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Manisha KY, Poyuran R, Narasimhaiah D, Kumar Paramasivan N, Ramachandran H, Erat Sreedharan S, Er J, Kumar S, Vinoda Thulaseedharan J, Sylaja PN. Thrombus histology does not predict stroke etiological subtype but influences recanalization. J Clin Neurosci 2024; 124:54-59. [PMID: 38643652 DOI: 10.1016/j.jocn.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/13/2024] [Accepted: 04/12/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND There is conflicting data on whether clot retrieved from mechanical thrombectomy can predict stroke etiology or the success of recanalization. We aimed to analyse the relation between thrombus histology and stroke aetiology as well as recanalization. METHODOLOGY Histopathological analysis of clots retrieved from patients with acute ischemic stroke and large vessel occlusion was done. Quantification of the amount of fibrin, red blood cells(RBC), platelets and white blood cells (WBC) in the clots were done. The clinical, imaging data and recanalization parameters were collected. The correlation between clot composition and stroke etiology as well as recanalization were analysed. RESULTS Of the 77 patients, the mean age was 58. 67 ± 12.96 years. The stroke etiology were cardioembolism 44(57.1 %), large artery atherosclerosis 13(16.8 %), other determined aetiology 4(5.1 %) and undetermined in 16(20.7 %) patients. There was no significant correlation between the proportions of RBC-rich, platelet-rich and fibrin-rich thrombi and the stroke etiology. The susceptibility vessel sign was associated with RBC-rich clot(92.3 % vs 7.7 %, p = .03). All RBC-rich clots(100 %) had good recanalization(p = .05). Platelet-rich clots needed less number of passes(64.7 % vs 35.3 %, p = .006) and reduced groin puncture to recanalization time(87.9 % vs 12.1 %, p = .033). WBC-rich clots required lesser number of passes(57.5 % vs 42.5 %, P = .044). In multivariate analysis, WBC-rich clots (OR 0.230, CI 0.07-0.78, p = .018) showed an independent association with reduced recanalization attempts, while platelet-rich clots showed reduced recanalization time(OR 0.09, CI 0.01-0.63, p = .016). CONCLUSION There was no correlation between thrombus histology and the etiological stroke subtype. However, clot composition predicted the degree of recanalization and number of passes.
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Affiliation(s)
- K Y Manisha
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - Rajalakshmi Poyuran
- Department of Pathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - Deepthi Narasimhaiah
- Department of Pathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - Naveen Kumar Paramasivan
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Harikrishnan Ramachandran
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Sapna Erat Sreedharan
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - Jayadevan Er
- Department of Imaging Science and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - Santhosh Kumar
- Department of Imaging Science and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - Jissa Vinoda Thulaseedharan
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
| | - P N Sylaja
- Comprehensive Stroke Care Program, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
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Heo JH, Yun J, Kim KH, Jung JW, Yoo J, Kim YD, Nam HS. Cancer-Associated Stroke: Thrombosis Mechanism, Diagnosis, Outcome, and Therapeutic Strategies. J Stroke 2024; 26:164-178. [PMID: 38836266 PMCID: PMC11164583 DOI: 10.5853/jos.2023.03279] [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: 10/04/2023] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 06/06/2024] Open
Abstract
Cancer can induce hypercoagulability, which may lead to stroke. This occurs when tumor cells activate platelets as part of their growth and metastasis. Tumor cells activate platelets by generating thrombin and expressing tissue factor, resulting in tumor cell-induced platelet aggregation. Histopathological studies of thrombi obtained during endovascular thrombectomy in patients with acute stroke and active cancer have shown a high proportion of platelets and thrombin. This underscores the crucial roles of platelets and thrombin in cancer-associated thrombosis. Cancer-associated stroke typically occurs in patients with active cancer and is characterized by distinctive features. These features include multiple infarctions across multiple vascular territories, markedly elevated blood D-dimer levels, and metastasis. The presence of cardiac vegetations on echocardiography is a robust indicator of cancer-associated stroke. Suspicion of cancer-associated stroke during endovascular thrombectomy arises when white thrombi are detected, particularly in patients with active cancer. Cancer-associated stroke is almost certain when histopathological examination of thrombi shows a very high platelet and a very low erythrocyte composition. Patients with cancer-associated stroke have high risks of mortality and recurrent stroke. However, limited data are available on the optimal treatment regimen for stroke prevention in these patients. Thrombosis mechanism in cancer is well understood, and distinct therapeutic targets involving thrombin and platelets have been identified. Therefore, direct thrombin inhibitors and/or antiplatelet agents may effectively prevent stroke recurrence. Additionally, this strategy has potential benefits in cancer treatment as accumulating evidence suggests that aspirin use reduces cancer progression, metastasis, and cancer-related mortality. However, clinical trials are necessary to assess the efficacy of this strategy involving the use of direct thrombin inhibitors and/or antiplatelet therapies.
