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Wei J, Jiang J, Zhu Y, Wei X, Sun Z, Sun J, Shi L, Du H, Shang K, Li Y. Clot-based time attenuation curve as a novel imaging predictor of mechanical thrombectomy functional outcome in acute ischemia stroke. Eur Radiol 2024; 34:2198-2208. [PMID: 37707551 DOI: 10.1007/s00330-023-10196-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 07/02/2023] [Accepted: 07/12/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVES To investigate whether a novel assessment of thrombus permeability obtained from perfusion computed tomography (CTP) can act as a more accurate predictor of clinical response to mechanical thrombectomy (MT) in acute ischemic stroke (AIS). MATERIALS AND METHODS We performed a study including two cohorts of AIS patients who underwent MT admitted to a single-center between April 2018 and February 2022: a retrospective development cohort (n = 71) and a prospective independent validation cohort (n = 96). Thrombus permeability was determined in terms of entire thrombus time-attenuation curve (TAC) on CTP. Association between thrombus TAC distributions and histopathological results was analyzed in the development cohort. Logistic regression was used to assess the performance of the TAC for predicting 90-day modified Rankin Scale (mRS) score, and good outcome was defined as a mRS score of ≤ 2. Basic clinical characteristics was used to build a routine clinical model. A combined model gathered TAC and basic clinical characteristics was also developed. The performance of the three models is compared on the independent validation set. RESULTS Two TAC distributions were observed-unimodal (uTAC) and linear (lTAC). TAC distributions achieved strong correlations (|r|= 0.627, p < 0.001) with histopathological results, in which uTAC associated with fibrin- and platelet-rich clot while lTAC associated with red blood cell-rich clot. The uTAC was independently associated with poor outcome (odds ratio, 0.08 [95% confidence interval (CI), 0.02-0.31]; p < 0.001). TAC distributions yielded an AUC of 0.78 (95% CI, 0.70-0.87) for predicting clinical outcome. When combined clinical characteristics, the performance was significantly improved (AUC, 0.85 [95% CI, 0.76-0.93]; p < 0.001) and higher than routine clinical model (AUC, 0.69 [95% CI, 0.59-0.83]; p < 0.001). CONCLUSIONS Thrombus TAC on CTP were found to be a promising new imaging biomarker to predict the outcomes of MT in AIS. CLINICAL RELEVANCE STATEMENT This study revealed that clot-based time attenuation curve based on admission perfusion CT could reflect the permeability and composition of thrombus and, also, provide valuable information to predict the clinical outcomes of mechanical thrombectomy in patients with acute ischemia stroke. KEY POINTS • Two time-attenuation curves distributions achieved strong correlations (|r|= 0.627, p < 0.001) with histopathological results. • The unimodal time-attenuation curve was independently associated with poor outcome (odds ratio, 0.08 [0.02-0.31]; p < 0.001). • The time-attenuation curve distributions yielded a higher performance for detecting clinical outcome than routine clinical model (AUC, 0.78 [0.70-0.87] vs 0.69 [0.59-0.83]; p < 0.001).
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Affiliation(s)
- Jianyong Wei
- Clinical Research Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingxuan Jiang
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
- Department of Radiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Yueqi Zhu
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Xiaoer Wei
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Zheng Sun
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Jianqing Sun
- Central Research Institute, United Imaging Healthcare, Shanghai, China
| | - Liang Shi
- Central Research Institute, United Imaging Healthcare, Shanghai, China
| | - Haiyan Du
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Kai Shang
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Yuehua Li
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China.
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Bertalan G, Duparc R, Krepuska M, Toth D, Madjidyar J, Thurner P, Schubert T, Kulcsar Z. Dynamic Perviousness Predicts Revascularization Success in Acute Ischemic Stroke. Diagnostics (Basel) 2024; 14:535. [PMID: 38473007 DOI: 10.3390/diagnostics14050535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND The predictive value of thrombus perviousness in acute ischemic stroke (AIS), as measured by computed tomography (CT), has been intensively studied with conflicting results. In this study, we investigate the predictive potential of the novel concept of dynamic perviousness using three-dimensional (3D) volumetric evaluation of occlusive thrombi. METHODS The full thrombus volume in 65 patients with a hyperdense artery sign on non-contrast CT (NCCT), who underwent mechanical thrombectomy (MT), was segmented. Perviousness maps were computed voxel-wise for the entire thrombus volume as thrombus attenuation increase (TAI) between NCCT and CT angiography (CTA) as well as between CTA and late venous phase CT (CTV). Perviousness was analyzed for its association with NIHSS at admission, Thrombolysis In Cerebral Infarction (TICI) score, and number of MT passes. RESULTS The mean late-uptake TAI of thrombi with NIHSS scores greater than 21 at admission was approximately 100% higher than for lower scored NIHSS (p between 0.05 and 0.005). Concerning revascularization results, thrombi requiring less than four MT passes had ca. 80% higher group mean late-uptake TAI than clots requiring four or more passes (p = 0.03), and thrombi with TICI score III had ca. 95% higher group mean late-uptake TAI than thrombi with TICI II (p = 0.03). Standard perviousness showed no significant correlation with MT results. CONCLUSION Standard thrombus perviousness of 3D clot volume is not associated with revascularization results in AIS. In contrast, dynamic perviousness assessed with a voxel-wise characterization of 3D thrombi volume may be a better predictor of MT outcomes than standard perviousness.
