Abstract WP43: Anti-Coagulation Therapy Prior to Mechanical Thrombectomy is Associated With Reduced Procedure Time and Low Proportion of Fibrin in Retrieved Thrombus

Introduction: Very few studies have investigated the relationship between the histopathology of the retrieved thrombus by mechanical thrombectomy for large vessel occlusion and anti-coagulation agents before mechanical thrombectomy. A study in vitro showed that clots of patients with anti-coagulation agents were dissolved easily compared to those of patients with aspirin. Hypothesis: Anti-coagulation therapy prior to mechanical thrombectomy is associated with reduced procedure time and low proportion of fibrin in retrieved thrombus. Methods: All retrieved thrombus was stained with hematoxylin-eosin. Embolic debris underwent quantitative analysis to quantify three main components: red blood cells, white blood cells and fibrin, by color based segmentation. Patients were assingned to receive either mechanical thrombectomy with anti-coagulation agents (AC-MT group) or mechanical thrombectomy alone (MT group). Considering influence by stroke etiology, patients with non-cardioembolism were excluded. Results: From August 2015 to Dec 2018, 226 consecutive patients were treated in our hospital by MT for acute large vessel occlusion. Histopathologic analysis of retrieved thrombus from 119 patients with acute stroke. 92 patients with cardioembolism were included. Patients were assigned to AC-MT group (n=35) or MT group (n=57). Clinical backgrounds were not significantly different. PT-INR was higher in AC-MT group. (1.32 vs 1.06; p<0.01) The proportion of patients with recombinant tissue plasminogen activator was not significantly different (26% vs 43%; p=0.12). AC-MT group had shorter puncture to recanalization time (median 38 vs 54 minutes; p<0.01) and tendency to reduce number of maneuvers [median 2 (range 1-4) vs 2 (range 1-6); p=0.06]. AC-MT group had lower proportion of fibrin in retrieved thrombus (44.3% vs 77.3%, p<0.01). Conclusion: Anti-coagulation therapy prior to mechanical thrombectomy is associated with reduced procedure time and low proportion of fibrin in retrieved thrombus.

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Abstract WP31: Fibrin Rich Thrombus versus Erythrocyte Rich Thrombus in Acute Large Vessel Occlusion

Stroke ◽

10.1161/str.48.suppl_1.wp31 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Kota Maekawa ◽

Masunari Shibata ◽

Masaru Seguchi ◽

Kazuto Kobayashi ◽

Hidetaka Nakajima ◽

...

Keyword(s):

Blood Cells ◽

Mechanical Thrombectomy ◽

Clinical Laboratory ◽

White Blood Cells ◽

Functional Independence ◽

Large Vessel ◽

Basilar Artery Occlusion ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Significant Difference

Objective: The aim of this study was to evaluate thrombus composition and its association with clinical, laboratory, and neurointerventional findings in patients treated by mechanical thrombectomy due to acute large vessel occlusion. Methods: From August 2015 to June 2016, 72 patients were treated in our hospital by mechanical thrombectomy using stent retriever and/or aspiration catheter. Retrieved thrombi underwent semiquantitative analysis to quantify red blood cells, white blood cells, and fibrin by area. We divided patients into two groups as fibrin rich group or erythrocyte rich group according to predominant composition in thrombus. Two groups were compared with respect to imaging, clinical, and neurointerventional data. Results: Histopathologic analysis of retrieved thrombus from 37 patients with acute stroke due to internal carotid artery, middle cerebral artery, or basilar artery occlusion was performed. Erythrocyte rich thrombi were present in 13 (35%) of cases, and fibrin rich thrombi in 24 (65%). Cardioembolic etiology was significantly more in patients with fibrin rich thrombi than those with erythrocyte rich thrombi (79% vs. 38%; p=0.01). All other clinical and laboratory characteristics did not differ. Patients with fibrin rich thrombi had greater number of recanalization maneuvers (2.8 ± 1.2 vs. 1.8 ± 1.6, p=0.04) and longer interval time between puncture and recanalization (62 ± 33.6 minutes vs. 42 ± 21.3 minutes; p=0.04). There is no significant difference in occluded vessels and mechanical thrombectomy devices between two groups. Patients with fibrin rich thrombi were lower rate of functional independence (mRS score, 0-2) at 90 days (33% vs. 75%; p=0.04). Conclusion: This study showed that fibirin rich thrombus was associated with extended procedure time, unfavorable clinical outcome and cardioembolic etiology.