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Affiliation(s)
- Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, Korea
| | - Jaeseob Yun
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang Hyun Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Wook Jung
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Joonsang Yoo
- Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, Korea
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3
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Karmakar A, Burgreen GW, Rydquist G, Antaki JF. A homogenized two-phase computational framework for meso- and macroscale blood flow simulations. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 247:108090. [PMID: 38394788 PMCID: PMC11018323 DOI: 10.1016/j.cmpb.2024.108090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND AND OBJECTIVE Owing to the complexity of physics linked with blood flow and its associated phenomena, appropriate modeling of the multi-constituent rheology of blood is of primary importance. To this effect, various kinds of computational fluid dynamic models have been developed, each with merits and limitations. However, when additional physics like thrombosis and embolization is included within the framework of these models, computationally efficient scalable translation becomes very difficult. Therefore, this paper presents a homogenized two-phase blood flow framework with similar characteristics to a single fluid model but retains the flow resolution of a classical two-fluid model. The presented framework is validated against four different sets of experiments. METHODS The two-phase model of blood presented here is based on the classical diffusion-flux framework. Diffusion flux models are known to be less computationally expensive than two-fluid multiphase models since the numerical implementation resembles single-phase flow models. Diffusion flux models typically use empirical slip velocity correlations to resolve the motion between phases. However, such correlations do not exist for blood. Therefore, a modified slip velocity equation is proposed, derived rigorously from the two-fluid governing equations. An additional drag law for red blood cells (RBCs) as a function of volume fraction is evaluated using a previously published cell-resolved solver. A new hematocrit-dependent expression for lift force on RBCs is proposed. The final governing equations are discretized and solved using the open-source software OpenFOAM. RESULTS The framework is validated against four sets of experiments: (i) flow through a rectangular microchannel to validate RBC velocity profiles against experimental measurements and compare computed hematocrit distributions against previously reported simulation results (ii) flow through a sudden expansion microchannel for comparing experimentally obtained contours of hematocrit distributions and normalized cell-free region length obtained at different flowrates and inlet hematocrits, (iii) flow through two hyperbolic channels to evaluate model predictions of cell-free layer thickness, and (iv) flow through a microchannel that mimics crevices of a left ventricular assist device to predict hematocrit distributions observed experimentally. The simulation results exhibit good agreement with the results of all four experiments. CONCLUSION The computational framework presented in this paper has the advantage of resolving the multiscale physics of blood flow while still leveraging numerical techniques used for solving single-phase flows. Therefore, it becomes an excellent candidate for addressing more complicated problems related to blood flow, such as modeling mechanical entrapment of RBCs within blood clots, predicting thrombus composition, and visualizing clot embolization.
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Affiliation(s)
- Abhishek Karmakar
- Department of Biomedical Engineering, Cornell University, Ithaca, NY, USA
| | - Greg W Burgreen
- Center for Advanced Vehicular Systems, Mississippi State University, Starkville, MS, USA
| | - Grant Rydquist
- Department of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY, USA
| | - James F Antaki
- Department of Biomedical Engineering, Cornell University, Ithaca, NY, USA.