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Affiliation(s)
- Gergely Bertalan
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Roxane Duparc
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Miklos Krepuska
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Daniel Toth
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Jawid Madjidyar
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Patrick Thurner
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Tilman Schubert
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, University Hospital Zürich, Frauenklinikstrasse 10, 8091 Zürich, Switzerland
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Schartz D, Akkipeddi SMK, Rahmani R, Ellens N, Houk C, Kohli GS, Worley L, Welle K, Bhalla T, Mattingly T, Morrell C, Bender MT. Ischemic Stroke Thrombus Perviousness Is Associated with Distinguishable Proteomic Features and Susceptibility to ADAMTS13-Augmented Thrombolysis. AJNR Am J Neuroradiol 2023; 45:22-29. [PMID: 38123915 PMCID: PMC10756583 DOI: 10.3174/ajnr.a8069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/20/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND PURPOSE Perviousness is the differential attenuation on CT of an intracranial arterial occlusive thrombus before and after IV contrast administration. While perviousness/permeability has been shown to be related to various clinical outcomes and reflects histopathologic composition, it remains unclear whether perviousness is also associated with differences in proteomic composition. MATERIALS AND METHODS Retrieved clots from 59 patients were evaluated with quantitative mass spectrometry. Proteomic differences between high-perviousness (≥11 HU) and low-perviousness (<11 HU) clots were investigated. Perviousness as a continuous variable was also correlated with protein abundance. Last, an ex vivo lysis assay was performed to investigate the differential susceptibility to tPA, deoxyribonuclease, and ADAMTS13 thrombolysis as a function of perviousness. RESULTS In total, 2790 distinct proteins were identified. Thrombus perviousness was associated with distinct proteomic features, including depletion of the macrophage marker CD14 (P = .039, z = 1.176) and hemoglobin subunit ζ (P = .046, z = 1.68) in pervious clots. Additionally, proteins involved in platelet cytoskeleton remodeling (tropomyosin α-3-chain) and granule secretion/aggregation (synaptotagmin-like protein 4/FC region receptor II-a) were associated with increasing perviousness (P < .006), among numerous other proteins. Monocyte/macrophage-associated proteins (apoptosis-associated specklike protein containing a CARD/SAMHD1) were also depleted in pervious emboli (P < .002). Ex vivo lysis indicated that pervious clots were more susceptible to ADAMTS13-augmented tPA thrombolysis compared with impervious clots (P < .05), though without differences in deoxyribonuclease digestion. CONCLUSIONS Thrombus perviousness is associated with complex proteomic features, including differential abundance of platelet-related proteins in highly permeable clots with monocyte/macrophage depletion. This association may help to explain why highly pervious thrombi were also found more susceptible to ADAMTS13-augmented thrombolysis.
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Affiliation(s)
- Derrek Schartz
- From the Department of Imaging Sciences (D.S., L.W.), University of Rochester Medical Center, Rochester, New York
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Sajal Medha K Akkipeddi
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Redi Rahmani
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Nathaniel Ellens
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Clifton Houk
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Gurkirat Singh Kohli
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Logan Worley
- From the Department of Imaging Sciences (D.S., L.W.), University of Rochester Medical Center, Rochester, New York
| | - Kevin Welle
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Tarun Bhalla
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Thomas Mattingly
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Craig Morrell
- Aab Cardiovascular Research Institute (C.M.), University of Rochester Medical Center, Rochester, New York
| | - Matthew T Bender
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
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Shang K, Zhu W, Ye L, Li Y. Effect of mechanical thrombectomy with and without intravenous thrombolysis on the functional outcome of patients with different degrees of thrombus perviousness. Neuroradiology 2023; 65:1657-1663. [PMID: 37640883 DOI: 10.1007/s00234-023-03210-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 08/06/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE This study aimed to investigate the long-term functional outcome of patients with different degrees of thrombus perviousness (TP) undergoing mechanical thrombectomy alone and those undergoing combined intravenous thrombolysis (IVT) plus mechanical thrombectomy. METHODS We conducted a retrospective analysis of consecutive patients with acute ischemic stroke due to large vessel occlusion who underwent mechanical thrombectomy alone or bridging therapy between January 2016 and October 2020. TP was quantified by thrombus attenuation increase (TAI) on admission computed tomography angiography compared with non-contrast computed tomography. After dichotomization of TAI as higher or lower perviousness, Fisher exact tests were performed to estimate the associations of different therapies with favorable functional outcomes [Modified Ranking Scale score at 90 days (90-day mRS) of 0 to 2]. RESULTS A total of 73 patients were included in our study. 35 (47.9%) thrombi were classified as higher-perviousness clots with TAI of ≥ 24 HU, and the other 38 thrombi were lower-perviousness clots. A favorable outcome with a 90-day mRS of 0 to 2 was observed in 32 patients. In patients with thrombi of lower perviousness, favorable outcome was more common in the bridging therapy group than in the thrombectomy-alone group (p = 0.013), whereas in patients with thrombi of higher perviousness, the long-term neurological outcome did not significantly differ between two therapy groups (p = 0.094). CONCLUSION Patients with thrombi of lower perviousness were recommended to undergo intravenous alteplase followed by endovascular thrombectomy, and those with thrombi of higher perviousness could undergo thrombectomy alone.
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Affiliation(s)
- Kai Shang
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Xuhui District, Shanghai, 200235, China
| | - Wangshu Zhu
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Xuhui District, Shanghai, 200235, China
| | - Lifang Ye
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Xuhui District, Shanghai, 200235, China
| | - Yuehua Li
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Xuhui District, Shanghai, 200235, China.
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Zhang ZMY, Si QQ, Chen HS, Yang Y, Zhang M, Wu SW, Meng Y, Li ML, Lin QQ, Liebeskind DS, Huang YN, Xu WH. High-resolution magnetic resonance imaging of acute intracranial artery thrombus. Eur J Neurol 2023; 30:3172-3181. [PMID: 37452734 DOI: 10.1111/ene.15985] [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: 04/11/2023] [Revised: 07/03/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND AND PURPOSE The development of high-resolution magnetic resonance imaging (HR-MRI) has enabled submillimeter-level evaluation of intracranial artery plaque and luminal thrombus. We sought to investigate the value of HR-MRI in assessing the pathogenesis of acute intracranial artery thrombus. METHODS We examined the presence of intracranial thrombus on three-dimensional T1-weighted HR-MRI in acute ischemic stroke patients with intracranial artery occlusion on magnetic resonance angiography. We defined two thrombus-related HR-MRI features (peri-thrombus plaque and distal residual flow beyond the thrombus) and analyzed their association with potential embolic sources. RESULTS Luminal thrombus and a shrunken artery without luminal thrombus were detected in 162 (96.4%) and six (3.6%) of 168 patients with intracranial artery occlusion, respectively. Among 111 patients with culprit major artery thrombus, peri-thrombus plaques were observed in 46.8% and distal residual flow beyond the thrombus in 64.0%. Patients with peri-thrombus plaque had a higher prevalence of diabetes (44.2% vs. 25.4%; p = 0.037), a lower prevalence of potential sources of cardioembolism (0% vs. 16.9%; p = 0.002), and a nonsignificantly lower prevalence of potential embolic sources from extracranial arteries (9.6% vs. 20.3%; p = 0.186) than those without. Patients with distal residual flow beyond the thrombus had a lower prevalence of potential sources of cardioembolism (1.4% vs. 22.5%; p < 0.001) and smaller infarct volumes (5.0 [1.4-12.7] mL vs. 16.6 [2.4-94.6] mL; p = 0.012) than those without. CONCLUSIONS Our study showed that HR-MRI helps clarify the pathogenesis of acute intracranial artery thrombus. The presence of peri-thrombus plaque and distal residual flow beyond the thrombus favor the stroke mechanism of atherosclerosis rather than cardioembolism.
