Fibrin Clot Architecture in Acute Ischemic Stroke Treated With Mechanical Thrombectomy With Stent-Retrievers　― Cohort Study ―

Krajíčková, Dagmar; Krajina, Antonı́n; Steiner, I; Vyšata, Oldřich; Herzig, Roman; Lojík, Miroslav; Chovanec, Vendelı́n; Raupach, Jan; Renc, Ondřej; Waishaupt, Jan; Vítková, Eva; Dulíček, Petr; Čabelková, P.; Vališ, Martin

doi:10.1253/circj.cj-17-0375

Cited by 21 publications

(26 citation statements)

References 45 publications

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“…In particular, some studies have highlighted the relationship between hypodense thrombus in NECT and a high proportion of fibrin within the thrombi, which has been discussed as an important cause for poor outcome [15,16,29]. This finding is also consistent with recent findings on methodological difficulties of MT in fibrincontaining thrombi [23,24].…”

Section: Discussionsupporting

confidence: 81%

“…Current studies have shown that the performance of different MT methods is largely determined by the histological composition of the thrombus [23,24]. While current treatment strategies do not include the factor of thrombus composition, potential new individualized therapy methods for specific thrombi, for example, exactly those containing fibrin, are conceivable.…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, thrombus density in CECT of fibrin and RBC rich thrombi is diametrically opposed to the density in NECT [13]. Current research focuses on the varying performance of different MT devices with regard to the use in histologically different thrombi [23,24].…”

Section: Introductionmentioning

confidence: 99%

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Thrombus Enhancement Is a Predictor of Clinical Outcome in Acute Ischemic Stroke after Mechanical Thrombectomy

et al. 2018

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Background: Ex vivo computed tomography (CT) studies of artificial blood thrombi showed that contrast enhancement (CE) is determined by fibrin-content, while unenhanced density is associated with red blood cells. Thus, the present study investigates patient outcome in association with combined thrombus density measures in native and contrast-enhanced CT (CECT) of acute ischemic stroke patients. Methods: This retrospective study includes 137 patients with M1 occlusions treated by mechanical thrombectomy (MT) between 2010 and 2016. Clinical outcome was determined with modified Rankin Scale (mRS) at 90 days. Differentiation of complete and incomplete large vessel occlusion (CLVO/ILVO) was based on CT and angiography. Two blinded readers classified blood thrombi based on native non-enhanced CT (NECT) as (a) hypo-, (b) iso-, and (c) hyperdense and in CECT angio measurements as (d) not-enhancing, (e) intermediate and (f) enhancing. To make sure that the mean is not represented in any of the maximum/minimum groups, thresholds in both cases were selected in a way that all values within one SD around the mean value form the isodense/intermediate group. In addition, the CE per se was correlated with the outcome. Correlations between imaging and clinical scales were performed with Spearman’s Rho. For the group testing Pearson chi-square test, Mann-Whitney U, as well parametric and nonparametric one-factor ANOVA “Kruskal-Wallis” test including Bonferroni correction for multiple tests ware used. Results: Twenty-three patients with ILVO (16.8%) differed significantly from patients with CLVO in mRS at admission (median 4 vs. 5) and after 90 days (median 1 vs. 4; p < 0.05) and thus were excluded. In the ILVO cohort, the classification according to NECT did not show statistical difference between hypo-, iso- and hyperdense CLVOs in regard to outcome. Classification of CLVOs according to CECT allowed an outcome prediction between the intermediate (median 3) and enhancing group (median 5) and between the enhancing and non-enhancing group (median 3; both p < 0.05) with a correlation of 291 between CE and higher mRS after 90 days (p < 0.005). Conclusions: CE of thrombi – especially in a range from over 18.4 to 40.35 Hounsfield Units – is an independent predictor of poor clinical outcome in patients undergoing MT due to acute middle cerebral artery occlusion.

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Section: Discussionsupporting

confidence: 81%

Section: Discussionmentioning

confidence: 99%

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Thrombus Enhancement Is a Predictor of Clinical Outcome in Acute Ischemic Stroke after Mechanical Thrombectomy

et al. 2018

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“…In the acute phase of thrombus formation, active cross-linking of adjacent fibrin monomers reduces structural porosity as the thrombus undergoes compaction. 18 The concentration of thrombin is important during this coagulative process as a higher concentration is associated with the establishment of a dense fibrin network of thin diameter strands, whereas a lower concentration results in a loose fibrin network of thick diameter strands. 19 Conversely, cardiogenic thrombi demonstrate a higher resistance against successful mechanical thrombectomy due to their fibrin-rich profile (histologically regarded as < 20% RBC content), generating a higher coefficient of friction when retrieved; however, their inherent rigidity is protective against PTF.…”

