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Background and Purpose- Nearly 30% of large vessel occlusion acute ischemic stroke clots are from an unknown source. We assessed histological clot composition in a series of patients with large vessel occlusion and investigated correlations between clot composition and stroke pathogenesis. Methods- As part of the multi-institutional STRIP registry (Stroke Thromboembolism Registry of Imaging and Pathology), consecutive emboli retrieved during mechanical thrombectomy were stained using Martius Scarlett Blue and analyzed using machine learning software. We assessed proportions of red blood cells, fibrin, platelets, and white blood cells. Correlations between clot components and stroke pathogenesis (large artery atherosclerosis, cardioembolism, and stroke of undetermined pathogenesis) were assessed using SPSS22. Results- One hundred five patients were included. The proportion of platelet-rich clots (55.0% versus 21.2%; P=0.005) and percentage of platelet content (22.1±4.2% versus 13.9±14.2%; P=0.03) was significantly higher in the large artery atherosclerosis group compared with the cardioembolic group. The proportion of platelet-rich clots (50.0% versus 21.2%; P=0.024) was also significantly higher in the cryptogenic group compared with cardioembolic cases. Large artery atherosclerosis and cryptogenic cases had a similar proportion of platelet-rich clots (55.0% versus 50.0%; P=0.636). There was no significant difference between stroke pathogenesis and the other major clot components. Conclusions- High platelet content of emboli is associated with a large artery atherosclerosis etiology of large vessel occlusion.
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Arteriopatias Oclusivas/sangue , Plaquetas/patologia , Doenças Arteriais Cerebrais/sangue , Arteriosclerose Intracraniana/sangue , Embolia Intracraniana/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Contagem de Células Sanguíneas , Retração do Coágulo , Trombose Coronária/sangue , Feminino , Humanos , Aprendizado de Máquina , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Acidente Vascular Cerebral/sangue , Trombectomia , Tromboembolia/sangue , Tromboembolia/patologiaRESUMO
PURPOSE: Flow diversion constitutes a pivotal advancement in endovascular intracranial aneurysm treatment, but requires development of a new skill set. The aim of this study is to determine whether outcomes after treatment with the Pipeline Embolization Device improve with experience. METHODS: We retrospectively reviewed all patients with intracranial aneurysms treated with Pipeline at two centers over a 4.5-year period. Baseline patient and aneurysm characteristics, complications, and angiographic outcomes were analyzed. RESULTS: One hundred forty patients underwent 150 Pipeline procedures to treat 167 intracranial aneurysms during the study period, 109 women, mean age 55.4 years. One hundred twenty-six aneurysms were ICA, mean size 10.2 mm and mean neck 6.4 mm. Intra-procedural technical difficulties were higher during the first 75 procedures compared with the subsequent 75 (13.3 vs 2.7%; p = 0.03), as combined major morbidity and neurological mortality (14.7 vs 4%; p = 0.046). In multivariate regression analysis, increased operator experience with Pipeline remained an independent predictor of intra-procedural technical difficulties (p = 0.02, odds ratio (OR) 0.015, 95% CI 0.0004-0.55) and combined major morbidity and neurological mortality (p = 0.03, OR 0.16, 95% CI 0.03-0.84). At last follow-up, 123 aneurysms were completely occluded (81.5%, mean 24 months). In our cohort, age ≤ 53 years was an independent predictor of complete aneurysm occlusion at last follow-up (p = 0.001, OR 0.92, 95% CI 0.88-0.97). Five aneurysms were retreated (3.3%). CONCLUSION: The Pipeline embolization device is an effective treatment for intracranial aneurysms. The risk of intra-procedural technical difficulties and combined major morbidity and neurological mortality decreases significantly with increased operator experience in Pipeline deployment and patient management.