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Affiliation(s)
- Zong-Mu-Yu Zhang
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qian-Qian Si
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yi Yang
- Department of Neurology, the First Hospital of Jilin University, Changchun, China
| | - Meng Zhang
- Department of Neurology, Army Medical Center of PLA, Beijing, China
| | - Shi-Wen Wu
- Department of Neurology and Radiology, General Hospital of Chinese People's Armed Police Forces, Beijing, China
| | - Yao Meng
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming-Li Li
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qian-Qian Lin
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - David S Liebeskind
- UCLA Department of Neurology, Neurovascular Imaging Research Core and UCLA Comprehensive Stroke Center, Los Angeles, California, USA
| | - Yi-Ning Huang
- Department of Neurology, Peking University First Hospital, Peking University, Beijing, China
| | - Wei-Hai Xu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Panyaping T, Udomkaewkanjana N, Keandoungchun J. Utility of dual energy CT in differentiating clot in acute ischemic stroke. Neuroradiol J 2023; 36:435-441. [PMID: 36541086 PMCID: PMC10588607 DOI: 10.1177/19714009221147234] [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] [Indexed: 07/20/2023] Open
Abstract
PURPOSE Red blood cells (RBC)-poor thrombi in acute ischemic stroke (AIS) are associated with longer recanalization time for mechanical thrombectomy than RBC-rich thrombi. The purpose of the study was to differentiate between RBC-rich and RBC-poor thrombi using dual energy computed tomography (DECT). MATERIALS AND METHODS This retrospective study was conducted on patients with acute arterial occlusion of anterior circulation who underwent DECT cerebral angiography, followed by mechanical thrombectomy with the pathological diagnosis of thrombi, dividing into RBC-rich and RBC-poor thrombi. The CT attenuation values and thrombus enhancement were measured in non-contrast scans and CTA phases at different energy levels and compared between RBC-rich and RBC-poor groups. RESULTS Fourteen acute stroke patients were included in the study. There were 7 patients in RBC-rich group and 7 patients in RBC-poor group. The CT attenuation values of RBC-rich thrombi were significantly higher than those of RBC-poor thrombi at energy levels of 40, 50, 60, 70, and 80 KeV, with the most significant difference at 80 KeV (p = 0.032). A cutoff value of 44.1 Hounsfield units (HU) on 80 keV monoenergetic reconstructions was used to distinguish between RBC-rich and RBC-poor thrombi. It achieved an area under the curve (AUC) of 0.878, sensitivity of 85.7%, specificity of 100%, and accuracy of 92.9%. The degree of enhancement was higher in RBC-poor thrombi than in RBC-rich thrombi, without statistically significant difference. CONCLUSION DECT could help differentiate between RBC-rich and RBC-poor thrombi by using CT attenuation values in non-contrast phase at lower energy levels (40-80 KeV).
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Affiliation(s)
- Theeraphol Panyaping
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nuchsarang Udomkaewkanjana
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jesada Keandoungchun
- Division of Neurology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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He Y, Xu J, Zhong W, Chen Z, Zhou Y, Li J, Luo Z, Lou M. Non-porous thrombi are less pervious and easier to be retrieved: implication from scanning electron microscopy study. J Neurointerv Surg 2023; 15:188-194. [PMID: 35347059 DOI: 10.1136/neurintsurg-2022-018689] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/10/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Scanning electron microscopy (SEM) studies found that the porosity of thrombi might vary among individuals. However, its relationship with the clinical presentation and efficacy of mechanical thrombectomy (MT) remains unknown. We aimed to characterize the ultrastructure of thrombi and explore its association with the complexity of MT and clot perviousness. METHODS SEM was used to observe the morphological features of different components of thrombi obtained from patients with anterior circulation large vessel occlusion undergoing MT and to determine the porosity of thrombi by semi-quantitative analysis. Non-porous thrombi were defined as thrombi with porosity <2%. Clot perviousness was also evaluated using thrombus attenuation increase on CT perfusion (TAIctp). We assessed the complexity of MT by attempts of retrieval >3 and procedural duration >60 min, defined as the time interval between groin puncture and recanalization. RESULTS A total of 49 thrombi were analyzed and 31 (63.3%) were classified as non-porous thrombi. The presence of non-porous thrombi was negatively associated with procedure >60 min (OR 0.152, 95% CI 0.031 to 0.734, p=0.019) and attempts >3 (OR 0.194, 95% CI 0.046 to 0.822, p=0.026) after adjustment. Additionally, receiver operating characteristic curve analysis indicated that TAIctp <17.9 Hounsfield units could predict the presence of non-porous thrombi with an area under the curve of 0.915. CONCLUSIONS Non-porous thrombi on SEM are easier to be retrieved during MT and could be identified as less pervious clots on CT images.