Section: Discussionmentioning

confidence: 99%

Iodine-stained fragmented thromboembolism

et al. 2019

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Aim Iodine-stained fragmented thromboembolism (ISFT) is a rare phenomenon encountered in the immediate aftermath of mechanical thrombectomy or rarely as a complication of post–carotid stenting. The aim was to describe the imaging appearance and discuss its pathophysiology. Method This is a retrospective review of patients who underwent mechanical thrombectomy for acute stroke at a single institution over the period of one year. All patients underwent the standard acute stroke imaging protocol (CT head, CT angiogram (CTA) and CT brain perfusion) and when clinically appropriate followed by catheter angiogram and mechanical thrombectomy. ISFT was defined as an arterial luminal filling defect with Hounsfield density equal to or greater than iodine seen on the biplanar CT or conventional CT. The presence and location of ISFT were documented. Standard CT angiogram (CTA) or magnetic resonance angiogram (MRA) was performed 24–48 hours after the neurointerventional procedure to assess for recanalization, volume of infarction and the fate of the ISFT. Results ISFTs were identified in eight (five males and three females, age range 18–80 years) out of 49 patients in the following locations: distal M1 ( n = 1), M2 ( n = 4), M3 ( n = 1), A1 ( n = 1), distal A2 ( n = 1). ISFT and vessel recanalization occurred in five patients on follow-up. ISFT and vessel occlusion persisted in two patients. Conclusion ISFT is likely the result of mechanical disruption of a thromboembolus, and porosity of the thromboembolus fragment may transiently retain iodinated contrast. Recognition of this entity may be important to aid detection of residual thromboembolism and avoid misinterpretation as calcified thromboembolism.

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“…With the advent of thrombectomy, it is now possible to examine the composition of thrombi extracted from the cerebral vessels of stroke patients . Thrombi containing large amounts of calcium phosphate are stiff, and less amenable to extraction .…”

Section: Thrombus Compositionmentioning

confidence: 99%

Fibrinolysis: strategies to enhance the treatment of acute ischemic stroke

Henderson

Weitz

Kim

2018

Journal of Thrombosis and Haemostasis

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Stroke is a major cause of disability worldwide, and is the second leading cause of death after ischemic heart disease. Until recently, tissue-type plasminogen activator (t-PA) was the only treatment for acute ischemic stroke. If administered within 4.5 h of symptom onset, t-PA improves the outcome in stroke patients. Mechanical thrombectomy is now the preferred treatment for patients with acute ischemic stroke resulting from a large-artery occlusion in the anterior circulation. However, the widespread use of mechanical thrombectomy is limited by two factors. First, only ⁓ 10% of patients with acute ischemic stroke have a proximal large-artery occlusion in the anterior circulation and present early enough to undergo mechanical thrombectomy within 6 h; an additional 9-10% of patients presenting within the 6-24-h time window may also qualify for the procedure. Second, not all stroke centers have the resources or expertise to perform mechanical thrombectomy. Nonetheless, patients who present to hospitals where thrombectomy is not an option can receive intravenous t-PA, and those with qualifying anterior circulation strokes can then be transferred to tertiary stroke centers where thrombectomy is available. Therefore, despite the advances afforded by mechanical thrombectomy, there remains a need for treatments that improve the efficacy and safety of thrombolytic therapy. In this review, we discuss: (i) current treatment options for acute ischemic stroke; (ii) the mechanism of action of fibrinolytic agents; and (iii) potential strategies to manipulate the fibrinolytic system to promote endogenous fibrinolysis or to enhance the efficacy of fibrinolytic therapy.

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Fibrin Clot Architecture in Acute Ischemic Stroke Treated With Mechanical Thrombectomy With Stent-Retrievers　― Cohort Study ―

Abstract: In patients with large artery IS treated with the MT using stent-retrievers, bridging therapy with IVT preceding MT and higher platelet count were associated with significant changes of the histological structure of blood clots.

Cited by 21 publications

References 45 publications

Thrombus Enhancement Is a Predictor of Clinical Outcome in Acute Ischemic Stroke after Mechanical Thrombectomy

Thrombus Enhancement Is a Predictor of Clinical Outcome in Acute Ischemic Stroke after Mechanical Thrombectomy

Iodine-stained fragmented thromboembolism

Fibrinolysis: strategies to enhance the treatment of acute ischemic stroke

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Fibrin Clot Architecture in Acute Ischemic Stroke Treated With Mechanical Thrombectomy With Stent-Retrievers ― Cohort Study ―

Abstract: In patients with large artery IS treated with the MT using stent-retrievers, bridging therapy with IVT preceding MT and higher platelet count were associated with significant changes of the histological structure of blood clots.

Cited by 21 publications

References 45 publications

Thrombus Enhancement Is a Predictor of Clinical Outcome in Acute Ischemic Stroke after Mechanical Thrombectomy

Thrombus Enhancement Is a Predictor of Clinical Outcome in Acute Ischemic Stroke after Mechanical Thrombectomy

Iodine-stained fragmented thromboembolism

Fibrinolysis: strategies to enhance the treatment of acute ischemic stroke

Contact Info

Product

Resources

About

Fibrin Clot Architecture in Acute Ischemic Stroke Treated With Mechanical Thrombectomy With Stent-Retrievers　― Cohort Study ―