Abstract
We evaluated the composition of individual clots retrieved during intra-arterial thrombectomy in relation to recanalization success, stroke subtype, and the presence of clot signs on initial brain images. We analyzed clot and interventional data from 145 retrieval trials performed for 37 patients (69.5±14.0 years, 20 men, large artery atherosclerosis, n = 7; cardioembolism, n = 22; undetermined etiology, n = 8) who had undergone intra-arterial thrombectomy. Rates of clot retrieval and successful recanalization (Arterial Occlusive Lesion score of 2–3) for separate retrieval trials were evaluated. The area occupied by red blood cell (RBC), fibrin/platelets, and white blood cell (WBC) was measured from digitized images of hematoxylin-eosin stained clots. Compositional differences were compared according to recanalization success, stroke subtype, and the presence of hyperdense clot sign on initial computed tomography and/or blooming artifact on magnetic resonance image. Of the 145 total retrieval trials (3.4±2.4 times per patient), clot was retrieved in 93 trials (64%), while recanalization was successful in 73 (50%). Fibrin/platelets (63%) occupied the greatest area in retrieved clots, followed by RBCs (33%) and WBCs (4%). Clots retrieved from successful recanalization exhibited higher RBC composition (37%) than those retrieved from non-recanalization trials (20%, p = 0.001). RBC composition was higher in cardioembolic stroke (38%) rather than large artery atherosclerosis (23%) and undetermined etiology (26%, p = 0.01). Clots exhibiting clot signs (40%) had higher RBC composition than those without clot signs (19%, p = 0.001). RBC-rich clots were associated with successful recanalization of intra-arterial thrombectomy, cardioembolic stroke, and the presence of clot-signs on initial brain images.
Highlights
Ischemic stroke is a serious condition with a high risk of lasting neurological disability
Stroke subtypes were classified in accordance with the Trial of ORG10172 in Acute Stroke Treatment (TOAST) [14] criteria, as follows: large artery atherosclerosis (LAA), cardioembolic stroke, stroke associated with undetermined causes. (S1 Table) The study protocol was approved by the Institutional Review Board of Chungnam National University Hospital (CNUH2014-10-015); the need for informed consent was waived due to the retrospective nature of the study
Intra-arterial thrombectomy (IAT) was performed as bridging therapy after intravenous thrombolysis (IVT), or as primary therapy in accordance with the critical pathway established at the Daejeon-Chungnam Regional Cerebrovascular Center of Chungnam National University Hospital [4]
Summary
Ischemic stroke is a serious condition with a high risk of lasting neurological disability. Intra-arterial thrombectomy (IAT) is effective in ensuring reperfusion following occlusion of intracranial vessels in patients with acute ischemic stroke [3]. Rapid reperfusion of the occluded vessel and surrounding regions within 6 h of stroke onset has been regarded as critical for achieving good functional outcomes following IAT [1,2,4,5]. Reperfusion within this time window is unsuccessful in approximately two-fifths of patients treated via IAT [4]. Additional studies have revealed that individual variations in vessel anatomy [7] and intracranial collateral development [8] may contribute to delayed or unsuccessful recanalization
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