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Dargazanli C, Blaquière M, Moynier M, de Bock F, Labreuche J, Ter Schiphorst A, Derraz I, Radu RA, Gascou G, Lefevre PH, Rapido F, Fendeleur J, Arquizan C, Bourcier R, Marin P, Machi P, Cagnazzo F, Hirtz C, Costalat V, Marchi N. Inflammation biomarkers in the intracranial blood are associated with outcome in patients with ischemic stroke. J Neurointerv Surg 2024:jnis-2023-021365. [PMID: 38514190 DOI: 10.1136/jnis-2023-021365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/18/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Performing endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) allows a port of entry for intracranial biological sampling. OBJECTIVE To test the hypothesis that specific immune players are molecular contributors to disease, outcome biomarkers, and potential targets for modifying AIS. METHODS We examined 75 subjects presenting with large vessel occlusion of the anterior circulation and undergoing EVT. Intracranial blood samples were obtained by microcatheter aspiration, as positioned for stent deployment. Peripheral blood samples were collected from the femoral artery. Plasma samples were quality controlled by electrophoresis and analyzed using a Mesoscale multiplex for targeted inflammatory and vascular factors. RESULTS We measured 37 protein biomarkers in our sample cohort. Through multivariate analysis, adjusted for age, intravenous thrombolysis, pretreatment National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT scores, we found that post-clot blood levels of interleukin-6 (IL-6) were significantly correlated (adjusted P value <0.05) with disability assessed by the modified Rankin Scale (mRS) score at 90 days, with medium effect size. Chemokine (C-C) ligand 17 CCL17/TARC levels were inversely correlated with the mRS score. Examination of peripheral blood showed that these correlations did not reach statistical significance after correction. Intracranial biomarker IL-6 level was specifically associated with a lower likelihood of favorable outcome, defined as a mRS score of 0-2. CONCLUSIONS Our findings show a signature of blood inflammatory factors at the cerebrovascular occlusion site. The correlations between these acute-stage biomarkers and mRS score outcome support an avenue for add-on and localized immune modulatory strategies in AIS.
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Affiliation(s)
- Cyril Dargazanli
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Marine Blaquière
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Marinette Moynier
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, France
| | - Frédéric de Bock
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Julien Labreuche
- Unité Statistique, Évaluation Économique, Data-management, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Adrien Ter Schiphorst
- Department of Neurology, CHRU Gui de Chauliac, University Hospital Centre Montpellier, Montpellier, France
| | - Imad Derraz
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, France
| | - Răzvan Alexandru Radu
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, France
| | - Gregory Gascou
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, France
| | - Pierre Henri Lefevre
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, France
| | - Francesca Rapido
- Department of Anesthesiology and Critical Care Medicine, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Julien Fendeleur
- Department of Anesthesiology and Critical Care Medicine, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Caroline Arquizan
- Department of Neurology, CHRU Gui de Chauliac, University Hospital Centre Montpellier, Montpellier, France
| | - Romain Bourcier
- Department of Neuroradiology, Université de Nantes, Nantes, France
| | - Philippe Marin
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Paolo Machi
- Department of Neuroradiology, Geneva University Hospitals, Geneve, Switzerland
| | - Federico Cagnazzo
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | | | - Vincent Costalat
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Nicola Marchi
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
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Jiang Y, Sun Z, Ge Z, Tao Z, Liu M, Zhong W, Dong N, Xu L, Wang H, Xu Y, Shen X. Differential expression of Semaphorin-7A /CD163-positive macrophages in large artery and cardiogenic stroke. BMC Neurol 2024; 24:70. [PMID: 38373967 PMCID: PMC10875813 DOI: 10.1186/s12883-024-03559-6] [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: 10/22/2023] [Accepted: 02/01/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Identification of the causes of stroke of undetermined etiology, specifically cardioembolism (CE) and non-CE causes, can inform treatment planning and prognosis prediction. The objective of this study was to analyze the disparities in thrombus composition, particularly Semaphorin-7A (Sema7A) and CD163, between patients diagnosed with large-artery atherosclerosis (LAA) and those with CE, and to investigate their potential association with prognosis. METHODS Thrombi were collected from patients who underwent mechanical thrombectomy at two hospitals. The patients were categorized into two groups: LAA and CE. We compared the levels of Sema7A and CD163 between these groups and analyzed their relationships with stroke severity, hemorrhagic transformation and prognosis. RESULTS The study involved a total of 67 patients. Sema7A expression was found to be significantly higher in the CE group compared to LAA (p < 0.001). Conversely, no statistically significant differences were observed for CD163 between the groups. The presence of Sema7A/CD163 did not show any associations with stroke severity or hemorrhagic transformation (all p > 0.05). However, both Sema7A (OR, 2.017; 95% CI, 1.301-3.518; p = 0.005) and CD163 (OR, 2.283; 95% CI, 1.252-5.724; p = 0.03) were associated with the poor prognosis for stroke, after adjusting for stroke severity. CONCLUSION This study highlights that CE thrombi exhibited higher levels of Sema7A expression compared to LAA thrombi. Moreover, we found a positive correlation between Sema7A/CD163 levels and the poor prognosis of patients with acute ischemic stroke.