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Affiliation(s)
- Yaode He
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jinjin Xu
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Wansi Zhong
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Zhicai Chen
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Ying Zhou
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Jiaping Li
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Zhongyu Luo
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Min Lou
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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He G, Deng J, Lu H, Wei L, Zhao Y, Zhu Y, Li Y. Thrombus enhancement sign on CT angiography is associated with the first pass effect of stent retrievers. J Neurointerv Surg 2023; 15:146-152. [PMID: 35110399 DOI: 10.1136/neurintsurg-2021-018447] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/13/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND The thrombus enhancement sign (TES) is thought to be associated with the source of the stroke and thrombus composition. We investigated whether this imaging sign along with other thrombus characteristics could be used to predict the successful first pass effect (FPE) of mechanical thrombectomy. METHODS 246 consecutive patients with acute ischemic stroke in the anterior circulation with large vessel occlusion who underwent thrombectomy with a stent retriever and clot collection were included. Patients were divided into FPE (modified Thrombolysis in Cerebral Infarction (mTICI) grade 2c or 3)/non-FPE (mTICI 0-2b) and modified FPE (mFPE) (mTICI 2b-3)/non-mFPE (mTICI 0-2a) groups based on flow restoration after the first pass. TES presence, thrombus density, thrombus length, clot burden score, and thrombus composition were compared. The association between FPE and imaging biomarkers, along with clinical and interventional parameters, was investigated by univariate and multivariate analysis. RESULTS FPE was achieved in 85 (34.6%) patients. TES presence was significantly lower in the FPE group (64.7% vs 80.7% in the non-FPE group, p=0.008) and mFPE group (69.1% vs 81.0% in the non-mFPE group, p=0.039). Histopathological examination revealed that TES (+) thrombi contained a higher fibrin/platelet proportion (50.9% vs 46.9% in TES (-) thrombi, p=0.029) and fewer erythrocytes (43.3% vs 47.3% in TES (-) thrombi, p=0.030). Thrombus characteristics, namely shorter thrombus length (p=0.032), higher erythrocyte proportions (p=0.026), and less fibrin/platelets (p=0.014), were confirmed in patients with FPE. In multivariable analysis, TES was the only independent predictor of FPE failure (OR 0.51, 95% CI 0.28 to 0.94; p=0.031). CONCLUSIONS TES was independently associated with first pass angiographic failure in patients treated with a stent retriever.
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Affiliation(s)
- Guangchen He
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiangshan Deng
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Haitao Lu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Liming Wei
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yuwu Zhao
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yuehua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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9
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Padmos RM, Arrarte Terreros N, Józsa TI, Závodszky G, Marquering HA, Majoie CBLM, Payne SJ, Hoekstra AG. Modelling collateral flow and thrombus permeability during acute ischaemic stroke. J R Soc Interface 2022; 19:20220649. [PMID: 36195117 PMCID: PMC9532024 DOI: 10.1098/rsif.2022.0649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The presence of collaterals and high thrombus permeability are associated with good functional outcomes after an acute ischaemic stroke. We aim to understand the combined effect of the collaterals and thrombus permeability on cerebral blood flow during an acute ischaemic stroke. A cerebral blood flow model including the leptomeningeal collateral circulation is used to simulate cerebral blood flow during an acute ischaemic stroke. The collateral circulation is varied to capture the collateral scores: absent, poor, moderate and good. Measurements of the transit time, void fraction and thrombus length in acute ischaemic stroke patients are used to estimate thrombus permeability. Estimated thrombus permeability ranges between 10-7 and 10-4 mm2. Measured flow rates through the thrombus are small and the effect of a permeable thrombus on brain perfusion during stroke is small compared with the effect of collaterals. Our simulations suggest that the collaterals are a dominant factor in the resulting infarct volume after a stroke.
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Affiliation(s)
- Raymond M. Padmos
- Computational Science Laboratory, Informatics Institute, Faculty of Science, University of Amsterdam, Science Park 904, Amsterdam 1098, The Netherlands,Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Mekelweg 2, Delft 2628, The Netherlands
| | - Nerea Arrarte Terreros
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, The Netherlands,Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Tamás I. Józsa
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Parks Road, Oxford OX1 3PJ, UK,Department of Radiology and Nuclear Medicine, Amsterdam Neuroscience, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Gábor Závodszky
- Computational Science Laboratory, Informatics Institute, Faculty of Science, University of Amsterdam, Science Park 904, Amsterdam 1098, The Netherlands
| | - Henk A. Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, The Netherlands,Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Stephen J. Payne
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Parks Road, Oxford OX1 3PJ, UK,Institute of Applied Mechanics, National Taiwan University, Taiwan
| | - Alfons G. Hoekstra
- Computational Science Laboratory, Informatics Institute, Faculty of Science, University of Amsterdam, Science Park 904, Amsterdam 1098, The Netherlands
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10
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Arrarte Terreros N, van Willigen BG, Niekolaas WS, Tolhuisen ML, Brouwer J, Coutinho JM, Beenen LFM, Majoie CBLM, van Bavel E, Marquering HA. Occult blood flow patterns distal to an occluded artery in acute ischemic stroke. J Cereb Blood Flow Metab 2022; 42:292-302. [PMID: 34550818 PMCID: PMC8795216 DOI: 10.1177/0271678x211044941] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Residual blood flow distal to an arterial occlusion in patients with acute ischemic stroke (AIS) is associated with favorable patient outcome. Both collateral flow and thrombus permeability may contribute to such residual flow. We propose a method for discriminating between these two mechanisms, based on determining the direction of flow in multiple branches distal to the occluding thrombus using dynamic Computed Tomography Angiography (dynamic CTA). We analyzed dynamic CTA data of 30 AIS patients and present patient-specific cases that identify typical blood flow patterns and velocities. We distinguished patterns with anterograde (N = 10), retrograde (N = 9), and both flow directions (N = 11), with a large variability in velocities for each flow pattern. The observed flow patterns reflect the interplay between permeability and collaterals. The presented method characterizes distal flow and provides a tool to study patient-specific distal tissue perfusion.
