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Yeo JYP, Teo KSH, Tan EY, Yaow C, Hariz H, Lim HS, Ng BJM, Wong YHL, Subramaniam C, Makmur A, Han W, Chan MYY, Sia CH, Jing M, Tan BYQ, Tang DKK, Yeo LLL. Pre-treatment radiological factors associated with poor functional outcome in an Asian cohort of large vessel occlusion acute ischemic stroke patients undergoing mechanical thrombectomy. Front Neurol 2024; 15:1415233. [PMID: 38988598 PMCID: PMC11234891 DOI: 10.3389/fneur.2024.1415233] [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: 04/10/2024] [Accepted: 06/14/2024] [Indexed: 07/12/2024] Open
Abstract
Background and aims Endovascular thrombectomy (EVT) is the current standard of care for large vessel occlusion (LVO) acute ischemic stroke (AIS); however, up to two-thirds of EVT patients have poor functional outcomes despite successful reperfusion. Many radiological markers have been studied as predictive biomarkers for patient outcomes in AIS. This study seeks to determine which clinico-radiological factors are associated with outcomes of interest to aid selection of patients for EVT for LVO AIS. Methods A retrospective study of patients who underwent EVT from 2016 to 2020 was performed. Data on various radiological variables, such as anatomical parameters, clot characteristics, collateral status, and infarct size, were collected alongside traditional demographic and clinical variables. Univariate and multivariate analysis was performed for the primary outcomes of functional independence at 3 months post-stroke (modified Rankin Scale 0-2) and secondary outcomes of in-hospital mortality and symptomatic intracranial hemorrhage. Results The study cohort comprised 325 consecutive patients with anterior circulation LVO AIS (54.5% male) with a median age of 68 years (interquartile range 57-76). The median NIHSS was 19. Age, hypertension, hyperlipidaemia, National Institutes of Health Stroke Scale (NIHSS), Alberta mCTA score, ASPECTS, clot length, thrombus HU and mTICI score and the angle between ICA and CCA were associated with functional outcomes at 3 months on univariate analysis. On multivariate analysis, age, Alberta mCTA collaterals and NIHSS were significantly associated with functional outcomes, while ASPECTS approached significance. Conclusion Among the many proposed radiological markers for patients in the hyperacute setting undergoing EVT, the existing well-validated clinico-radiological measures remain strongly associated with functional status.
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Affiliation(s)
- Joshua Y. P. Yeo
- Department of Medicine, National University Hospital, Singapore, Singapore
| | - Kevin Soon Hwee Teo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - En Ying Tan
- Department of Medicine, National University Hospital, Singapore, Singapore
| | - Clyve Yaow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - H. Hariz
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - H. S. Lim
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - B. J. M. Ng
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Y. H. L. Wong
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Cantiriga Subramaniam
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Andrew Makmur
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Weiping Han
- Institute of Molecular and Cell Biology, Singapore, Singapore
| | - Mark Y. Y. Chan
- National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Ching-Hui Sia
- National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Mingxue Jing
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Benjamin Y. Q. Tan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - David K. K. Tang
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Leonard Leong Litt Yeo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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2