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Competência Clínica , Embolização Terapêutica/instrumentação , Aneurisma Intracraniano/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia Cerebral , Desenho de Equipamento , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: Delayed ipsilateral intraparenchymal hemorrhage (IPH) has been reported following technically successful treatment of intracranial aneurysms using flow-diverting stents in up to 8.5% of patients. We report a similar, though less frequent phenomenon in the setting of stent-assisted coil embolization. METHODS: Institutional review board approval was obtained. A retrospective analysis of a prospective neurointerventional procedure registry was performed to review all IPHs that occurred in aneurysm patients within 90 days of endovascular treatment performed between November 2002 and November 2014 at one institution. Age, sex, hypertension, dual antiplatelet therapy, and technical details of the procedure were recorded. RESULTS: A total of 1697 patients underwent endovascular treatment of an intracranial aneurysm without a flow diverter at our institution during the study period. Among these, 138 patients underwent stent-assisted coiling (8.1%). Of these, three patients (2.2%) suffered a delayed IPH within the vascular territory distal to the treated lesion (one woman, median age 60 years). CONCLUSIONS: Recently described in the setting of flow diversion, delayed ipsilateral IPH is not limited to flow-diverting stents. Though less frequent, a potential for this complication may exist following any intracranial stenting procedure, possibly related to hemorrhagic conversion of microembolic phenomena in the setting of dual antiplatelet or anticoagulation therapy.
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Hemorragia Cerebral/epidemiologia , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Aneurisma Intracraniano/epidemiologia , Aneurisma Intracraniano/cirurgia , Complicações Pós-Operatórias/epidemiologia , Stents/estatística & dados numéricos , Idoso , Causalidade , Angiografia Cerebral/estatística & dados numéricos , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/prevenção & controle , Comorbidade , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/estatística & dados numéricos , Feminino , Humanos , Incidência , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/prevenção & controle , Fatores de Risco , Resultado do TratamentoRESUMO
Cerebral amyloid angiopathy (CAA) is a cerebrovascular disease in which ß-amyloid peptides are deposited in leptomeningeal, cortical, and subcortical arteries, arterioles, and capillaries. Most individuals with CAA are asymptomatic. However, patients with CAA can present with cognitive impairment and other neurologic deficits caused by vascular wall amyloid deposition leading to hemorrhage. We present a unique case of CAA in a middle-aged woman with a history of cerebral cortex microhemorrhages and cortical edema. Imaging and pathology findings suggested CAA as the main etiology of this presentation. This is a very rare case of CAA coexisting with aneurysmal subarachnoid hemorrhage. Finally, we present a full discussion on the pathogenesis, clinical features, diagnosis, and treatment of CAA.
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Angiopatia Amiloide Cerebral/diagnóstico , Embolização Terapêutica/métodos , Hemorragia Subaracnóidea/diagnóstico , Angiografia , Angiopatia Amiloide Cerebral/complicações , Angiopatia Amiloide Cerebral/terapia , Diagnóstico Diferencial , Eletroencefalografia , Feminino , Seguimentos , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Hemorragia Subaracnóidea/etiologia , Hemorragia Subaracnóidea/terapia , Tomografia Computadorizada por Raios X , Ultrassonografia Doppler TranscranianaRESUMO
BACKGROUND: Stent development has focused recently on low-profile, self-expandable stents compatible with 0.0165 inch microcatheters. The LVIS EVO is the second-generation version of the Low-Profile Visualized Intraluminal Support (LVIS) with improved visibility and resheathability. The LVIS EVO underwent a limited premarket release (PMR) in December 2023. This study aims to report the early safety and feasibility experience with the LVIS EVO stent for the treatment of intracranial aneurysms in the United States (US). METHODS: This was a multicenter, retrospective, observational study evaluating patients who underwent treatment of an intracranial aneurysm with an LVIS EVO stent after the limited PMR. All physicians who had placed an LVIS EVO stent were asked to input their cases after institutional review board approval was obtained. The data were then sent to a single center for analysis. Any patient aged 18 years or older who underwent treatment of an intracranial aneurysm with a LVIS EVO stent in the US was included from the initial PMR in December 2023 until April 2024. Patient age (or ≤90 years old), sex, preoperative modified Rankin Scale (mRS), aneurysm location, aneurysm