Hyperdense vessel sign as a potential guide for the choice of stent retriever versus contact aspiration as first-line thrombectomy strategy

Abstract

BackgroundThe first-pass effect (FPE) has emerged as a key metric for efficacy in mechanical thrombectomy (MT). The hyperdense vessel sign (HDVS) on non-contrast head CT (NCCT) indicates a higher clot content of red blood cells.ObjectiveTo assess whether the HDVS could serve as an imaging biomarker for guiding first-line device selection in MT.MethodsA prospective MT database was reviewed for consecutive patients with anterior circulation large vessel occlusion stroke who underwent thrombectomy with stent retriever (SR) or contact aspiration (CA) as first-line therapy between January 2012 and November 2018. Pretreatment NCCT scans were evaluated for the presence of HDVS. The primary outcome was FPE (modified Thrombolysis in Cerebral Infarction score 2c/3). The primary analysis was the interaction between HDVS and thrombectomy modality on FPE. Secondary analyses aimed to evaluate the predictors of FPE.ResultsA total of 779 patients qualified for the analysis. HDVS and FPE were reported in 473 (60.7%) and 286 (36.7%) patients, respectively. The presence of HDVS significantly modified the effect of thrombectomy modality on FPE (p=0.01), with patients with HDVS having a significantly higher rate of FPE with a SR (41.3% vs 22.2%, p=0.001; adjusted OR 2.11 (95% CI 1.20 to 3.70), p=0.009) and non-HDVS patients having a numerically better response to CA (41.4% vs 33.9%, p=0.28; adjusted OR 0.58 (95% CI 0.311 to 1.084), p=0.088). Age (OR 1.01 (95% CI 1.00 to 1.02), p=0.04) and balloon guide catheter (OR 2.08 (95% CI 1.24 to 3.47), p=0.005) were independent predictors of FPE in the overall population.ConclusionOur data suggest that patients with HDVS may have a better response to SRs than CA for the FPE. Larger confirmatory prospective studies are warranted.

Per-pass analysis of acute ischemic stroke clots: impact of stroke etiology on extracted clot area and histological composition

“…3 9 17 Recent studies have suggested that clot-based radiomic features can also predict successful mechanical thrombectomy strategies 28 and that patients with a hyperdense artery sign have a higher rate of first-pass effect when treated with stentrievers than with contact aspiration. 29 With an improved understanding of the factors that influence the composition of acute ischemic stroke clots, the treatment approach may be influenced by suspected etiology in addition to diagnostic imaging. Our findings suggest that clot histological composition and clot area vary significantly with suspected etiology.…”

Thrombus Composition and Efficacy of Thrombolysis and Thrombectomy in Acute Ischemic Stroke

“…60,101,[107][108][109][110][111] Interestingly, a study by Mahmoud et al seeking to assess whether HMCAS could serve as an imaging biomarker for guiding first-line device selection in mechanical thrombectomy demonstrated that patients with HMCAS may have a better response to stent retrievers compared to contact aspiration for first pass effect. 112 However, even though the association between clot density and clot composition is specific, the highly heterogenous nature of AIS clot limits the sensitivity of this technique. 104 Despite the relationship between HMCAS and BA with RBC-rich thrombi, emphasis should not be placed heavily on using these signs to predict successful clot retrieval as many other factors may influence recanalization.…”

Prognosis with non-contrast CT and CT Perfusion imaging in thrombolysis-treated acute ischemic stroke

“…For instance, the software itself did not take into account pre-existing cerebral attenuation changes, such as leukoencephalopathy, old infarcts and atypical parenchymal defects [27]. Herweh and colleagues reported in their previous publication [18] similar variation among multiple readers. Additionally, the fair agreement between the neurologist's ASPECTS interpretation and the reference standard was on par with some published data [13].…”

“…Hyperdense vessel sign (HDVS) is another significant NCCT finding which indicates a higher clot content of red blood cells and lends for early therapeutic prognosis [18]. Presence of HDVS was highly predictive of successful recanalization after mechanical thrombectomy but also associated with poor outcomes after intravenous thrombolysis [18][19][20]. In this study, we applied an automated system to compute ASPECTS and detect potential HDVS from NCCT images.…”