls. In summary, cerebral thrombi of COVID-19 patients can harbor SARS-CoV2 and are characterized by an increased neutrophil number and tNLR and higher ACE2 expression. These findings suggest neutrophils as the possible culprit in COVID-19-related thrombosis.
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Affiliation(s)
- Angela Genchi
- Neuroimmunology Unit, Institute of Experimental Neurology, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
- Department of Neurology, San Raffaele Hospital, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Aurora Semerano
- Neuroimmunology Unit, Institute of Experimental Neurology, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
- Department of Neurology, San Raffaele Hospital, Milan, Italy
| | - Ghil Schwarz
- Department of Neurology, San Raffaele Hospital, Milan, Italy
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Beatrice Dell'Acqua
- Neuroimmunology Unit, Institute of Experimental Neurology, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
- Department of Neurology, San Raffaele Hospital, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Giorgia Serena Gullotta
- Neuroimmunology Unit, Institute of Experimental Neurology, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Michela Sampaolo
- Department of Microbiology and Virology, San Raffaele Hospital, Milan, Italy
| | - Enzo Boeri
- Department of Microbiology and Virology, San Raffaele Hospital, Milan, Italy
| | | | | | - Susanna Diamanti
- Department of Medicine and Surgery, San Gerardo Hospital and Milano-Bicocca University, Milan, Italy
| | - Andrea Bergamaschi
- Neuroimmunology Unit, Institute of Experimental Neurology, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Stefano Grassi
- Department of Pathology, San Raffaele Hospital, Milan, Italy
| | - Paola Podini
- Neuropathology Unit, San Raffaele Hospital, Milan, Italy
| | - Pietro Panni
- Department of Neuroradiology, San Raffaele Hospital, Milan, Italy
| | | | - Franco Simionato
- Department of Neuroradiology, San Raffaele Hospital, Milan, Italy
| | | | - Paolo Remida
- Department of Neuroradiology, San Gerardo Hospital, Monza, Italy
| | - Luca Valvassori
- Department of Neuroradiology, San Gerardo Hospital, Monza, Italy
| | - Andrea Falini
- University Vita-Salute San Raffaele, Milan, Italy
- Department of Neuroradiology, San Raffaele Hospital, Milan, Italy
| | - Carlo Ferrarese
- Department of Medicine and Surgery, San Gerardo Hospital and Milano-Bicocca University, Milan, Italy
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Guillaume Saliou
- Service of Diagnostic and Interventional Radiology, Interventional Neuroradiological Unit, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Steven Hajdu
- Service of Diagnostic and Interventional Radiology, Interventional Neuroradiological Unit, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Simone Beretta
- Department of Medicine and Surgery, San Gerardo Hospital and Milano-Bicocca University, Milan, Italy
| | - Luisa Roveri
- Department of Neurology, San Raffaele Hospital, Milan, Italy
| | - Massimo Filippi
- Department of Neurology, San Raffaele Hospital, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Davide Strambo
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Gianvito Martino
- Neuroimmunology Unit, Institute of Experimental Neurology, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Marco Bacigaluppi
- Neuroimmunology Unit, Institute of Experimental Neurology, San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy.
- Department of Neurology, San Raffaele Hospital, Milan, Italy.
- University Vita-Salute San Raffaele, Milan, Italy.
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