measurements, and information about preoperative antiplatelet management were all collected. Data on periprocedural complications, 30-day mortality, discharge mRS, and length of stay were also collected. RESULTS: Some 53 patients with 55 aneurysms underwent treatment with the LVIS EVO stent at 15 institutions. All aneurysms were unruptured. The most common location was the anterior communicating artery (35%) followed by the middle cerebral artery bifurcation (31%). All patients were on dual antiplatelet therapy. The average aneurysm size was 5.2 mm with a neck size of 3.7 mm. The smallest distal parent vessel size was 1.2 mm and 36% of stents were deployed in distal parent vessels <2 mm. All (100%) cases had successful deployment and the stent was repositioned in 10% of cases. A single stent was utilized in 91% of cases. Coils were placed in 48 cases (87.2%) and a microcatheter was jailed in 98% of those cases. Immediate Raymond Roy (RR) Class I occlusion was obtained in 33%, Class II in 22%, Class IIIa in 37%, and Class IIIb in 8% of cases. There were no delayed thromboembolic or hemorrhagic complications. CONCLUSIONS: The LVIS EVO is a braided, self-expanding, retrievable stent with enhanced visibility and smaller cell size. The drawn filled tube (DFT) technology results in improved visibility of the stent, allowing for more controlled stent positioning and visualization of vessel wall apposition. All cases in our series had complete neck coverage and good wall apposition. There were no thromboembolic or hemorrhagic complications.
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BACKGROUND AND PURPOSE: Intracerebral hemorrhage (ICH) results in high mortality and morbidity for patients. Previous retrospective studies correlated the spot sign score (SSSc) with ICH expansion, mortality, and clinical outcome among ICH survivors. We performed a prospective study to validate the SSSc for the prediction of ICH expansion, mortality, and clinical outcome among survivors. METHODS: We prospectively included consecutive patients with primary ICH presenting to a single institution for a 1.5-year period. All patients underwent baseline noncontrast computed tomography (CT) and multidetector CT angiography performed within 24 hours of admission and a follow-up noncontrast CT within 48 hours after the initial CT. The ICH volume was calculated on the noncontrast CT images using semiautomated software. The SSSc was calculated on the multidetector CT angiographic source images. We assessed in-hospital mortality and modified Rankin Scale at discharge and at 3 months among survivors. A multivariate logistic regression analysis was performed to determine independent predictors of hematoma expansion, in-hospital mortality, and poor clinical outcome. RESULTS: A total of 131 patients met the inclusion criteria. Of the 131 patients, a spot sign was detected in 31 patients (24%). In a multivariate analysis, the SSSc predicted significant hematoma expansion (odds ratio, 3.1; 95% confidence interval, 1.77-5.39; P≤0.0001), in-hospital mortality (odds ratio, 4.1; 95% confidence interval, 2.11-7.94; P≤0.0001), and poor clinical outcome (odds ratio, 3; 95% confidence interval, 1.4-4.42; P=0.004). In addition, the SSSc was an accurate grading scale for ICH expansion, modified Rankin Scale at discharge, and in-hospital mortality. CONCLUSIONS: The SSSc demonstrated a strong stepwise correlation with hematoma expansion and clinical outcome in patients with primary ICH.
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Angiografia Cerebral/métodos , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/patologia , Tomografia Computadorizada por Raios X/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hematoma/patologia , Mortalidade Hospitalar , Humanos , Processamento de Imagem Assistida por Computador/métodos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Estudos Prospectivos , Resultado do TratamentoRESUMO
Many disorders can cause aneurysm and/or dissection of the cerebral arteries, including fibromuscular dysplasia (FMD), connective tissue disorders, cerebral vasculitis, infection, and vascular malformations. Arterial fenestration is a rare congenital finding that can also cause aneurysms, and can rarely dissect and bleed. Treatment of aneurysm and dissection with subarachnoid hemorrhage can be very complicated, and requires case-by-case analysis of the risks and benefits of antithrombotic therapy. To the authors' knowledge, no case of double fenestration of the basilar artery has been reported. This report presents a case of concurring vertebral artery dissection and double fenestration of the basilar artery with aneurysm. The fenestration and FMD are considered possible main contributing causes of this presentation. A literature review of cerebrovascular fenestration and FMD is provided and the relationship between the 2 is considered. Lastly, the use of antithrombotic therapy in the setting of subarachnoid hemorrhage, dissection, and stent placement is discussed.
