Analyses of thrombi in acute ischemic stroke: A consensus statement on current knowledge and future directions

Meyer, Simon F. De; Andersson, Tommy; Baxter, Blaise; Bendszus, Martin; Brouwer, Patrick A.; Brinjikji, Waleed; Campbell, Bruce; Costalat, Vincent; Dávalos, Antoni; Demchuk, Andrew M.; Dippel, Diederik W.J.; Fiehler, Jens; Fischer, Urs; Gilvarry, Michael; Gounis, Matthew J.; Gralla, Jan; Jansen, Olav; Jovin, Tudor G; Kallmes, David F.; Khatri, Pooja; Lees, Kennedy R.; López‐Cancio, Elena; Majoie, Charles B. L. M.; Marquering, Henk A.; Narata, Ana Paula; Nogueira, Raul G; Ringleb, Peter A.; Siddiqui, Adnan H.; Szikora, István; Vale, David; Kummer, Rüdiger von; Yoo, Albert J.; Hacke, Werner; Liebeskind, David S

doi:10.1177/1747493017709671

Cited by 139 publications

(121 citation statements)

References 38 publications

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“…For instance, it may be that cardiac thrombi have a different composition or age than thrombi of noncardiac origin. 29 Another potential explanation could be the risk of sICH. The proportion of patients who developed a sICH after EVT alone (ie, without prior IVT) was almost 5% higher in patients without atrial fibrillation than in patients with atrial fibrillation (7.3% versus 2.8%, Table 8), which could partly explain the worse outcome of patients without atrial fibrillation who received EVT alone.…”

Section: Discussionmentioning

confidence: 99%

Endovascular Treatment With or Without Prior Intravenous Alteplase for Acute Ischemic Stroke

Chalos

LeCouffe

Uyttenboogaart

et al. 2019

JAHA

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Background It is unclear whether intravenous thrombolysis ( IVT ) with alteplase before endovascular treatment ( EVT ) is beneficial for patients with acute ischemic stroke caused by a large vessel occlusion. We compared clinical and procedural outcomes, safety, and workflow between patients treated with both IVT and EVT and those treated with EVT alone in routine clinical practice. Methods and Results Using multivariable regression, we evaluated the association of IVT + EVT with 90‐day functional outcome (modified Rankin Scale), mortality, reperfusion, first‐pass effect, and symptomatic intracranial hemorrhage in the MR CLEAN (Multicenter Randomised Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) Registry. Of 1485 patients, 1161 (78%) were treated with IVT + EVT , and 324 (22%) with EVT alone. Patients treated with IVT + EVT had atrial fibrillation less often (16% versus 44%) and had better pre‐stroke modified Rankin Scale scores (pre‐stroke modified Rankin Scale 0: 73% versus 52%) than those treated with EVT alone. Procedure time was shorter in the IVT + EVT group (median 62 versus 68 minutes). Nontransferred IVT + EVT patients had longer door‐to‐groin‐puncture times (median 105 versus 94 minutes). IVT + EVT was associated with better functional outcome (adjusted common odds ratio 1.47; 95% CI : 1.10–1.96) and lower mortality (adjusted odds ratio 0.58; 95% CI : 0.40–0.82). Successful reperfusion, first‐pass effect, and symptomatic intracranial hemorrhage did not differ between groups. Conclusions In this observational study, patients treated with IVT + EVT had better clinical outcomes than patients who received EVT alone. This finding may demonstrate a true benefit of IVT before EVT , but its interpretation is hampered by the possibility of residual confounding and selection bias. Randomized trials are required to properly assess the effect of IVT before EVT .

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Section: Discussionmentioning

confidence: 99%

Endovascular Treatment With or Without Prior Intravenous Alteplase for Acute Ischemic Stroke

Chalos

LeCouffe

Uyttenboogaart

et al. 2019

JAHA

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“…In addition, other parameters like pre-interventional systemic thrombolysis or duration of clinical symptoms may play a role in embolic events and have to be analyzed in further prospective studies. In this study – and in every study analyzing thrombus material [13] – patients can be included only if it was possible to retrieve thrombus material. This might explain the high recanalization rates in our study.…”

Section: Discussionmentioning

confidence: 99%

“…Erythrocyte-rich thrombi showed increased viscosity and deformability and decreased elasticity and stiffness, and these characteristics might increase the effectiveness of thrombectomy [6]. A recent consensus statement of stroke experts has concluded that further “thrombus research will be key to advancing the understanding of thrombus and improving acute ischemic stroke therapy” [13]. …”

Section: Introductionmentioning

confidence: 99%

Ischemic Stroke: Histological Thrombus Composition and Pre-Interventional CT Attenuation Are Associated with Intervention Time and Rate of Secondary Embolism