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A nomogram for predicting thrombus composition in stroke patients with large vessel occlusion: combination of thrombus density and perviousness with clinical features. Neuroradiology 2023; 65:371-380. [PMID: 36064806 DOI: 10.1007/s00234-022-03046-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/24/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To establish a nomogram incorporating pretreatment imaging parameters and clinical characteristics for predicting the thrombus composition of acute ischemic stroke (AIS) with large vessel occlusion (LVO). METHODS We retrospectively enrolled patients with occlusion of the Middle Cerebral Artery (MCA) who underwent Mechanical Thrombectomy (MT). Retrieved thrombi were stained with Hematoxylin and Eosin (H&E) and Martius Scarlet Blue (MSB). Thrombi are assigned to the Fibrin-rich or RBC-rich group based on the relative fractions of Red Blood Cells (RBC), fibrin, and platelet. The independent risk factors for Fibrin-rich clots were determined via univariate and multivariate logistic regression analysis and were then integrated to establish a nomogram. RESULTS In total, 98 patients were included in this study. Patients with fibrin-rich clots had worse functional outcome [modified Rankin scale (mRS) 0-2, 34.7% vs 63.2%, p = 0.005], longer procedure time (76.8 min vs 50.8 min, p = 0.001), and increased maneuvers of MT (1.84 vs 1.46, p = 0.703) than those with RBC-rich clots. The independent risk factors for Fibrin-rich clots were lower perviousness measured by Non-Contrast Computer Tomography (NCCT) and CT Angiography (CTA), lower thrombus relative attenuation on NCCT, elevated Platelet-WBC ratio (PWR) of admission peripheral blood, and previous antithrombotic medication. The nomogram showed good discrimination with an area under the Receiver Operating Characteristic (ROC) curve (AUC) of 0.852 (95% CI: 0.778-0.926). The calibration curve and decision curve analysis also displayed satisfactory accuracy and clinical utility. CONCLUSION This study has developed and internally validated an easy-to-use nomogram which can help predict clot composition and optimize therapeutic strategies for thrombectomy.
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Bruggeman AAE, Aberson N, Kappelhof M, Dutra BG, Hoving JW, Brouwer J, Tolhuisen ML, Terreros NA, Konduri PR, Boodt N, Roos YBWEM, van Zwam WH, Bokkers R, Martens J, Marquering HA, Emmer BJ, Majoie CBLM. Association of thrombus density and endovascular treatment outcomes in patients with acute ischemic stroke due to M1 occlusions. Neuroradiology 2022; 64:1857-1867. [PMID: 35570210 PMCID: PMC9365751 DOI: 10.1007/s00234-022-02971-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/29/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE We aimed to study the association of non-contrast CT (NCCT) thrombus density with procedural and clinical outcomes in patients with acute ischemic stroke who underwent endovascular treatment (EVT). Since thrombus density is associated with thrombus location, we focused on M1 occlusions only. METHODS Patients with available thin-slice (< 2.5 mm) NCCT were included from a nationwide registry. Regression models were used to assess the relation between thrombus density (per Hounsfield unit [HU]) and the following outcomes. For reperfusion grade, adjusted common odds ratios (acOR) indicated a 1-step shift towards improved outcome per HU increase in thrombus density. For the binary outcomes of first-pass reperfusion (first-pass extended thrombolysis in cerebral infarction [eTICI] 2C-3, FPR), functional independence [90-day modified Rankin Scale (mRS) score of 0-2] and mortality), aORs were reported. Adjusted β coefficients (aβ) were reported for 24-h NIHSS and procedure duration in minutes. Outcome differences between first-line treatment devices (stent retriever versus aspiration) were assessed with interaction terms. RESULTS In 566 patients with M1 occlusions, thrombus density was not associated with reperfusion (acOR 1.01, 95% CI 0.99-1.02), FPR (aOR 1.01, 95% CI 0.99-1.03), mortality (aOR 0.98, 95% CI 0.95-1.00), 24-h NIHSS (aβ - 0.7%, 95% CI - 1.4-0.2), or procedure duration (aβ 0.27, 95% CI - 0.05-0.58). In multivariable analysis, thrombus density was associated with functional independence (aOR 1.02, 95% CI 1.00-1.05). No interaction was found between thrombus density and first-line treatment device for any outcome. CONCLUSION In patients with M1 occlusions, thrombus density was not clearly associated with procedural and clinical outcomes after EVT.