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Affiliation(s)
- Yi Jiang
- Department of Geriatrics, Bengbu Medical College Clinical College of Lianyungang Second People's Hospital, Lianyungang, 222000, China
| | - Zhichao Sun
- Department of Pathology, Lianyungang Second People's Hospital, Lianyungang, 222000, China
| | - Zhonglin Ge
- Department of Neurology, Lianyungang Second People's Hospital, Lianyungang, 222000, China.
| | - Zhonghai Tao
- Department of Neurology, Lianyungang Second People's Hospital, Lianyungang, 222000, China
| | - Mengqian Liu
- Department of Geriatrics, Lianyungang Hospital Affiliated to Jiangsu University, Lianyungang, 222000, China
| | - Wen Zhong
- Department of Geriatrics, Lianyungang Hospital Affiliated to Jiangsu University, Lianyungang, 222000, China
| | - Nan Dong
- Department of Neurology, Shaoxing Central Hospital, Shaoxing, China
| | - Lei Xu
- Department of Pathology, Lianyungang Second People's Hospital, Lianyungang, 222000, China
| | - Hui Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yiwen Xu
- Department of Infectious Disease, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Xiaozhu Shen
- Department of Geriatrics, Bengbu Medical College Clinical College of Lianyungang Second People's Hospital, Lianyungang, 222000, China.
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Patel TR, Santo BA, Baig AA, Waqas M, Monterio A, Levy EI, Siddiqui AH, Tutino VM. Histologically interpretable clot radiomic features predict treatment outcomes of mechanical thrombectomy for ischemic stroke. Neuroradiology 2023; 65:737-749. [PMID: 36600077 DOI: 10.1007/s00234-022-03109-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/21/2022] [Indexed: 01/06/2023]
Abstract
PURPOSE Radiomics features (RFs) extracted from CT images may provide valuable information on the biological structure of ischemic stroke blood clots and mechanical thrombectomy outcome. Here, we aimed to identify RFs predictive of thrombectomy outcomes and use clot histomics to explore the biology and structure related to these RFs. METHODS We extracted 293 RFs from co-registered non-contrast CT and CTA. RFs predictive of revascularization outcomes defined by first-pass effect (FPE, near to complete clot removal in one thrombectomy pass), were selected. We then trained and cross-validated a balanced logistic regression model fivefold, to assess the RFs in outcome prediction. On a subset of cases, we performed digital histopathology on the clots and computed 227 histomic features from their whole slide images as a means to interpret the biology behind significant RF. RESULTS We identified 6 significantly-associated RFs. RFs reflective of continuity in lower intensities, scattered higher intensities, and intensities with abrupt changes in texture were associated with successful revascularization outcome. For FPE prediction, the multi-variate model had high performance, with AUC = 0.832 ± 0.031 and accuracy = 0.760 ± 0.059 in training, and AUC = 0.787 ± 0.115 and accuracy = 0.787 ± 0.127 in cross-validation testing. Each of the 6 RFs was related to clot component organization in terms of red blood cell and fibrin/platelet distribution. Clots with more diversity of components, with varying sizes of red blood cells and fibrin/platelet regions in the section, were associated with RFs predictive of FPE. CONCLUSION Upon future validation in larger datasets, clot RFs on CT imaging are potential candidate markers for FPE prediction.
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Affiliation(s)
- Tatsat R Patel
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Briana A Santo
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Ammad A Baig
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Muhammad Waqas
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Andre Monterio
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Elad I Levy
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Vincent M Tutino
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA.
- Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo, NY, USA.
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA.
- Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, NY, USA.
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA.
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Song P, Xie J, Li W, Zhang X, Sun Z, You C. Effect of plasma thrombin-antithrombin complex on ischemic stroke: a systematic review and meta-analysis. Syst Rev 2023; 12:17. [PMID: 36788633 PMCID: PMC9930276 DOI: 10.1186/s13643-023-02174-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/11/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Thrombin-antithrombin complex (TAT) is a prethrombotic marker, and its application in ischemic stroke is still uncertain. The purpose of this systematic review and meta-analysis is to evaluate the relationship between plasma TAT and ischemic stroke base on the current evidence. METHODS A systematic literature search was conducted for searching the relative studies that investigated the association of TAT and ischemic stroke in PubMed, EMBASE, and Cochrane library databases. Mean difference and 95% confidence interval as the effect sizes were synthesized by random effects model in Review Manager (RevMan) Version 5.4. The heterogeneity was investigated using the chi-square test and the possible sources of heterogeneity were explored by sensitivity analysis and meta-regression. The publication bias was estimated by Egger's tests. RESULTS A total of 12 eligible studies were included involving 1431 stroke cases and 532 healthy controls, of which six studies were eventually included in the meta-analysis. Plasma TAT in patients with ischemic stroke was significantly higher than that in healthy controls (MD 5.31, 95% CI = 4.12-6.51, P < 0.0001, I2 = 97.8%). There is a difference of TAT level in the same period among cardioembolic, lacunar, and atherothrombotic stroke (all P < 0.0001), in which the cardioembolic stroke with the highest level. Meanwhile, it is significant of TAT levels among various phases of cardioembolic stroke and the acute phase are markedly elevated (MD 7.75, 95CI%, 6.07-9.43, P < 0.001). However, no difference was found in the atherothrombotic (P = 0.13) and lacunar stroke (P = 0.34). Besides, the higher TAT level is closely related to the poor prognosis of patients with ischemic stroke, including higher recurrence, mortality, unfavorable recovery (modified Rankin scale > 2), and poor revascularization. CONCLUSIONS This study suggested that plasma TAT levels are different in ischemic stroke subtypes, which are closely associated with the progression and might have an effect on the prognosis. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD: 42021248787.