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Clot permeability and histopathology: is a clot’s perviousness on CT imaging correlated with its histologic composition?

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-014979 ◽

2019 ◽

Vol 12 (1) ◽

pp. 38-42 ◽

Cited By ~ 7

Author(s):

John Charles Benson ◽

Sean T Fitzgerald ◽

Ramanathan Kadirvel ◽

Collin Johnson ◽

Daying Dai ◽

...

Keyword(s):

Blood Cells ◽

Mechanical Thrombectomy ◽

White Blood Cells ◽

Intravenous Thrombolysis ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Hounsfield Units ◽

Vessel Occlusion ◽

Favorable Clinical Outcome ◽

Contrast Ct

BackgroundClot perviousness in large vessel occlusion has been shown to be associated with improved recanalization outcomes with mechanical thrombectomy and intravenous thrombolysis.ObjectiveTo evaluate the association between clot perviousness based on thrombus attenuation increase (TAI) on CT, and histologic composition of clots in acute ischemic stroke (AIS).MethodsA retrospective review was completed of patients with AIS secondary to large vessel occlusion, non-contrast CT (NCCT) and CT angiography (CTA) images, and histologic analysis of the retrieved clot. TAI was measured by subtracting clot attenuation on NCCT from the attenuation on CTA. Up to 3 regions of interest (ROIs) were evaluated on each clot; the average attenuation was used for analysis if multiple ROIs were assessed. Pervious clots were defined as TAI ≥10 Hounsfield units (HUs); impervious clots had TAI <10 HU. Histopathologic analyses of clots were assessed for relative compositions of red blood cells (RBCs), white blood cells (WBCs), fibrin, and platelets/other.Results57 patients were included. Pervious clots were more likely to be RBC rich (p=0.04); impervious clots were more likely to be fibrin and WBC rich (p=0.01 for both). Pervious clots also had greater RBC density than impervious clots (49.8% and 33.0%, respectively; p=0.006); fibrin density of pervious clots was lower than that of impervious clots (17.8% and 23.2%, respectively; p=0.02).ConclusionClot perviousness, assessed on NCCT and CTA imaging, is associated with higher RBC density and lower fibrin density, offering a possible explanation for the higher rates of successful thrombectomy and favorable clinical outcome seen in such patients.

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Intraarterial urokinase for thrombus migration after mechanical thrombectomy for large vessel ischemic stroke

Interventional Neuroradiology ◽

10.1177/15910199211069464 ◽

2021 ◽

pp. 159101992110694

Author(s):

Hiroaki Neki ◽

Takehiro Katano ◽

Takuma Maeda ◽

Aoto Shibata ◽

Hiroyuki Komine ◽

...

Keyword(s):

Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Functional Independence ◽

Large Vessel ◽

Modified Rankin Scale ◽

Large Vessel Occlusion ◽

Procedure Time ◽

Vessel Occlusion ◽

The Uk ◽

Ultimate Purpose

Background Achieving rapid and complete reperfusion is the ultimate purpose for ischemic stroke with large vessel occlusion (LVO). Although mechanical thrombectomy (MT) had been a proverbially important procedure, medium vessel occlusion (MeVO) with thrombus migration can sporadically occur after MT. Moreover, the safe and effective approach for such had been unknown. We reported thrombolysis with intraarterial urokinase for MeVO with thrombus migration after MT. Methods We included 122 patients who were treated by MT with LVO stroke at our institution between April 2019 and March 2021. Of 26 patients (21.3%) who developed MeVO with thrombus migration after MT, 11 (9.0%) underwent additional MT (MT group) and 15 (12.3%) received intraarterial urokinase (UK group). The procedure time; angiographically modified Treatment in Cerebral Ischemia Scale (mTICI); functional independence, which was defined as modified Rankin Scale 0–2, on day 30 or upon discharge; and symptomatic and asymptomatic intracerebral hemorrhage (ICH) were compared between the UK and MT groups. Results The procedure time, mTICI, and asymptomatic ICH did not significantly differ between the groups. In the UK group, 8 of 15 (53.3%) patients obtained functional independence, and the functional independence rate was significantly higher in the UK group than in the MT group ( p < 0.05). Symptomatic ICH did not occur in the UK group, and its incidence was significantly smaller than that in the MT group ( p < 0.05). Conclusion The results of this study suggest that intraarterial urokinase for MeVO with thrombus migration after MT may safely improve angiographic reperfusion.