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Affiliation(s)
- Agnetha A. E. Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Room G1-240, Meibergdreef 9 1105 AZ, Amsterdam, The Netherlands
| | - Nyk Aberson
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Room G1-240, Meibergdreef 9 1105 AZ, Amsterdam, The Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Room G1-240, Meibergdreef 9 1105 AZ, Amsterdam, The Netherlands ,Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Bruna G. Dutra
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Room G1-240, Meibergdreef 9 1105 AZ, Amsterdam, The Netherlands ,Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan W. Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Room G1-240, Meibergdreef 9 1105 AZ, Amsterdam, The Netherlands
| | - Josje Brouwer
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Manon L. Tolhuisen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Room G1-240, Meibergdreef 9 1105 AZ, Amsterdam, The Netherlands ,Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Nerea Arrarte Terreros
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Room G1-240, Meibergdreef 9 1105 AZ, Amsterdam, The Netherlands ,Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Praneeta R. Konduri
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Room G1-240, Meibergdreef 9 1105 AZ, Amsterdam, The Netherlands ,Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Nikki Boodt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands ,Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Yvo B. W. E. M. Roos
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Wim H. van Zwam
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Reinoud Bokkers
- Department of Radiology and Nuclear Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Jasper Martens
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Henk A. Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Room G1-240, Meibergdreef 9 1105 AZ, Amsterdam, The Netherlands ,Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Room G1-240, Meibergdreef 9 1105 AZ, Amsterdam, The Netherlands
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Room G1-240, Meibergdreef 9 1105 AZ, Amsterdam, The Netherlands
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Quantitative thrombus characteristics on thin-slice computed tomography improve prediction of thrombus histopathology: results of the MR CLEAN Registry. Eur Radiol 2022; 32:7811-7823. [PMID: 35501573 PMCID: PMC9668956 DOI: 10.1007/s00330-022-08762-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Thrombus computed tomography (CT) characteristics might be used to assess histopathologic thrombus composition in patients treated with endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). We aimed to assess the variability in thrombus composition that could be predicted with combined thrombus CT characteristics. METHODS Thrombi of patients enrolled in the MR CLEAN Registry between March 2014 and June 2016 were histologically analyzed with hematoxylin-eosin staining and quantified for percentages of red blood cells (RBCs) and fibrin/platelets. We estimated the association between general qualitative characteristics (hyperdense artery sign [HAS], occlusion location, clot burden score [CBS]) and thrombus composition with linear regression, and quantified RBC variability that could be explained with individual and combined characteristics with R2. For patients with available thin-slice (≤ 2.5 mm) imaging, we performed similar analyses for general and quantitative characteristics (HAS, occlusion location, CBS, [relative] thrombus density, thrombus length, perviousness, distance from ICA-terminus). RESULTS In 332 included patients, the presence of HAS (aβ 7.8 [95% CI 3.9-11.7]) and shift towards a more proximal occlusion location (aβ 3.9 [95% CI 0.6-7.1]) were independently associated with increased RBC and decreased fibrin/platelet content. With general characteristics, 12% of RBC variability could be explained; HAS was the strongest predictor. In 94 patients with available thin-slice imaging, 30% of RBC variability could be explained; thrombus density and thrombus length were the strongest predictors. CONCLUSIONS Quantitative thrombus CT characteristics on thin-slice admission CT improve prediction of thrombus composition and might be used to further guide clinical decision-making in patients treated with EVT for AIS in the future. KEY POINTS • With hyperdense artery sign and occlusion location, 12% of variability in thrombus RBC content can be explained. • With hyperdense artery sign, occlusion location, and quantitative thrombus characteristics on thin-slice (≤ 2.5 mm) non-contrast CT and CTA, 30% of variability in thrombus RBC content can be explained. • Absolute thrombus density and thrombus length were the strongest predictors for thrombus composition.