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Affiliation(s)
- Peipei Song
- Laboratory Medicine Center, Lanzhou University Second Hospital, Lanzhou, 730000, China
| | - Jianqin Xie
- Department of Anesthesiology, Lanzhou University Second Hospital, Lanzhou, 730000, China
| | - Wei Li
- Laboratory Medicine Center, Lanzhou University Second Hospital, Lanzhou, 730000, China
| | - Xinying Zhang
- Laboratory Medicine Center, Lanzhou University Second Hospital, Lanzhou, 730000, China
| | - Zhipeng Sun
- Academic Department, Sysmex Shanghai Ltd., Shanghai, 200120, China
| | - Chongge You
- Laboratory Medicine Center, Lanzhou University Second Hospital, Lanzhou, 730000, China.
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8
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Mereuta OM, Agarwal T, Ghozy S, Dai D, Arul S, Brinjikji W, Kallmes DF, Kadirvel R. Shell Versus Core Architecture and Biology of Thrombi in Acute Ischemic Stroke: A Systematic Review. Clin Appl Thromb Hemost 2023; 29:10760296231213632. [PMID: 37960892 PMCID: PMC10647960 DOI: 10.1177/10760296231213632] [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: 05/11/2023] [Revised: 10/02/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND The presence of an outer shell has been recently described as a common feature of acute ischemic stroke (AIS) thrombi. We performed a systematic review of the current literature on shell genesis, structure, and clinical significance. METHODS Following PRISMA guidelines, we searched Ovid Cochrane Central Register of Controlled Trials, Embase, Medline, Scopus, and Web of Science for studies reporting the composition and structure of AIS thrombi and clot analogs. Identified studies were added to Covidence software for primary screening. Two reviewers independently screened titles and abstracts followed by full-text screening. RESULTS From 1290 identified studies, 10 were included in this review. Studies using histology/immunohistochemistry/immunofluorescence described fibrin, platelets, von Willebrand factor, and neutrophil extracellular traps as the main components of the shell. Scanning electron microscopy demonstrated a dense, compact fibrin/platelet-rich shell, and a core rich in polyhedrocytes. Microfluidics studies identified highly activated P-selectin-positive platelets and fibrin forming the core while secondary agonists adenosine diphosphate and thromboxane, along with loosely packed P-selectin-negative platelets constituted the shell. CONCLUSIONS The composition, compaction, and integrity of the shell may impact thrombolysis and revascularization outcomes. The preponderance of studies supported this conclusion.