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Affiliation(s)
- Nerea Arrarte Terreros
- Department of Biomedical Engineering and Physics,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
- Nerea Arrarte Terreros, Department
of Biomedical Engineering and Physics, Amsterdam UMC, location AMC,
Meibergdreef 9, 1011 AZ Amsterdam, the Netherlands.
| | - Bettine G van Willigen
- Department of Biomedical Engineering and Physics,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
- Cardiovascular Biomechanics, Eindhoven University of
Technology, Eindhoven, the Netherlands
| | - Wera S Niekolaas
- Department of Biomedical Engineering and Physics,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Manon L Tolhuisen
- Department of Biomedical Engineering and Physics,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Josje Brouwer
- Department of Neurology, Amsterdam UMC, location AMC,
Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, location AMC,
Amsterdam, the Netherlands
| | - Ludo FM Beenen
- Department of Radiology and Nuclear Medicine,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Charles BLM Majoie
- Department of Radiology and Nuclear Medicine,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Ed van Bavel
- Department of Biomedical Engineering and Physics,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
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11
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Lin Y, Kang N, Kang J, Lv S, Wang J. Predictive value of time-variant color-coded multiphase CT angiography (mCTA) regarding clinical outcome of acute ischemic stroke: in comparison with conventional mCTA and CT perfusion. Acta Radiol 2022; 63:84-92. [PMID: 33356350 DOI: 10.1177/0284185120981770] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Color-coded multiphase computed tomography angiography (mCTA) can provide time-variant blood flow information of collateral circulation for acute ischemic stroke (AIS). PURPOSE To compare the predictive values of color-coded mCTA, conventional mCTA, and CT perfusion (CTP) for the clinical outcomes of patients with AIS. MATERIAL AND METHODS Consecutive patients with anterior circulation AIS were retrospectively reviewed at our center. Baseline collateral scores of color-coded mCTA and conventional mCTA were assessed by a 6-point scale. The reliabilities between junior and senior observers were assessed by weighted Kappa coefficients. Receiver operating characteristic (ROC) curves and multivariate logistic regression model were applied to evaluate the predictive capabilities of color-coded mCTA and conventional mCTA scores, and CTP parameters (hypoperfusion and infarct core volume) for a favorable outcome of AIS. RESULTS A total of 138 patients (including 70 cases of good outcomes) were included in our study. Patients with favorable prognoses were correlated with better collateral circulations on both color-coded and conventional mCTA, and smaller hypoperfusion and infarct core volume (all P < 0.05) on CTP. ROC curves revealed no significant difference between the predictive capability of color-coded and conventional mCTA (P = 0.427). The predictive value of CTP parameters tended to be inferior to that of color-coded mCTA score (all P < 0.001). Both junior and senior observers had consistently excellent performances (κ = 0.89) when analyzing color-coded mCTA maps. CONCLUSION Color-coded mCTA provides prognostic information of patients with AIS equivalent to or better than that of conventional mCTA and CTP. Junior radiologists can reach high diagnostic accuracy when interpreting color-coded mCTA images.
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Affiliation(s)
- Yu Lin
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, Fujian, PR China
| | - Nannan Kang
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, Fujian, PR China
| | - Jianghe Kang
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, Fujian, PR China
| | - Shaomao Lv
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, Fujian, PR China
| | - Jinan Wang
- Department of Radiology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, Fujian, PR China
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12
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Lau HL, Gardener H, Coutts SB, Saini V, Field TS, Dowlatshahi D, Smith EE, Hill MD, Romano JG, Demchuk AM, Menon BK, Asdaghi N. Radiographic Characteristics of Mild Ischemic Stroke Patients With Visible Intracranial Occlusion: The INTERRSeCT Study. Stroke 2021; 53:913-920. [PMID: 34753303 DOI: 10.1161/strokeaha.120.030380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Early neurological deterioration occurs in one-third of mild strokes primarily due to the presence of a relevant intracranial occlusion. We studied vascular occlusive patterns, thrombus characteristics, and recanalization rates in these patients. METHODS Among patients enrolled in INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography), a multicenter prospective study of acute ischemic strokes with a visible intracranial occlusion, we compared characteristics of mild (National Institutes of Health Stroke Scale score, ≤5) to moderate/severe strokes. RESULTS Among 575 patients, 12.9% had a National Institutes of Health Stroke Scale score ≤5 (median age, 70.5 [63-79]; 58% male; median National Institutes of Health Stroke Scale score, 4 [2-4]). Demographics and vascular risk factors were similar between the two groups. As compared with those with a National Institutes of Health Stroke Scale score >5, mild patients had longer symptom onset to assessment times (onset to computed tomography [240 versus 167 minutes] and computed tomography angiography [246 versus 172 minutes]), more distal occlusions (M3, anterior cerebral artery and posterior cerebral artery; 22% versus 6%), higher clot burden score (median, 9 [6-9] versus 6 [4-9]), similar favorable thrombus permeability (residual flow grades I-II, 21% versus 19%), higher collateral flow (9.1 versus 7.6), and lower intravenous alteplase treatment rates (55% versus 85%). Mild patients were more likely to recanalize (revised arterial occlusion scale score 2b/3, 45%; 49% with alteplase) compared with moderate/severe strokes (26%; 29% with alteplase). In an adjusted model for sex, alteplase, residual flow, and time between the two vessel imagings, intravenous alteplase use (odds ratio, 3.80 [95% CI, 1.11-13.00]) and residual flow grade (odds ratio, 8.70 [95% CI, 1.26-60.13]) were associated with successful recanalization among mild patients. CONCLUSIONS Mild strokes with visible intracranial occlusions have different vascular occlusive patterns but similar thrombus permeability compared with moderate/severe strokes. Higher thrombus permeability and alteplase use were associated with successful recanalization, although the majority do not recanalize. Randomized controlled trials are needed to assess the efficacy of new thrombolytics and endovascular therapy in this population.
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Affiliation(s)
- H Lee Lau
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL (H.L.L., H.G., V.S., J.G.R., N.A.)
| | - Hannah Gardener
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL (H.L.L., H.G., V.S., J.G.R., N.A.)
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.)
| | - Vasu Saini
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL (H.L.L., H.G., V.S., J.G.R., N.A.)
| | - Thalia S Field
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada (T.S.F.)
| | - Dar Dowlatshahi
- Department of Neuroscience, Ottawa Hospital Research Institute, Ontario, Canada (D.D.).,Department of Epidemiology, Ottawa Hospital Research Institute, Ontario, Canada (D.D.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.)
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.)
| | - Jose G Romano
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL (H.L.L., H.G., V.S., J.G.R., N.A.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.)
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.).,Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada. (S.B.C., E.E.S., M.D.H., A.M.D., B.K.M.)
| | - Negar Asdaghi
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL (H.L.L., H.G., V.S., J.G.R., N.A.)