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5
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Bhambri A, Adapa AR, Liu Y, Boeckh-Behrens T, Procházka V, Hernández-Fernández F, Barbella-Aponte RA, Hashimoto T, Savastano LE, Gemmete JJ, Chaudhary N, Shih AJ, Pandey AS. Thrombus Histology as It Relates to Mechanical Thrombectomy: A Meta-Analysis and Systematic Review. Neurosurgery 2021; 89:1122-1131. [PMID: 34634805 DOI: 10.1093/neuros/nyab366] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/06/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Appropriate thrombus-device interaction is critical for recanalization. Histology can serve as a proxy for mechanical properties, and thus inform technique selection. OBJECTIVE To investigate the value of histologic characterization, we conducted a systematic review and meta-analysis on the relationship between thrombus histology and recanalization, technique, etiology, procedural efficiency, and imaging findings. METHODS In this meta-analysis, we identified studies published between March 2010 and March 2020 reporting findings related to the histologic composition of thrombi in large vessel occlusion stroke. Studies with at least 10 patients who underwent mechanical thrombectomy using stent retriever or aspiration were considered. Only studies in which retrieved thrombi were histologically processed were included. Patient-level data were requested when data could not be directly extracted. The primary outcome assessed was the relationship between thrombus histology and angiographic outcome. RESULTS A total of 22 studies encompassing 1623 patients met inclusion criteria. Clots associated with good angiographic outcome had higher red blood cell (RBC) content (mean difference [MD] 9.60%, 95% CI 3.85-15.34, P = .008). Thrombi retrieved by aspiration had less fibrin (MD -11.39, 95% CI -22.50 to -0.27, P = .046) than stent-retrieved thrombi. Fibrin/platelet-rich clots were associated with longer procedure times (MD 13.20, 95% CI 1.30-25.10, P = .037). Hyperdense artery sign was associated with higher RBC content (MD 14.17%, 95% CI 3.07-25.27, P = .027). No relationship was found between composition and etiology. CONCLUSION RBC-rich thrombi were associated with better recanalization outcomes and shorter procedure times, suggesting that preinterventional compositional characterization may yield important prognostic and therapeutic guidance.
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Affiliation(s)
- Ankur Bhambri
- College of Medicine, Central Michigan University, Saginaw, Michigan, USA
| | | | - Yang Liu
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Václav Procházka
- Department of Imaging Methods, University of Ostrava, Ostrava, Czech Republic
| | - Francisco Hernández-Fernández
- Interventional Neuroradiology Unit, Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | | | - Tetsuya Hashimoto
- Department of Neurology, University of California, Los Angeles, Los Angeles, California, USA
| | - Luis E Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph J Gemmete
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Albert J Shih
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Aditya S Pandey
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
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Kadowaki M, Tenjin H, Tokuyama T, Kawakatsu T, Kida S, Makita I, Sakamoto T, Takao M, Kasahara M, Saito O, Kurozumi K. Histopathological Composition of Thrombus in Acute Ischemic Stroke May Vary Even Within the Same Patient: A Preliminary Study Examining Clots According to Their Area of Retrieval. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 16:6-11. [PMID: 37502029 PMCID: PMC10370624 DOI: 10.5797/jnet.oa.2020-0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 03/08/2021] [Indexed: 07/29/2023]
Abstract
Objective Mechanical thrombectomy enables histopathological examination of clots in patients who have suffered acute ischemic strokes. Many studies have described about the relationship between the histopathological compositions of retrieved thrombi and imaging findings, clinical outcomes, and stroke etiology without consensus. In this study, we examined the histological composition of thrombi according to their retrieval site and methods. Methods We divided retrieved clots into three parts (those retrieved from the proximal and distal parts of the stent retriever, and those aspirated through the guiding catheter) and then histopathologically analyzed their compositions by measuring the area occupied by red blood cells (RBCs), fibrin/platelets (F/Ps), and white blood cells (WBCs). Results Each specimen showed various composition even within the same patient. For example, the area occupied by RBCs was 20.9% ± 12.1%, 30.5% ± 13.5%, and 41.3% ± 16.1% in the clot retrieved from the proximal and distal parts of the stent retriever, and those aspirated through the guiding catheter, respectively. Conclusion Histopathological clot composition may vary even within the patient. Further research is needed to investigate more objective methods of histopathological analysis and their clinical significance.
