Clot Histopathology in Ischemic Stroke with Infective Endocarditis

Abstract

ABSTRACT:Background: Endovascular thrombectomy (EVT) has shown efficacy in acute ischemic stroke (AIS) patients with infective endocarditis (IE). The possibility to undertake advanced histopathological clot analysis following EVT offers a new avenue to establish the etiological basis of the stroke – which is often labelled “cryptogenic.” In this paper, we present our findings from four consecutive patients with IE who underwent EVT following an AIS at our tertiary referral comprehensive stroke centre. Methods: Comprehensive histopathological analysis of clot retrieved after EVT, including morphology, was undertaken. Results: The consistent observation was the presence of dense paucicellular fibrinoid material mixed/interspersed with clusters of bacterial cocci. This clot morphology may be specific to septic embolus due to IE unlike incidental bacteraemia and could possibly explain the refractoriness of such clots to systemic thrombolysis. Conclusion: Detailed morphological and histopathological analysis of EVT-retrieved clots including Gram staining can assist in etiological classification of the clot. Understanding the composition of the clot may be of clinical value in early diagnostics and mapping treatment planning in IE.

Prognostic capacity of hyperdense middle cerebral artery sign in anterior circulation acute ischaemic stroke patients receiving reperfusion therapy: a systematic review and meta-analysis

“…Moreover, the interaction of HMCAS with good and poor collaterals [ 39 ] and their role in mediating outcomes following reperfusion therapy is an another potential area of further research. Notably, the role of clot composition, including imaging features, such as clot density or clot perviousness, has been of increasing clinical interest as they may be useful in guiding treatment selection [ 9 , 15 ]. For example, it is postulated that a very dense artery, would be composed of RBC and thus amenable to aspiration with EVT; and less to IVT using alteplase for example [ 9 ].…”

“…For example, it is postulated that a very dense artery, would be composed of RBC and thus amenable to aspiration with EVT; and less to IVT using alteplase for example [ 9 ]. The pathologic correlations of actual EVT-retrieved clot features with the preintervention non-invasive imaging features, such as HMCAS on NCCT or blooming artefact on MRI are also of pathophysiological significance [ 14 , 45 , 46 ].…”

“…Despite the emerging role of HMCAS, its prognostic role in clinical settings, in settings of reperfusion therapy, needs further consideration. Indeed, the clot composition (such as the degree of clot density, relative composition of red blood cells (RBCs) [ 9 ]) in addition to other factors, such as time to reperfusion [ 10 ], baseline stroke severity [ 11 ], collateral status [ 12 , 13 ], etc., are associated with the efficacy of the EVT [ 14 , 15 ]. This study sought to investigate the association of HMCAS with clinical outcomes and its prognostic capacity in anterior circulation AIS patients receiving reperfusion therapy by performing a systematic review and meta-analysis.…”

Cerebral collaterals in acute ischaemia: Implications for acute ischaemic stroke patients receiving reperfusion therapy

“…These specific patient factors may mediate responses to recanalization therapies in general, EVT in particular (Bang et al, 2011;Elijovich et al, 2016;Gerber et al, 2016;. Therefore, multimodal strategies, including-but not limited to-systems-based approaches to reduce treatment delay in acute ischaemic stroke (Bhaskar, Thomas, et al, 2019;Venkat et al, 2018), advanced histopathological analyses to delineate underlying aetiology in cryptogenic stroke (Bhaskar, Cordato, et al, 2017;Bhaskar, Saab, et al, 2019) and advanced imaging to estimate tissue at risk and collateral status (Bang et al, 2011;, could improve acute stroke workflow (Bhaskar et al, 2020), diagnosis and treatment planning (Bhaskar et al, 2018).…”

Clot Composition Analysis as a Diagnostic Tool to Gain Insight into Ischemic Stroke Etiology: A Systematic Review

“…78,91,101 Case reports also used these specific stainings to identify elastic fibers, hemosiderin granules, collagen fibrous stalks, calcium deposits, and myofibroblast-like cells, usually in atypical thrombi. 15,23,30,43,102 The presence of foreign bodies in thrombi has also been evaluated. Delaminated polymer coating particulates were readily detected in 33% of H&E-stained preparations.…”