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Artéria Basilar/anormalidades , Aneurisma Intracraniano/congênito , Malformações Vasculares/terapia , Procedimentos Cirúrgicos Vasculares/métodos , Dissecação da Artéria Vertebral/congênito , Artéria Vertebral/anormalidades , Adulto , Artéria Basilar/diagnóstico por imagem , Artéria Basilar/cirurgia , Angiografia Cerebral , Diagnóstico Diferencial , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Angiografia por Ressonância Magnética , Tomografia Computadorizada por Raios X , Malformações Vasculares/cirurgia , Artéria Vertebral/diagnóstico por imagem , Artéria Vertebral/cirurgia , Dissecação da Artéria Vertebral/diagnóstico por imagem , Dissecação da Artéria Vertebral/cirurgiaRESUMO
INTRODUCTION: The US Woven EndoBridge Intra-saccular Therapy (WEB-IT) study is a pivotal, prospective, single arm, investigational device exemption study to evaluate the safety and effectiveness of the WEB device for the treatment of wide neck bifurcation aneurysms (WNBAs). We present complete 5 year data for the cohort of 150 patients. METHODS: 150 patients with WNBAs were enrolled at 21 US and six international centers. Imaging from the index procedure, 6 month, 1 year, 3 year, and 5 year follow-up were reviewed by a core laboratory. Adverse events were reviewed and adjudicated by a clinical events adjudicator. RESULTS: 83 patients had 5 year follow-up imaging and 123 had clinical follow-up. No ruptured (0/9) or unruptured aneurysm (0/141) rebled or bled during follow-up. No new device or procedure related adverse events or serious adverse events were reported after 1 year. At 5 years, using the LOCF method, complete occlusion was observed in 58.1% and adequate occlusion in 87.2% of patients. For patients with both 1 year and 5 year occlusion statuses available, 76.8% (63/82) of aneurysms remained stable or improved with no retreatment. After 1 year, 18 aneurysms were retreated, 11 of which were adequately occluded at 1 year, and 15 of which were retreated in the absence of any deterioration in occlusion grade. CONCLUSIONS: Five year follow-up data from the WEB-IT study demonstrated that the WEB device was safe and effective when used in the treatment of WNBAs. Aneurysm occlusion rates achieved at 1 year follow-up were durable, with rates of progressive thrombosis far exceeding rates of recurrence over time.
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Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Humanos , Resultado do Tratamento , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Estudos Prospectivos , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Estudos RetrospectivosRESUMO
BACKGROUND: Platelets and von Willebrand factor (vWF) are key components of acute ischemic stroke (AIS) emboli. We aimed to investigate the CD42b (platelets)/vWF expression, its association with stroke etiology and the impact these components may have on the clinical/procedural parameters. METHODS: CD42b/vWF immunostaining was performed on 288 emboli collected as part of the multicenter STRIP Registry. CD42b/VWF expression and distribution were evaluated. Student's t-test and χ2 test were performed as appropriate. RESULTS: The mean CD42b and VWF content in clots was 44.3% and 21.9%, respectively. There was a positive correlation between platelets and vWF (r=0.64, p<0.001**). We found a significantly higher vWF level in the other determined etiology (p=0.016*) and cryptogenic (p=0.049*) groups compared with cardioembolic etiology. No significant difference in CD42b content was found across the etiology subtypes. CD42b/vWF patterns were significantly associated with stroke etiology (p=0.006*). The peripheral pattern was predominant in atherosclerotic clots (36.4%) while the clustering (patchy) pattern was significantly associated with cardioembolic and cryptogenic origin (66.7% and 49.8%, respectively). The clots corresponding to other determined etiology showed mainly a diffuse pattern (28.1%). Two types of platelets were distinguished within the CD42b-positive clusters in all emboli: vWF-positive platelets were observed at the center, surrounded by vWF-negative platelets. Thrombolysis correlated with a high platelet content (p=0.03*). vWF-poor and peripheral CD42b/vWF pattern correlated with first pass effect (p=0.03* and p=0.04*, respectively). CONCLUSIONS: The vWF level and CD42b/vWF distribution pattern in emboli were correlated with AIS etiology and revascularization outcome. Platelet content was associated with response to thrombolysis.