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Affiliation(s)
- Makoto Kadowaki
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Hiroshi Tenjin
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Tsutomu Tokuyama
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Toru Kawakatsu
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Satoru Kida
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Ippei Makita
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Tomoya Sakamoto
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Masaki Takao
- Department of Clinical Laboratory, National Center Hospital of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Masao Kasahara
- Department of Pathology, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Osamu Saito
- Department of Neurosurgery, Shizuoka Red Cross Hospital, Shizuoka, Shizuoka, Japan
| | - Kazuhiko Kurozumi
- Department of Neurosurgery, Hamamatsu University Hospital, Hamamatsu, Shizuoka, Japan
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Sukovatykh BS, Bolomatov NV, Sidorov DV, Sukovatykh MB. [Acute cerebral circulation impairment associated with percutaneous coronary intervention]. ANGIOLOGIIA I SOSUDISTAIA KHIRURGIIA = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:175-182. [PMID: 35050264 DOI: 10.33529/angio2021420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The article deals with generalized literature data on the current importance of the problem concerning acute cerebral ischemia occurring during percutaneous coronary interventions. Pathophysiological mechanisms of the development of acute cerebral circulation impairment are described, with their classification. Also considered are various risk factors which may cause this formidable complication, followed by describing modern methods of its surgical treatment. It is noted that the main risk factors for neurological complications appearing after revascularization of coronary arteries include age, accompanying diseases (instability of arterial pressure, diabetes mellitus, atrial fibrillation, atherorosclerotic lesions of the aorta and brachiocephalic arteries, previous stroke), as well as systolic dysfunction, leukocytosis, and a low level of cognitive function prior to operation. The development of acute cerebral circulation impairment during and after percutaneous coronary intervention is an indication for using methods of endovascular treatment. It is most appropriate to use a combination of direct percutaneous thrombectomy and a stent retriever. It is underlined in the article that removal of the thrombus form the cerebral artery is not an independent surgical procedure but rather a methodology envisaging an operation to be performed from the simplest technique to the most complicated one. As the first procedure, it is necessary to perform thrombaspiration and then, if ineffective, a second stage consisting in thrombextraction with the help of a stent retriever. Besides, in order to increase efficacy of thrombaspiration there have been worked out several techniques combining the use of direct thrombextraction and a stent retriever. Described in detail are 4 most commonly used techniques.
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Affiliation(s)
- B S Sukovatykh
- Department of General Surgery, Kursk State Medical University of the RF Ministry of Public Health, Kursk, Russia
| | - N V Bolomatov
- Department of Roentgenosurgical Methods of Diagnosis and Treatment, Pirogov National Medical and Surgical Centre, Moscow, Russia
| | - D V Sidorov
- Department of Roentgenosurgical Methods of Diagnosis and Treatment, Orel Regional Clinical Hospital, Orel, Russia
| | - M B Sukovatykh
- Department of General Surgery, Kursk State Medical University of the RF Ministry of Public Health, Kursk, Russia
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Banno H, Kawai Y, Sato T, Tsuruoka T, Sugimoto M, Kodama A, Komori K. Low-density vulnerable thrombus/plaque volume on preoperative computed tomography predicts for spinal cord ischemia after endovascular repair for thoracic aortic aneurysm. J Vasc Surg 2020; 73:1557-1565.e1. [PMID: 33068765 DOI: 10.1016/j.jvs.2020.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Similar to open surgical repair, thoracic endovascular aortic repair (TEVAR) carries a risk of spinal cord ischemia (SCI). However, the generally lower incidence of SCI after TEVAR compared with that after open surgical repair, despite the inability to preserve the intercostal arteries, indicates different pathophysiologic mechanisms with the two procedures. We hypothesized that a microembolism from an aortic mural thrombus is the main cause of SCI. Thus, we evaluated the association between the density of a mural thrombus in the descending thoracic aorta and the development of SCI. METHODS A retrospective review of a prospectively assembled database was performed for all patients who had undergone surgery at a single