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13
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Benson JC, Kallmes DF, Larson AS, Brinjikji W. Radiology-Pathology Correlations of Intracranial Clots: Current Theories, Clinical Applications, and Future Directions. AJNR Am J Neuroradiol 2021; 42:1558-1565. [PMID: 34301640 DOI: 10.3174/ajnr.a7249] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/06/2021] [Indexed: 11/07/2022]
Abstract
In recent years, there has been substantial progression in the field of stroke clot/thrombus imaging. Thrombus imaging aims to deduce the histologic composition of the clot through evaluation of various imaging characteristics. If the histology of a thrombus can be reliably determined by noninvasive imaging methods, critical information may be extrapolated about its expected response to treatment and about the patient's clinical outcome. Crucially, as we move into an era of stroke therapy individualization, determination of the histologic composition of a clot may be able to guide precise and targeted therapeutic effort. Most radiologists, however, remain largely unfamiliar with the topic of clot imaging. This article will review the current literature regarding clot imaging, including its histologic backdrop, the correlation of images with cellular components and treatment responsiveness, and future expectations.
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Affiliation(s)
- J C Benson
- From the Department of Neuroradiology, Mayo Clinic, Rochester, Minnesota
| | - D F Kallmes
- From the Department of Neuroradiology, Mayo Clinic, Rochester, Minnesota
| | - A S Larson
- From the Department of Neuroradiology, Mayo Clinic, Rochester, Minnesota
| | - W Brinjikji
- From the Department of Neuroradiology, Mayo Clinic, Rochester, Minnesota
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14
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Berndt M, Mück F, Maegerlein C, Wunderlich S, Zimmer C, Wirth S, Mönch S, Kaesmacher J, Friedrich B, Boeckh-Behrens T. Introduction of CTA-index as Simplified Measuring Method for Thrombus Perviousness. Clin Neuroradiol 2020; 31:773-781. [PMID: 32990766 PMCID: PMC8463362 DOI: 10.1007/s00062-020-00957-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 08/27/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Thrombus features on admission CT are useful imaging markers for clot characterization, stroke pathogenesis and outcome prediction. In this context, thrombus perviousness is a promising parameter, but reliable assessment in daily clinical practice is demanding. The aim of the present study was to evaluate an easy to assess measuring method for thrombus permeability at the time of admission. METHODS The CTA-index, which measures relative thrombus attenuation on admission CTA, was compared to the known perviousness parameter in a cohort of 101 patients with large-vessel occlusions of the middle cerebral artery and correlated to clinical outcome parameters (mRS after 90 days, ≤2 rated as favorable). For validation, this correlation was tested in a second independent cohort (n = 87), and possible associations between the CTA-index and outcome measurements (NIHSS/mRS/mTICI) were assessed. RESULTS In the first cohort a coherence between conventional perviousness measurements and the CTA-index was shown. The CTA-index differed significantly between favorable (-0.55 ± 0.16) and non-favorable outcomes (-0.64 ± 0.14, p = 0.01). In the validation cohort this result could be independently reproduced (-0.52 ± 0.13/-0.70 ± 0.09, p < 0.01). The CTA-index showed an association with low NIHSS at discharge (p < 0.01), favorable outcome after 90 days (p < 0.001) and with better reperfusion (measured by mTICI score, p = 0.04). CONCLUSION The CTA-index is an easy to assess imaging parameter on admission CTA in the acute stroke phase and is associated with angiographic and clinical outcome. It can be considered as a simplified measuring method for thrombus perviousness, which is known to provide useful information for further stroke progress and clinical course as well as therapeutic and rehabilitative decisions.
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Affiliation(s)
- Maria Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany.
| | - Fabian Mück
- Department of Radiology, Helios Klinikum München West, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Stefan Wirth
- Clinic and Polyclinic for Radiology, Ludwig-Maximilians-University of Munich, Munich, Germany
- Department of Radiology and Nuclear Medicine, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Sebastian Mönch
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Johannes Kaesmacher
- Department of Neuroradiology, Inselspital, University Hospital Bern, University Bern, Bern, Switzerland
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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15
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Wang Z, Xie J, Tang TY, Zeng CH, Zhang Y, Zhao Z, Zhao DL, Geng LY, Deng G, Zhang ZJ, Ju SH, Teng GJ. Collateral Status at Single-Phase and Multiphase CT Angiography versus CT Perfusion for Outcome Prediction in Anterior Circulation Acute Ischemic Stroke. Radiology 2020; 296:393-400. [PMID: 32484415 DOI: 10.1148/radiol.2020192029] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Collateral status assessed with single- or multiphase CT angiography can be used to predict outcome in patients with acute ischemic stroke (AIS); however, little is known about whether these measures could be comparable with CT perfusion parameters. Purpose To compare the predictive ability of collateral score systems assessed with single- or multiphase CT angiography and CT perfusion parameters in determining clinical outcomes in patients with AIS. Materials and Methods In this retrospective study, data obtained from October 2017 to August 2018 in consecutive patients with AIS caused by isolated anterior circulation large artery occlusion and that were obtained within 24 hours after onset were reviewed. The collateral score was assessed by using established scoring systems described by Menon et al. The correlations between single- and multiphase collateral scores, hypoperfusion, and ischemic core volume and final infarct volume (FIV) determined by follow-up diffusion-weighted imaging or unenhanced CT were studied. Receiver operating characteristic curves and multivariable logistic regression analysis were performed to assess the predictive ability of scoring systems and CT perfusion parameters for a favorable clinical outcome. Results A total of 119 patients (median age, 75 years; interquartile range, 66-82 years; 74 men) were included. Both single- and multiphase Menon scores had a moderate negative correlation with FIV (r = -0.43, P < .001; r = -0.44, P < .001). Receiver operating characteristic curve analysis revealed the multiphase Menon score performed better than the single-phase Menon score (area under the curve [AUC], 0.72 vs 0.64; P = .045) in the prediction of a favorable 90-day modified Rankin scale score. There was no difference between multiphase Menon score and hypoperfusion volume (AUC, 0.72 vs 0.72; P = .97) or ischemic core volume (AUC, 0.72 vs 0.71; P = .94). Multivariable analysis showed multiphase Menon score was an independent predictor of good clinical outcomes (odds ratio = 3.04, P = .001). Conclusion Multiphase Menon score performed better than single-phase Menon score and was comparable with CT perfusion parameters in determining clinical outcomes in patients with acute ischemic stroke. © RSNA, 2020.