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Affiliation(s)
| | - Tamanna Agarwal
- Faculty of Medicine in Hradec Kralove, Charles University, Prague, Czech Republic
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Daying Dai
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Santhosh Arul
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Ram Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
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SUGIYAMA N, HASEGAWA H, KUDO K, MIYAHARA R, SAITO R, MARUKI C, TAKASE M, KONDO A, OISHI H. Cholesterol Crystals in the Retrieved Thrombus by Mechanical Thrombectomy for Cerebral Embolism: A Case Report and Literature Review. NMC Case Rep J 2022; 9:225-230. [PMID: 36061909 PMCID: PMC9398466 DOI: 10.2176/jns-nmc.2022-0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/02/2022] [Indexed: 11/20/2022] Open
Abstract
There are only a few case reports in which cholesterol crystals were found in the thrombus retrieved by mechanical thrombectomy for cryptogenic stroke, leading to a definitive diagnosis. We herein report a case of aortogenic embolic stroke diagnosed by the presence of rich cholesterol crystals in the retrieved thrombus and review the previously reported cases. A woman in her 80s was transferred as an emergency due to consciousness disturbance, right conjugate deviation, and severe left hemiparesis. Magnetic resonance imaging showed occlusion of the right middle cerebral artery (MCA) and acute infarction in the territory. The MCA was recanalized by thrombectomy using an aspiration catheter and stent retriever, and the symptoms improved. Although the physiological examination did not detect the embolic source during hospitalization, pathological examination of the thrombus revealed atheroma with numerous cholesterol crystal clefts and intermixing of fibrin. Contrast-enhanced computed tomography performed based on the pathological results showed atheromatous lesions in the aortic arch as the embolic source. As a subsequent treatment, medications of a strong statin and an antiplatelet agent were continued, and the patient had no recurrence. The finding that the retrieved thrombus is a simple atheroma containing cholesterol crystals with poor hemocytes suggests embolism due to plaque rupture. Pathological examination of the thrombus obtained by thrombectomy is one of the useful diagnostic approaches for stroke etiology and the determination of its treatment.
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Affiliation(s)
| | | | - Kentaro KUDO
- Department of Neurosurgery, Koshigaya Municipal Hospital
| | - Ryo MIYAHARA
- Department of Neurosurgery, Koshigaya Municipal Hospital
| | - Rikizo SAITO
- Department of Neurosurgery, Koshigaya Municipal Hospital
| | | | - Masaru TAKASE
- Department of Pathology, Koshigaya Municipal Hospital
| | - Akihide KONDO
- Department of Neurosurgery, Graduate School of Medicine, Juntendo University
| | - Hidenori OISHI
- Department of Neuroendovascular Therapy, Graduate School of Medicine, Juntendo University
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10
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Clot Morphology in Acute Ischemic Stroke Decision Making. Int J Mol Sci 2022; 23:ijms232012373. [PMID: 36293230 PMCID: PMC9604475 DOI: 10.3390/ijms232012373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/09/2022] [Accepted: 10/13/2022] [Indexed: 11/17/2022] Open
Abstract
Stroke is a leading cause of death and disability in the world, and the provision of reperfusion therapy and endovascular therapy, in particular, have revolutionized the treatment of patients with stroke and opened opportunities to look at brain clots retrieved after the procedure. The use of histopathology and molecular profiling of clots is of growing research and clinical interest. However, its clinical implications and incorporation within stroke workflows remain suboptimal. Recent studies have indicated that the study of brain clots may inform the mechanism of stroke and hence guide treatment decision-making in select groups of patients, especially patients without a defined cause or known mechanism. This article provides a comprehensive overview of various clot histopathological examinations in acute stroke-care settings, their clinical utility, and existing gaps and opportunities for further research. We also provide targeted recommendations to improve clot analysis workflow, hence standardizing its incorporation into clinical practice.
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Shimizu H, Hatakeyama K, Saito K, Shobatake R, Takahashi N, Deguchi J, Tokunaga H, Shimada K, Nakagawa I, Myochin K, Sakai K, Kubo M, Yamashita A, Obayashi C, Sugie K, Matsumoto M. Age and composition of the thrombus retrieved by mechanical thrombectomy from patients with acute ischemic stroke are associated with revascularization and clinical outcomes. Thromb Res 2022; 219:60-69. [PMID: 36126564 DOI: 10.1016/j.thromres.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/24/2022] [Accepted: 09/05/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Understanding the composition of stroke thrombi retrieved by mechanical thrombectomy is essential to clarify the pathogenesis of stroke. However, it is difficult to evaluate thrombus composition precisely and objectively. Immunohistochemical staining was used to evaluate thrombus composition and age. MATERIALS AND METHODS Consecutive thrombi (n = 108) retrieved from patients who underwent mechanical thrombectomy for acute large-vessel ischemic stroke were retrospectively analyzed. Lytic features of granulocytes and CD163 were estimated as indicators of the age of the cardioembolic (CE) thrombus. RESULTS The stroke subtypes were as follows: CE, 74 cases; large artery atherosclerosis, 11; undetermined etiology, 12; and other determined etiology, 11. There were no statistical differences in thrombi composition according to stroke subtypes. The fibrin area was positively correlated with the red blood cell (RBC) and platelet areas. The following analysis was performed using CE only. Regarding age, the thrombus was judged as fresh in 30.0 % and older in 70.0 % based on the lytic features. The RBC areas of older thrombi were smaller than those of fresh thrombi. The puncture-to-reperfusion time of older thrombi was longer than that of fresh thrombi. Platelet-rich thrombi were associated with a greater number of maneuvers, a smaller prevalence of TICI 3, and unfavorable functional outcomes compared to platelet-poor thrombi. The number of CD163 positive cells in thrombi with anticoagulants was higher than in those without anticoagulants. CONCLUSION Thrombus composition correlated with revascularization and clinical outcomes. The composition of an acute ischemic thrombus may reflect the pathophysiology of stroke and influence treatment efficacy.