institution from October 2008 to December 2018. Patient demographics and procedure-related variables were collected. The volume and Hounsfield unit (HU) value of mural thrombi in the whole descending thoracic aorta were estimated on preoperative computed tomography using a three-dimensional workstation. Logistic regression analysis was performed to identify the risk factors for SCI development. RESULTS Of the 367 patients who had undergone TEVAR during the study period, 155 were excluded because of previous arch surgery (n = 59), previous descending thoracic aortic surgery (n = 6), previous TEVAR (n = 6), unavailability of optimal preoperative computed tomography data (n = 17), double-barreled dissection (n = 40), and other reasons. The mean ± standard deviation age of the remaining 212 patients was 75.8 ± 6.4 years, and 42 (19.8%) were women. Of the 212 patients, 14 (6.6%) developed SCI after TEVAR. The low mean density of the mural thrombus, total thrombus volume, low-density (≥-100 HU but <30 HU) thrombus volume, intermediate-density (≥30 HU but <150 HU) thrombus volume, treatment length, urgent surgery, and baseline dialysis differed significantly between patients with and without SCI. Although subsequent multivariate analysis could not be performed owing to the small number of SCI events, vulnerable low-density thrombus/plaque was a stronger predictor among the aneurysm-related factors of SCI after TEVAR on univariate analysis. Well-known risk factors, such as distal coverage between T8 and L1, left subclavian artery coverage, previous abdominal aortic surgery, and prophylactic spinal drainage, did not show significant differences. CONCLUSIONS The results from the present study have demonstrated that among aneurysm-related factors, a lower density mural thrombus/plaque in the descending thoracic aorta is a predictor of SCI development after TEVAR. These results suggest that microembolism is one of the important mechanisms of SCI after TEVAR, which might change the prophylactic strategy.
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Affiliation(s)
- Hiroshi Banno
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Yohei Kawai
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomohiro Sato
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Tsuruoka
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayuki Sugimoto
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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9
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Huang SJ, Diao SS, Lu Y, Li T, Zhang LL, Ding YP, Fang Q, Cai XY, Xu Z, Kong Y. Value of thrombus imaging in predicting the outcomes of patients with large-vessel occlusive strokes after endovascular therapy. Neurol Sci 2020; 41:1451-1458. [PMID: 32086687 DOI: 10.1007/s10072-020-04296-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 11/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute ischemic stroke leads to serious long-term disability and high mortality, especially in patients with large-vessel occlusive strokes. Nowadays, endovascular therapy is considered as an alternative treatment for these patients. Several studies have used thrombus characteristics based on non-contrast computed tomography (NCCT) and computed tomography angiography (CTA) to predict prognosis in ischemic stroke. We conducted a systematic review to identify potential imaging predictive factors for successful recanalization and improved clinical outcome after endovascular therapy in patients with large-vessel occlusion (LVO) in anterior arterial circulation. METHODS The PubMed databases were searched for related studies reported between September 18, 2009, and September 18, 2019. RESULTS We selected 11 studies on revascularization and 12 studies on clinical outcome. Patients with thrombus of higher Hounsfield unit (HU), shorter length, higher clot burden score, and increased thrombus permeability may achieve higher recanalization and improved clinical outcome, but the matter is still under debate. CONCLUSION Imaging of thrombus can be used as an aseessment tool to predict the outcomes and it needs further studies in the future.
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Affiliation(s)
- Shuang-Jiao Huang
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Shan-Shan Diao
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Yue Lu
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Tan Li
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Lu-Lu Zhang
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Yi-Ping Ding
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Qi Fang
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Xiu-Ying Cai
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China.
| | - Zhuan Xu
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China.
| | - Yan Kong
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China.
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