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AVC Isquêmico , Acidente Vascular Cerebral , Trombose , Humanos , Fator de von Willebrand/metabolismo , Plaquetas/metabolismo , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/metabolismo , Trombose/metabolismoRESUMO
BACKGROUND: Mechanical thrombectomy (MT) has become standard for large vessel occlusions, but rates of complete recanalization are suboptimal. Previous reports correlated radiographic signs with clot composition and a better response to specific techniques. Therefore, understanding clot composition may allow improved outcomes. METHODS: Clinical, imaging, and clot data from patients enrolled in the STRIP Registry from September 2016 to September 2020 were analyzed. Samples were fixed in 10% phosphate-buffered formalin and stained with hematoxylin-eosin and Martius Scarlett Blue. Percent composition, richness, and gross appearance were evaluated. Outcome measures included the rate of first-pass effect (FPE, modified Thrombolysis in Cerebral Infarction 2c/3) and the number of passes. RESULTS: A total of 1430 patients of mean±SD age 68.4±13.5 years (median (IQR) baseline National Institutes of Health Stroke Scale score 17.2 (10.5-23), IV-tPA use 36%, stent-retrievers (SR) 27%, contact aspiration (CA) 27%, combined SR+CA 43%) were included. The median (IQR) number of passes was 1 (1-2). FPE was achieved in 39.3% of the cases. There was no association between percent histological composition or clot richness and FPE in the overall population. However, the combined technique resulted in lower FPE rates for red blood cell (RBC)-rich (P<0.0001), platelet-rich (P=0.003), and mixed (P<0.0001) clots. Fibrin-rich and platelet-rich clots required a higher number of passes than RBC-rich and mixed clots (median 2 and 1.5 vs 1, respectively; P=0.02). CA showed a trend towards a higher number of passes with fibrin-rich clots (2 vs 1; P=0.12). By gross appearance, mixed/heterogeneous clots had lower FPE rates than red and white clots. CONCLUSIONS: Despite the lack of correlation between clot histology and FPE, our study adds to the growing evidence supporting the notion that clot composition influences recanalization treatment strategy outcomes.
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This study was conducted to determine whether spot sign score correlates with average rate of hematoma expansion and whether average rate of expansion predicts in-hospital mortality and clinical outcome in spontaneous intracerebral hemorrhage (ICH). The study included 367 patients presenting to the Emergency Department (ED) from January 1, 2000 to December 31, 2008 with nontraumatic ICH. All received noncontrast computed tomography (NCCT) of the head and multidetector CT angiography (MDCTA) on presentation to the ED and a follow-up NCCT within 48 h. Imaging was used to determine the hematoma location and volume, average rate of expansion, and spot sign score. Primary outcome measures included in-hospital mortality and clinical outcome based on modified Rankin Scale at 3 months or at discharge. Regression analysis was performed to correlate spot sign score and average rate of hematoma expansion. ICH expansion was identified in 194 of 367 patients (53%). In a multivariate analysis, rate of ICH expansion predicted mortality (hazard ratio 1.1, CI 1.08-1.12, p < 0.0001). Patients who expired had an average rate of ICH expansion of 2.8 ml/h compared to 0.2 ml/h in survivors. Spot sign score on presentation to the ED correlated with the average rate of hematoma expansion. Average rate of hematoma expansion predicts mortality in spontaneous ICH. Spot sign score on presentation correlates with rate of expansion, supporting the hypothesis that high spot sign scores likely reflect active bleeding in acute ICH.