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Affiliation(s)
- Zhi Wang
- From the Jiangsu Key Laboratory of Molecular and Functional Imaging and Center of Interventional Radiology and Vascular Surgery, Departments of Radiology (Z.W., T.Y.T., C.H.Z., Y.Z., Z.Z., D.L.Z., G.D., S.H.J., G.J.T.), and Neurology (J.X., L.Y.G., Z.J.Z.), Zhongda Hospital, Medical School, Southeast University, 87 Dingjiaqiao Rd, Nanjing 210009, China
| | - Jian Xie
- From the Jiangsu Key Laboratory of Molecular and Functional Imaging and Center of Interventional Radiology and Vascular Surgery, Departments of Radiology (Z.W., T.Y.T., C.H.Z., Y.Z., Z.Z., D.L.Z., G.D., S.H.J., G.J.T.), and Neurology (J.X., L.Y.G., Z.J.Z.), Zhongda Hospital, Medical School, Southeast University, 87 Dingjiaqiao Rd, Nanjing 210009, China
| | - Tian-Yu Tang
- From the Jiangsu Key Laboratory of Molecular and Functional Imaging and Center of Interventional Radiology and Vascular Surgery, Departments of Radiology (Z.W., T.Y.T., C.H.Z., Y.Z., Z.Z., D.L.Z., G.D., S.H.J., G.J.T.), and Neurology (J.X., L.Y.G., Z.J.Z.), Zhongda Hospital, Medical School, Southeast University, 87 Dingjiaqiao Rd, Nanjing 210009, China
| | - Chu-Hui Zeng
- From the Jiangsu Key Laboratory of Molecular and Functional Imaging and Center of Interventional Radiology and Vascular Surgery, Departments of Radiology (Z.W., T.Y.T., C.H.Z., Y.Z., Z.Z., D.L.Z., G.D., S.H.J., G.J.T.), and Neurology (J.X., L.Y.G., Z.J.Z.), Zhongda Hospital, Medical School, Southeast University, 87 Dingjiaqiao Rd, Nanjing 210009, China
| | - Yi Zhang
- From the Jiangsu Key Laboratory of Molecular and Functional Imaging and Center of Interventional Radiology and Vascular Surgery, Departments of Radiology (Z.W., T.Y.T., C.H.Z., Y.Z., Z.Z., D.L.Z., G.D., S.H.J., G.J.T.), and Neurology (J.X., L.Y.G., Z.J.Z.), Zhongda Hospital, Medical School, Southeast University, 87 Dingjiaqiao Rd, Nanjing 210009, China
| | - Zhen Zhao
- From the Jiangsu Key Laboratory of Molecular and Functional Imaging and Center of Interventional Radiology and Vascular Surgery, Departments of Radiology (Z.W., T.Y.T., C.H.Z., Y.Z., Z.Z., D.L.Z., G.D., S.H.J., G.J.T.), and Neurology (J.X., L.Y.G., Z.J.Z.), Zhongda Hospital, Medical School, Southeast University, 87 Dingjiaqiao Rd, Nanjing 210009, China
| | - Deng-Ling Zhao
- From the Jiangsu Key Laboratory of Molecular and Functional Imaging and Center of Interventional Radiology and Vascular Surgery, Departments of Radiology (Z.W., T.Y.T., C.H.Z., Y.Z., Z.Z., D.L.Z., G.D., S.H.J., G.J.T.), and Neurology (J.X., L.Y.G., Z.J.Z.), Zhongda Hospital, Medical School, Southeast University, 87 Dingjiaqiao Rd, Nanjing 210009, China
| | - Lei-Yu Geng
- From the Jiangsu Key Laboratory of Molecular and Functional Imaging and Center of Interventional Radiology and Vascular Surgery, Departments of Radiology (Z.W., T.Y.T., C.H.Z., Y.Z., Z.Z., D.L.Z., G.D., S.H.J., G.J.T.), and Neurology (J.X., L.Y.G., Z.J.Z.), Zhongda Hospital, Medical School, Southeast University, 87 Dingjiaqiao Rd, Nanjing 210009, China
| | - Gang Deng
- From the Jiangsu Key Laboratory of Molecular and Functional Imaging and Center of Interventional Radiology and Vascular Surgery, Departments of Radiology (Z.W., T.Y.T., C.H.Z., Y.Z., Z.Z., D.L.Z., G.D., S.H.J., G.J.T.), and Neurology (J.X., L.Y.G., Z.J.Z.), Zhongda Hospital, Medical School, Southeast University, 87 Dingjiaqiao Rd, Nanjing 210009, China
| | - Zhi-Jun Zhang
- From the Jiangsu Key Laboratory of Molecular and Functional Imaging and Center of Interventional Radiology and Vascular Surgery, Departments of Radiology (Z.W., T.Y.T., C.H.Z., Y.Z., Z.Z., D.L.Z., G.D., S.H.J., G.J.T.), and Neurology (J.X., L.Y.G., Z.J.Z.), Zhongda Hospital, Medical School, Southeast University, 87 Dingjiaqiao Rd, Nanjing 210009, China
| | - Sheng-Hong Ju
- From the Jiangsu Key Laboratory of Molecular and Functional Imaging and Center of Interventional Radiology and Vascular Surgery, Departments of Radiology (Z.W., T.Y.T., C.H.Z., Y.Z., Z.Z., D.L.Z., G.D., S.H.J., G.J.T.), and Neurology (J.X., L.Y.G., Z.J.Z.), Zhongda Hospital, Medical School, Southeast University, 87 Dingjiaqiao Rd, Nanjing 210009, China
| | - Gao-Jun Teng
- From the Jiangsu Key Laboratory of Molecular and Functional Imaging and Center of Interventional Radiology and Vascular Surgery, Departments of Radiology (Z.W., T.Y.T., C.H.Z., Y.Z., Z.Z., D.L.Z., G.D., S.H.J., G.J.T.), and Neurology (J.X., L.Y.G., Z.J.Z.), Zhongda Hospital, Medical School, Southeast University, 87 Dingjiaqiao Rd, Nanjing 210009, China
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Punter MTJJM, Vos BE, Mulder BM, Koenderink GH. Poroelasticity of (bio)polymer networks during compression: theory and experiment. SOFT MATTER 2020; 16:1298-1305. [PMID: 31922166 DOI: 10.1039/c9sm01973a] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Soft living tissues like cartilage can be considered as biphasic materials comprising a fibrous complex biopolymer network and a viscous background liquid. Here, we show by a combination of experiment and theoretical analysis that both the hydraulic permeability and the elastic properties of (bio)polymer networks can be determined with simple ramp compression experiments in a commercial rheometer. In our approximate closed-form solution of the poroelastic equations of motion, we find the normal force response during compression as a combination of network stress and fluid pressure. Choosing fibrin as a biopolymer model system with controllable pore size, measurements of the full time-dependent normal force during compression are found to be in excellent agreement with the theoretical calculations. The inferred elastic response of large-pore (μm) fibrin networks depends on the strain rate, suggesting a strong interplay between network elasticity and fluid flow. Phenomenologically extending the calculated normal force into the regime of nonlinear elasticity, we find strain-stiffening of small-pore (sub-μm) fibrin networks to occur at an onset average tangential stress at the gel-plate interface that depends on the polymer concentration in a power-law fashion. The inferred permeability of small-pore fibrin networks scales approximately inverse squared with the fibrin concentration, implying with a microscopic cubic lattice model that the number of protofibrils per fibrin fiber cross-section decreases with protein concentration. Our theoretical model provides a new method to obtain the hydraulic permeability and the elastic properties of biopolymer networks and hydrogels with simple compression experiments, and paves the way to study the relation between fluid flow and elasticity in biopolymer networks during dynamical compression.