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Erythrocyte-Rich Thrombus Is Associated with Reduced Number of Maneuvers and Procedure Time in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy

Cerebrovascular Diseases Extra ◽

10.1159/000486042 ◽

2018 ◽

Vol 8 (1) ◽

pp. 39-49 ◽

Cited By ~ 44

Author(s):

Kota Maekawa ◽

Masunari Shibata ◽

Hideki Nakajima ◽

Akane Mizutani ◽

Yotaro Kitano ◽

...

Keyword(s):

Blood Cells ◽

Mechanical Thrombectomy ◽

Clinical Laboratory ◽

White Blood Cells ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Time Interval ◽

Procedure Time ◽

Vessel Occlusion ◽

Computed Tomography Images

Background: Only few studies have investigated the relationship between the histopathology of retrieved thrombi and clinical outcomes. This study aimed to evaluate thrombus composition and its association with clinical, laboratory, and neurointerventional findings in patients treated by mechanical thrombectomy due to acute large vessel occlusion. Methods: At our institution, 79 patients were treated by mechanical thrombectomy using a stent retriever and/or aspiration catheter between August 2015 and August 2016. The retrieved thrombi were quantitatively analyzed to quantify red blood cells, white blood cells, and fibrin by area. We divided the patients into two groups – a fibrin-rich group and an erythrocyte-rich group – based on the predominant composition in the thrombus. The groups were compared for imaging, clinical, and neurointerventional data. Results: The retrieved thrombi from 43 patients with acute stroke from internal carotid artery, middle cerebral artery, or basilar artery occlusion were histologically analyzed. Erythrocyte-rich thrombi were present in 18 cases, while fibrin-rich thrombi were present in 25 cases. A cardioembolic etiology was significantly more prevalent among the patients with fibrin-rich thrombi than among those with erythrocyte-rich thrombi. Attenuation of thrombus density as shown on computed tomography images was greater in patients with erythrocyte-rich thrombi than in those with fibrin-rich thrombi. All other clinical and laboratory characteristics remained the same. Patients with erythrocyte-rich thrombi had a smaller number of recanalization maneuvers, shorter procedure times, a shorter time interval between arrival and recanalization, and a higher percentage of stent retrievers in the final recanalization procedure. The occluded vessels did not differ significantly. Conclusions: In this study, erythrocyte-rich thrombus was associated with noncardioembolic etiology, higher thrombus density, and reduced procedure time.

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Abstract 1122‐000182: Histological Composition of Large Vessel Occlusion Stroke‐Causing Thrombi to Identify Etiologies: Systematic Review and Meta‐Analysis

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000182 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Paul Yeung‐Lai‐Wah ◽

Kunakorn Atchaneeyasakul ◽

Kyle Sheu ◽

Neal Rao ◽

David Liebeskind ◽

...

Keyword(s):

Blood Cells ◽

Mechanical Thrombectomy ◽

Meta Analysis ◽

Cryptogenic Stroke ◽

Large Vessel ◽

Large Artery ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Histological Difference ◽

Significant Difference

Introduction : More than a third of large vessel occlusion ischemic strokes do not have clear etiology. Mechanical thrombectomy provides a method to retrieve stroke‐causing thrombi and potentially identifying the etiology. A systematic meta‐analysis is performed to determine if there is a histological difference in red blood cell (RBC) composition of thrombi after the etiology of the stroke is known. Methods : We performed a systematic search through PUBMED and EMBASE. Studies meeting inclusion criteria were identified in which the large vessel occlusion stroke‐causing thrombi histology and etiology of the stroke were determined as either large artery atherosclerotic (LAA), cardioembolic (CE) or cryptogenic. Studies that had the data available or extractable data were selected. Random‐effect models were used to compare the histological difference between each etiology. Results : From inception to August 2021, 4 studies (n = 1022) were used to compare CE vs LAA, 5 studies (n = 1247) were used to compare CE vs cryptogenic and 4 studies (n = 654) were used to compare LAA vs cryptogenic. There was no significant difference in the red blood cells vs white blood cells/fibrin/platelets component between the stroke origins of CE vs LAA (mean difference (MD) ‐1.87; 95% confidence internal [CI]: ‐16.51, 12.78), CE vs cryptogenic (MD 1.18; 95% CI: ‐1.49, 3.86) and LAA vs cryptogenic (MD 7.20; 95% CI: ‐3.93, 18.34). Conclusions : There was no significant gross histological difference between CE, LAA and cryptogenic stroke etiologies and of the large vessel occlusion stroke‐causing thrombi retrieved by mechanical thrombectomy. Further studies into biochemical or genetic markers may be needed to identify stroke etiology.