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Angiografia Cerebral/métodos , Hemorragia Cerebral/diagnóstico por imagem , Tomografia Computadorizada Espiral/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/mortalidade , Criança , Serviço Hospitalar de Emergência/organização & administração , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Valor Preditivo dos Testes , Prognóstico , Curva ROC , Interpretação de Imagem Radiográfica Assistida por Computador , Análise de Regressão , Fatores de Risco , Sensibilidade e Especificidade , Taxa de SobrevidaRESUMO
BACKGROUND: There is conflicting evidence on the utility of intravenous (IV) alteplase in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT). METHODS: This was a post hoc analysis of the COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion. We compared clinical, procedural and angiographic outcomes of patients with and without prior IV alteplase administration. RESULTS: In the COMPASS trial, 235 patients had presented to the hospital within the first 4 hours of stroke symptom onset and were eligible for analysis. On univariate analysis, administration of IV alteplase prior to MT was found to be significantly associated with favorable outcomes (modified Rankin scale (mRS) 0-2 at 3 months; 55.6% vs 40.0% in the MT-only group, P=0.037). However, on multivariate analysis, only baseline (pre-stroke) mRS, admission National Institutes of Health Stroke Scale (NIHSS) score and age were identified as independent predictors of favorable outcomes at 3 months. We found higher final thrombolysis in cerebral infarction (TICI) 2b/3 rates in patients without the use of alteplase prior to the aspiration first approach (100.0% vs 87.9% in IV altepase +aspiration first MT, P=0.03). In the stent retriever first group, final TICI 2b/3 rates were identical in patients with and without IV alteplase administration (87.5% and 87.5%, P=1.0). CONCLUSIONS: Prior administration of IV alteplase may adversely affect the efficacy of aspiration, but does not seem to influence the stent retriever first approach to MT in patients with anterior circulation ELVO.
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Acidente Vascular Cerebral , Trombectomia , Ativador de Plasminogênio Tecidual , Isquemia Encefálica/etiologia , Infarto Cerebral/etiologia , Humanos , Lactente , Recém-Nascido , Estudos Retrospectivos , Stents/efeitos adversos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/cirurgia , Trombectomia/efeitos adversos , Trombectomia/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Compositional and structural features of retrieved clots by thrombectomy can provide insight into improving the endovascular treatment of ischemic stroke. Currently, histological analysis is limited to quantification of compositions and qualitative description of the clot structure. We hypothesized that heterogeneous clots would be prone to poorer recanalization rates and performed a quantitative analysis to test this hypothesis. METHODS: We collected and did histology on clots retrieved by mechanical thrombectomy from 157 stroke cases (107 achieved first-pass effect (FPE) and 50 did not). Using an in-house algorithm, the scanned images were divided into grids (with sizes of 0.2, 0.3, 0.4, 0.5, and 0.6 mm) and the extent of non-uniformity of RBC distribution was computed using the proposed spatial heterogeneity index (SHI). Finally, we validated the clinical significance of clot heterogeneity using the Mann-Whitney test and an artificial neural network (ANN) model. RESULTS: For cases with FPE, SHI values were smaller (0.033 vs 0.039 for grid size of 0.4 mm, P=0.028) compared with those without. In comparison, the clot composition was not statistically different between those two groups. From the ANN model, clot heterogeneity was the most important factor, followed by fibrin content, thrombectomy techniques, red blood cell content, clot area, platelet content, etiology, and admission of intravenous tissue plasminogen activator (IV-tPA). No statistical difference of clot heterogeneity was found for different etiologies, thrombectomy techniques, and IV-tPA administration. CONCLUSIONS: Clot heterogeneity can affect the clot response to thrombectomy devices and is associated with lower FPE. SHI can be a useful metric to quantify clot heterogeneity.