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Affiliation(s)
- Hisao Shimizu
- Department of Neurology, Nara Medical University, Kashihara, Japan
| | - Kinta Hatakeyama
- Department of Pathology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kozue Saito
- Department of Neurology, Nara Medical University, Kashihara, Japan
| | | | | | - Jun Deguchi
- Department of Neurosurgery, Nara City Hospital, Nara, Japan
| | | | - Keiji Shimada
- Department of Pathology, Nara City Hospital, Nara, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Kashihara, Japan
| | - Kaoru Myochin
- Department of Radiology and Interventional Radiology Center, Nara Medical University, Kashihara, Japan
| | - Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Masayuki Kubo
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Atsushi Yamashita
- Department of Pathology, Faculty of Medicine, Miyazaki University, Miyazaki, Japan
| | - Chiho Obayashi
- Department of Diagnostic Pathology, Nara Medical University, Kashihara, Japan
| | - Kazuma Sugie
- Department of Neurology, Nara Medical University, Kashihara, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan.
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Wang R, Wang Z, Jiang L, Gu G, Zheng B, Xian L, Zhang Y, Wang J. High Actin Expression in Thrombus of Acute Ischemic Stroke Can Be a Biomarker of Atherothrombotic Origin Stroke. Front Neurol 2022; 13:896428. [PMID: 35937070 PMCID: PMC9355373 DOI: 10.3389/fneur.2022.896428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/20/2022] [Indexed: 11/24/2022] Open
Abstract
Background As the treatment target, the imaging information and histologic characteristics of the thrombus may differ according to the stroke subtype. This study aimed to provide the correlative study of stroke etiology with the non-contrast CT, and histological composition of retrieved clots in acute ischemic stroke (AIS). Materials and Methods A total of 94 patients with AIS who underwent the endovascular treatment with successfully retrieved clots from January 2017 to October 2020 were enrolled in the present study. Histological analysis was performed using hematoxylin and eosin (H&E) staining and immunostaining with CD3, CD20, CD105, and actin antibodies. CT obtained at the patients' admission was to measure the attenuation and volume of all thrombus. Results A total of 94 subjects were included in this study. Fifty-six patients were classified as cardioembolic (CE), and 38 were classified with large-artery atherosclerosis (LAA). The subjects with LAA tend to exhibit higher actin and CD105 levels, and lower Hounsfield Unit (HU) values than subjects with CE. After adjusting for confounders, the actin was positively correlated with CD105 but not with HU values. Logistics regression shows actin was valuable for the prediction of LAA (OR, 1.148; 95% CI, 1.075–1.227; p < 0.001), even adjusted for age, sex, and intervention type (OR, 1.129; 95% CI, 1.048–1.216; p = 0.001), CT density and CD105 (OR, 1.161; 95% CI, 1.056–1.277; p = 0.002). Actin levels have a strong accuracy in differentiating LAA from CE, especially combined with CT density and CD105, which yielded a sensitivity of 63.2%, a specificity of 89.3%, with the area under the curve (AUC) at 0.821 (95% CI, 0.731–0.912). Conclusion Our findings suggest that actin's level was a major factor differentiating atherothrombotic origin strokes from the cardioembolic stroke. Clinical Trial Registration ChiCTR2100051173.