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Current treatment of Acute Ischemic Stroke in Vojvodina

Medicinski pregled ◽

10.2298/mpns1712459z ◽

2017 ◽

Vol 70 (11-12) ◽

pp. 459-464 ◽

Cited By ~ 1

Author(s):

Zeljko Zivanovic ◽

Aleksandra Lucic ◽

Biljana Radovanovic ◽

Svetlana Ruzicka-Kaloci ◽

Mirjana Jovicevic ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Recombinant Tissue Plasminogen Activator ◽

Large Vessel ◽

Therapeutic Modality ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Mortality And Morbidity

Intravenous Thrombolysis in Acute Ischemic Stroke. Acute ischemic stroke is a major cause of mortality and morbidity in the world. Intravenous thrombolysis with recombinant tissue plasminogen activator remains the standard treatment for acute ischemic stroke for any patient presenting within 4.5 hours from symptom onset. However, it is more effective and safe when treatment starts early. This therapy for acute ischemic stroke has been administered in Vojvodina since 2008. Various factors influence the outcome after intravenous thrombolysis. Timely recanalization and reperfusion is associated with better clinical outcomes. Mechanical Thrombectomy - a New Therapeutic Modality for the Treatment of Acute Ischemic Stroke. Nevertheless, the rate of recanalization and favorable outcomes for patients with acute ischemic stroke due to large vessel occlusion are low after intravenous thrombolysis. In such patients mechanical thrombectomy has demonstrated significantly higher rates of recanalization and improved outcomes compared with intravenous thrombolysis alone. This endovascular reperfusion therapy began to be implemented in Vojvodina in 2016. Conclusion. Intravenous thrombolysis continues to play a key role in the treatment of all acute ischemic stroke patients, but mechanical thrombectomy should be the ?gold standard? in the cases with large vessel occlusion.

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Abstract 1122‐000206: Predictors of Hemorrhagic Transformation after Mechanical Thrombectomy in Large Vessel Occlusion Ischemic Stroke

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000206 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Vera Sharashidze ◽

Vasu Saini ◽

Amer Malik ◽

Jose Romano

Keyword(s):

Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Hemorrhagic Transformation ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Procedure Time ◽

Inpatient Mortality ◽

Vessel Occlusion ◽

Symptomatic Intracranial Hemorrhage ◽

Iv Tpa

Introduction : Stroke is a major cause of morbidity and mortality around the globe. Mechanical thrombectomy (MT) is the standard of care for patients with large vessel occlusion strokes. However, mechanical thrombectomy is associated with a number of complications. Symptomatic intracranial hemorrhage is one of the most feared complications of mechanical thrombectomy. In the pooled analysis of five trials, 4.4% of patients developed symptomatic intracranial hemorrhage. Treating physicians should have a good understanding of the potential complications of MT in order to optimize the safety and benefits of this procedure. Yet, the causes of hemorrhagic transformation are largely unknown and the predictors identified in previous studies vary. The goal of our study is to identify the rate and reliable predictors of radiological hemorrhagic transformation (RHT) and symptomatic hemorrhagic transformation (sICH) post mechanical thrombectomy in large vessel ischemic strokes. Methods : This was a retrospective analysis of consecutive large vessel occlusion acute ischemic stroke patients undergoing mechanical thrombectomy in a comprehensive stroke center (spanning 02/2015 ‐ 09/2018). Outcome measures included radiological hemorrhagic transformation (RHT) and symptomatic hemorrhagic transformation (sICH). sICH was defined as RHT with worsening of 4points in 24–36h NIHSS (ECASS II criteria) and by at least 1point (NINDS criteria).RHT was further classified according to Heidelberg‐bleeding classification as HI1, HI2, PH1, PH2, and SAH. Independent covariates predictive of RHT or symptomatic hemorrhage (sICH) were identified with multivariable logistic regression. Clinical opinion and the existing literature were used to reduce the number of variables collected at baseline to those considered potentially predictive of stroke progression. Results : Out of 341 patients who underwent thrombectomy, 32% had a radiological hemorrhagic transformation. The median age was 71. Smoking, IV tPA, longer procedure time, and lower TICI scores were associated with RHT. On a separate multivariate analysis, coronary artery disease was a separate predictor of hemorrhagic transformation. Patients with RHT had higher inpatient mortality and less mRs < 3 at discharge. Conclusions : RHT is associated with poor functional outcomes and inpatient mortality. Factors such as smoking, IV tPA, longer procedure time, and lower TICI scores were associated with RHT.

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