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Isquemia Encefálica , Acidente Vascular Cerebral , Trombose , Humanos , Ativador de Plasminogênio Tecidual , Trombectomia/métodos , Trombose/patologia , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Fibrina/análise , Isquemia Encefálica/complicaçõesRESUMO
BACKGROUND: Several animal studies have demonstrated that mechanical thrombectomy (MT) for acute ischemic stroke (AIS) may cause vessel wall injury (VWI). However, the histological changes in human cerebral arteries following MT are difficult to determine. OBJECTIVE: To investigate the occurrence of VWI during MT by histological and immunohistochemical evaluation of AIS clots. METHODS: As part of the multicenter STRIP registry, 277 clots from 237 patients were analyzed using Martius Scarlett Blue stain and immunohistochemistry for CD34 (endothelial cells) and smooth muscle actin (smooth muscle cells). RESULTS: MT devices used were aspiration catheters (100 cases), stentriever (101 cases), and both (36 cases). VWI was found in 33/277 clots (12%). There was no significant correlation between VWI and MT device. The degree of damage varied from grade I (mild intimal damage, 24 clots), to grade II (relevant intimal and subintimal damage, 3 clots), and III (severe injury, 6 clots). VWI clots contained significantly more erythrocytes (p=0.006*) and less platelets/other (p=0.005*) than non-VWI clots suggesting soft thrombus material.Thrombolysis correlated with a lower rate of VWI (p=0.04*). VWI cases showed a significantly higher number of passes (2 [1-4] vs 1 [1-3], p=0.028*) and poorer recanalization outcome (p=0.01*) than cases without VWI. CONCLUSIONS: Histological markers of VWI were present in 12% of AIS thrombi, suggesting that VWI might be related to MT. VWI was associated with soft thrombus consistency, higher number of passes and poorer revascularization outcome. There was no significant correlation between VWI and MT device.
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Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Trombose , Isquemia Encefálica/cirurgia , Células Endoteliais , Humanos , Acidente Vascular Cerebral/cirurgia , Trombectomia/efeitos adversos , Trombose/patologia , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: to determine the accuracy of susceptibility-weighted MRI (SWI) for the detection of arteriovenous shunting (AVS) in vascular malformations of the brain (BVM). METHODS: we retrospectively identified 60 patients who had been evaluated for known or suspected BVM by both SWI and digital subtraction angiography, without intervening treatment, during a 3-year period. SWI images were retrospectively assessed by 2 independent reviewers for the presence of AVS as determined by the presence of signal hyperintensity within a venous structure in the vicinity of the BVM. Discrepancies were resolved by consensus among a panel of 3 neuroradiologists. Accuracy parameters of SWI for the detection of AVS were calculated using digital subtraction angiography as the reference standard. RESULTS: a total of 80 BVM were identified in the 60 patients included in our study. Of the 29 BVM with AVS on digital subtraction angiography, 14 were untreated arteriovenous malformations, 10 were previously treated arteriovenous malformations, and 5 were untreated dural arteriovenous fistulas. Overall, SWI was 93% sensitive and 98% specific for the detection of AVS in BVM, with excellent interobserver agreement (κ=0.94). In the 14 previously treated arteriovenous malformations, SWI was 100% sensitive and specific for the detection of AVS. In the 28 BVM associated with intracerebral hemorrhage, SWI was 100% sensitive and 96% specific for the detection of AVS. CONCLUSIONS: SWI is accurate for the detection of arteriovenous shunting in vascular malformations of the brain and, for some patients, SWI may offer a noninvasive alternative to angiography in screening for or follow-up of treated BVM.