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Affiliation(s)
- Rongyu Wang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhiqiang Wang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
- Department of Neurology, Chengdu BOE Hospital, Chengdu, China
| | - Lianyan Jiang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Gangfeng Gu
- Department of Neurology, Ya'an People's Hospital, Ya'an, China
| | - Bo Zheng
- Department of Neurology, Ya'an People's Hospital, Ya'an, China
| | - Liulin Xian
- Acupuncture and Tuina College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yaodan Zhang
- Department of Neurology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jian Wang
- Department of Neurology, Ya'an People's Hospital, Ya'an, China
- *Correspondence: Jian Wang
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Mereuta OM, Abbasi M, Arturo Larco JL, Dai D, Liu Y, Arul S, Kadirvel R, Hanel RA, Yoo AJ, Almekhlafi MA, Layton KF, Delgado Almandoz JE, Kvamme P, Mendes Pereira V, Jahromi BS, Nogueira RG, Gounis MJ, Patel B, Aghaebrahim A, Sauvageau E, Bhuva P, Soomro J, Demchuk AM, Thacker IC, Kayan Y, Copelan A, Nazari P, Cantrell DR, Haussen DC, Al-Bayati AR, Mohammaden M, Pisani L, Rodrigues GM, Puri AS, Entwistle J, Meves A, Savastano L, Cloft HJ, Nimjee SM, McBane Ii RD, Kallmes DF, Brinjikji W. Correlation of von Willebrand factor and platelets with acute ischemic stroke etiology and revascularization outcome: an immunohistochemical study. J Neurointerv Surg 2022; 15:488-494. [PMID: 35595407 DOI: 10.1136/neurintsurg-2022-018645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/01/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Platelets and von Willebrand factor (vWF) are key components of acute ischemic stroke (AIS) emboli. We aimed to investigate the CD42b (platelets)/vWF expression, its association with stroke etiology and the impact these components may have on the clinical/procedural parameters. METHODS CD42b/vWF immunostaining was performed on 288 emboli collected as part of the multicenter STRIP Registry. CD42b/VWF expression and distribution were evaluated. Student's t-test and χ2 test were performed as appropriate. RESULTS The mean CD42b and VWF content in clots was 44.3% and 21.9%, respectively. There was a positive correlation between platelets and vWF (r=0.64, p<0.001**). We found a significantly higher vWF level in the other determined etiology (p=0.016*) and cryptogenic (p=0.049*) groups compared with cardioembolic etiology. No significant difference in CD42b content was found across the etiology subtypes. CD42b/vWF patterns were significantly associated with stroke etiology (p=0.006*). The peripheral pattern was predominant in atherosclerotic clots (36.4%) while the clustering (patchy) pattern was significantly associated with cardioembolic and cryptogenic origin (66.7% and 49.8%, respectively). The clots corresponding to other determined etiology showed mainly a diffuse pattern (28.1%). Two types of platelets were distinguished within the CD42b-positive clusters in all emboli: vWF-positive platelets were observed at the center, surrounded by vWF-negative platelets. Thrombolysis correlated with a high platelet content (p=0.03*). vWF-poor and peripheral CD42b/vWF pattern correlated with first pass effect (p=0.03* and p=0.04*, respectively). CONCLUSIONS The vWF level and CD42b/vWF distribution pattern in emboli were correlated with AIS etiology and revascularization outcome. Platelet content was associated with response to thrombolysis.
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Affiliation(s)
| | - Mehdi Abbasi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jorge L Arturo Larco
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Daying Dai
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yang Liu
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhosh Arul
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ricardo A Hanel
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Albert J Yoo
- Department of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Mohammed A Almekhlafi
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kennith F Layton
- Department of Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Josser E Delgado Almandoz
- Department of NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Peter Kvamme
- Department of Radiology, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Vitor Mendes Pereira
- Departments of Medical Imaging and Surgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Babak S Jahromi
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Matthew J Gounis
- Department of Radiology, University of Massachusetts Medical School, New England Center for Stroke Research, Worcester, Massachusetts, USA
| | - Biraj Patel
- Departments of Radiology and Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Amin Aghaebrahim
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Department of Neurosurgery, Baptist Medical Center, Jacksonville, Florida, USA
| | - Parita Bhuva
- Department of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Jazba Soomro
- Department of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Texas, USA
| | - Andrew M Demchuk
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ike C Thacker
- Department of Radiology, Baylor University Medical Center, Dallas, Texas, USA
| | - Yasha Kayan
- Department of NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Alexander Copelan
- Department of NeuroInterventional Radiology, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Pouya Nazari
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Donald Robert Cantrell
- Departments of Radiology and Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Mahmoud Mohammaden
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Leonardo Pisani
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Gabriel Martins Rodrigues
- Department of Neurology, Emory University, Atlanta, Georgia, USA.,Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Medical School, New England Center for Stroke Research, Worcester, Massachusetts, USA
| | - John Entwistle
- Departments of Radiology and Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Alexander Meves
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Luis Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Harry J Cloft
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shahid M Nimjee
- Department of Neurological Surgery, Ohio State University, Columbus, Ohio, USA
| | - Robert D McBane Ii
- Gonda Vascular Center, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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