Sporns

Hanning²,

Schwindt

et al. 2017

Cerebrovasc Dis

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Background and Purpose: The introduction of stent retrievers has made the complete extraction and histological analysis of human thrombi possible. A number of large randomized trials have proven the efficacy of thrombectomy for ischemic stroke; however, thrombus composition could have an impact on the efficacy and risk of the intervention. We therefore investigated the impact of histologic thrombus features on interventional outcome and procedure-related embolisms. For a pre-interventional estimation of histologic features and outcome parameters, we assessed the pre-interventional CT attenuation of the thrombi. Methods: We prospectively included all consecutive patients with occlusion of the middle cerebral artery who underwent thrombectomy between December 2013 and February 2016 at our university medical center. Samples were histologically analyzed (H&E, Elastica van Gieson, Prussian blue); additionally, immunohistochemistry for CD3, CD20, and CD68/KiM1P was performed. Main thrombus components (fibrin, erythrocytes, and white blood cells) were determined and compared to intervention time, frequency of secondary embolisms, as well as additional clinical and interventional parameters. Additionally, we assessed the pre-interventional CT attenuation of the thrombi in relation to the unaffected side (rHU) and their association with histologic features. Results: One hundred eighty patients were included; of these, in 168 patients (93.4%), complete recanalization was achieved and 27 patients (15%) showed secondary embolism in the control angiogram. We observed a significant association of high amounts of fibrin (p < 0.001), low percentage of red blood cells (p < 0.001), and lower rHU (p < 0.001) with secondary embolism. Higher rHU values were significantly associated with higher amounts of fibrin (p ≤ 0.001) and low percentage of red blood cells (p ≤ 0.001). Additionally, high amounts of fibrin were associated with longer intervention times (p ≤ 0.001), whereas thrombi with high amounts of erythrocytes correlated with shorter intervention times (p ≤ 0.001). ROC analysis revealed reliable prediction of secondary embolisms for low rHU (AUC = 0.746; p ≤ 0.0001), low amounts of RBC (AUC = 0.764; p ≤ 0.0001), and high amounts of fibrin (AUC = 0.773; p ≤ 0.0001). Conclusions: Fibrin-rich thrombi with low erythrocyte percentage are significantly associated with longer intervention times. Embolisms in the thrombectomy process occur more often in thrombi with a small fraction of red blood cells and a low CT-density, suggesting a higher fragility of these thrombi.

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“…Factors for the absence of FR include stent maldeployment at a segment distal to the thrombus, atherothrombotic occlusion, thrombus properties, [8][9][10] and insufficient stent deployment. Furthermore, additional distal thrombus or vascular collapse due to disturbance of microcirculation may result in the absence of FR.…”

Section: Discussionmentioning

confidence: 99%

Relationship between Flow Restoration/Re-occlusion and Recanalization during Deployment of Stent Retriever

Kokuzawa

Yamada

Kanou

et al. 2018

JNET

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Objective: There has been no detailed study reporting the relationship between flow restoration (FR)/re-occlusion status and recanalization results during the acute thrombectomy using stent retrievers. In this study, we examined the influence of FR/re-occlusion during stent deployment on recanalization in our experiences. Subjects and Methods:In all, 24 patients with cardiogenic cerebral embolism underwent thrombectomy with a TREVO stent retriever (10 males, 14 females, mean age: 77.2 years). Intravenous tissue plasminogen activator (tPA) infusion was preceded in 17 of 24 patients, occlusion sites were as follows: internal carotid artery, 9 patients; M1 of middle cerebral artery, 13 patients; and basilar artery, 2 patients. We investigated the relationship between the presence or absence of FR/re-occlusion and grade of recanalization thrombolysis in cerebral infarction (TICI). We also examined the interval from FR until re-occlusion and frequency of stent deployment. Results:In the first session of stent deployment, FR and subsequent re-occlusion were observed in 11 patients (11/24, 46%). Of these, TICI 2b or higher grade recanalization was achieved in nine patients (9/11, 81%). Of 10 patients who had FR but no re-occlusion in the first session of stent deployment (10/24, 42%), TICI 2b or higher scale recanalization was achieved in 4 (4/10, 40%). In three patients without FR (3/24, 13%), TICI 2b or higher scale recanalization was not achieved. Of the above 11 patients who showed FR and subsequent re-occlusion in the first session of stent deployment, the waiting time until re-occlusion was 5 minutes in seven patients and 10 minutes in four patients.Of the 10 patients who had FR but no re-occlusion, the waiting time was 5 minutes in four patients, 10 minutes in four patients, and 20 minutes in two patients. In 9 of the 24 patients, several sessions of stent deployment were required, and the total frequency of stent deployment was 37 times. In 37 sessions of stent deployment showed the achievement of FR and re-occlusion in 17 sessions (17/37, 46%). Of these, TICI 2b or higher scale recanalization was achieved in 14 (14/17, 82%). Of 12 sessions with FR but no re-occlusion (12/37, 32%), TICI 2b or higher scale recanalization was achieved in 5 (5/12, 41%). TICI 2b or higher scale recanalization was not achieved in eight sessions without FR (8/37, 22%). Conclusion:Flow restoration immediately after stent deployment was a necessary condition for recanalization. If re-occlusion is confirmed after FR, satisfactory recanalization may be achieved at a high percentage. The results demonstrated that satisfactory recanalization was not achieved without FR, and less likely without re-occlusion following FR.

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Analyses of thrombi in acute ischemic stroke: A consensus statement on current knowledge and future directions

Cited by 139 publications

References 38 publications

Endovascular Treatment With or Without Prior Intravenous Alteplase for Acute Ischemic Stroke

Endovascular Treatment With or Without Prior Intravenous Alteplase for Acute Ischemic Stroke

Ischemic Stroke: Histological Thrombus Composition and Pre-Interventional CT Attenuation Are Associated with Intervention Time and Rate of Secondary Embolism

Relationship between Flow Restoration/Re-occlusion and Recanalization during Deployment of Stent Retriever

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