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Affiliation(s)
- Melle T J J M Punter
- AMOLF, Theory of Biomolecular Matter, Science Park 104, 1098XG Amsterdam, The Netherlands.
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17
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Comparison of different methods of thrombus permeability measurement and impact on recanalization in the INTERRSeCT multinational multicenter prospective cohort study. Neuroradiology 2019; 62:301-306. [PMID: 31713667 DOI: 10.1007/s00234-019-02320-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 10/30/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To compare the association of different measures of intracranial thrombus permeability on non-contrast computerized tomography (NCCT) and computed tomography angiography (CTA) with recanalization with or without intravenous alteplase. METHODS Patients with anterior circulation occlusion from the INTERRSeCT study were included. Thrombus permeability was measured on non-contrast CT and CTA using the following methods: [1] automated method, mean attenuation increase on co-registered thin (< 2.5 mm) CTA/NCCT; [2] semi-automated method, maximum attenuation increase on non-registered CTA/NCCT (ΔHUmax); [3] manual method, maximum attenuation on CTA (HUmax); and [4] visual method, residual flow grade. Primary outcome was recanalization with intravenous alteplase on the revised AOL scale (2b/3). Regression models were compared using C-statistic, Akaike (AIC), and Bayesian information criterion (BIC). RESULTS Four hundred eighty patients were included in this analysis. Statistical models using methods 2, 3, and 4 were similar in their ability to discriminate recanalizers from non-recanalizers (C-statistic 0.667, 0.683, and 0.634, respectively); method 3 had the least information loss (AIC = 483.8; BIC = 492.2). A HUmax ≥ 89 measured with method 3 provided optimal sensitivity and specificity in discriminating recanalizers from non-recanalizers [recanalization 55.4% (95%CI 46.2-64.6) when HUmax > 89 vs. 16.8% (95%CI 13.0-20.6) when HUmax ≤ 89]. In sensitivity analyses restricted to patients with co-registered CTA/NCCT (n = 88), methods 1-4 predicted recanalization similarly (C-statistic 0.641, 0.688, 0.640, 0.648, respectively) with Method 2 having the least information loss (AIC 104.8, BIC 109.8). CONCLUSION Simple methods that measure thrombus permeability are as reliable as complex image processing methods in discriminating recanalizers from non-recanalizers.
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Benson JC, Fitzgerald ST, Kadirvel R, Johnson C, Dai D, Karen D, Kallmes DF, Brinjikji W. Clot permeability and histopathology: is a clot's perviousness on CT imaging correlated with its histologic composition? J Neurointerv Surg 2019; 12:38-42. [PMID: 31239329 DOI: 10.1136/neurintsurg-2019-014979] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/24/2019] [Accepted: 05/25/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Clot perviousness in large vessel occlusion has been shown to be associated with improved recanalization outcomes with mechanical thrombectomy and intravenous thrombolysis. OBJECTIVE To evaluate the association between clot perviousness based on thrombus attenuation increase (TAI) on CT, and histologic composition of clots in acute ischemic stroke (AIS). METHODS A retrospective review was completed of patients with AIS secondary to large vessel occlusion, non-contrast CT (NCCT) and CT angiography (CTA) images, and histologic analysis of the retrieved clot. TAI was measured by subtracting clot attenuation on NCCT from the attenuation on CTA. Up to 3 regions of interest (ROIs) were evaluated on each clot; the average attenuation was used for analysis if multiple ROIs were assessed. Pervious clots were defined as TAI ≥10 Hounsfield units (HUs); impervious clots had TAI <10 HU. Histopathologic analyses of clots were assessed for relative compositions of red blood cells (RBCs), white blood cells (WBCs), fibrin, and platelets/other. RESULTS 57 patients were included. Pervious clots were more likely to be RBC rich (p=0.04); impervious clots were more likely to be fibrin and WBC rich (p=0.01 for both). Pervious clots also had greater RBC density than impervious clots (49.8% and 33.0%, respectively; p=0.006); fibrin density of pervious clots was lower than that of impervious clots (17.8% and 23.2%, respectively; p=0.02). CONCLUSION Clot perviousness, assessed on NCCT and CTA imaging, is associated with higher RBC density and lower fibrin density, offering a possible explanation for the higher rates of successful thrombectomy and favorable clinical outcome seen in such patients.
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Affiliation(s)
| | - Sean T Fitzgerald
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,CURAM- Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | | | - Collin Johnson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Daying Dai
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Doyle Karen
- CURAM- Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - David F Kallmes
- Department of Neuroradiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Waleed Brinjikji
- Department of Neuroradiology, Mayo Clinic, Rochester, Minnesota, USA
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