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Angiografia Digital/métodos , Anastomose Arteriovenosa/diagnóstico por imagem , Malformações Vasculares do Sistema Nervoso Central/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética/métodos , Anastomose Arteriovenosa/cirurgia , Malformações Vasculares do Sistema Nervoso Central/cirurgia , Feminino , Humanos , Masculino , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
BACKGROUND AND PURPOSE: The purpose of this study was to determine the utility of postcontrast susceptibility-weighted MRI (PCSWI) in the evaluation of vascular malformations of the brain (BVM). METHODS: We retrospectively evaluated PCSWI and digital subtraction angiography data from 16 consecutive patients with known or suspected BVM, which had been entered into a prospectively maintained database during a 1-year period. There had been no intervening treatment or change in patients' symptoms between the PCSWI and digital subtraction angiography studies. The use of PCSWI in the detection of arteriovenous shunting was compared with that of routine noncontrast susceptibility-weighted imaging, time-of-flight MR angiography, and contrast-enhanced MR angiography using digital subtraction angiography results as the reference standard. The presence of arteriovenous shunting in PCSWI or susceptibility-weighted imaging sequences was defined by the presence of abnormal signal hyperintensity in the venous structures adjacent to the BVM. RESULTS: A total of 17 BVMs were identified by digital subtraction angiography (9 newly diagnosed arteriovenous malformations, 3 dural arteriovenous fistulas, 4 treated arteriovenous malformations with residual arteriovenous shunting, and 1 complex developmental venous anomaly). PCSWI was 100% sensitive and 100% specific with 100% positive predictive value and 100% negative predictive value for the detection of arteriovenous shunting in these BVMs. The PCSWI/susceptibility-weighted imaging signal intensity ratio in the most prominent early draining venous structure was 1.2±0.32. CONCLUSIONS: PCSWI appears to be superior to susceptibility-weighted imaging, time-of-flight MR angiography, and contrast-enhanced MR angiography in detecting arteriovenous shunting in BVMs and may be useful in the initial diagnosis and follow-up of patients with BVMs.
Assuntos
Angiografia Digital/tendências , Encéfalo/diagnóstico por imagem , Malformações Arteriovenosas Intracranianas/diagnóstico por imagem , Angiografia por Ressonância Magnética/tendências , Adulto , Encéfalo/irrigação sanguínea , Estudos de Coortes , Meios de Contraste , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos RetrospectivosRESUMO
BACKGROUND: Clot density (Hounsfield units, HU) and perviousness (post-contrast increase in the HU of clot) are thought to be associated with clot composition. We evaluate whether these imaging characteristics were associated with angiographic outcomes of aspiration and stent retriever thrombectomy in COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion. METHODS: Clot density and perviousness were measured by two independent operators who were blind to all the final angiographic and clinical outcomes. The association of clot density and perviousness with the Thrombolysis In Cerebral Infarction (TICI) scale after first pass was assessed using univariate and multivariate analysis. RESULTS: Among all patients enrolled in COMPASS, 165 were eligible for the post-hoc analysis (81 patients in the aspiration first and 84 in the stent retriever first groups). Overall mean perviousness of clot was significantly higher in patient with mTICI 2b-3 after first pass (28.6±22.9 vs 20.3±19.2, p=0.017). Mean perviousness among patients who achieved TICI 2c/3 versus TICI 2b versus TICI 0-2a in the aspiration first group varied significantly (32.6±26.1, 35.3±24.4, and 17.7±13.1, p=0.013). The association of perviousness with first pass success was not significant in the stent retriever group. Using multivariate analysis, high perviousness (defined as cut-off >27.6) was an independent predictor of TICI 2b-3 (OR 3.82, 95% CI 1.10 to 13.19; p=0.034). CONCLUSIONS: Clot perviousness is associated with first pass angiographic success in patients treated with the aspiration first approach for thrombectomy.
Assuntos
Stents , Trombectomia/métodos , Trombose/diagnóstico por imagem , Trombose/cirurgia , Idoso , Idoso de 80 Anos ou mais , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/etiologia , Infarto Cerebral/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Stents/tendências , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/cirurgia , Trombose/complicações , Resultado do TratamentoRESUMO
BACKGROUND: The Woven EndoBridge (WEB) device is approved in the USA for treatment of unruptured wide-neck bifurcation aneurysms. However, the safety and effectiveness of the WEB device in the treatment of ruptured intracranial aneurysms is not clear. We aim to evaluate the perioperative safety and effectiveness of the WEB device in patients with ruptured intracranial aneurysms. METHODS: This retrospective study, conducted at eight centers in the USA, included patients with ruptured intracranial aneurysms treated with the WEB device in the setting of subarachnoid hemorrhage (SAH). Safety outcomes included intraoperative complications such as vessel perforation, thromboembolic events, and postoperative hemorrhagic or thromboembolic complications based on radiologic imaging. The primary effectiveness outcome was adequate (complete and neck remnant) aneurysm occlusion, according to the Raymond-Roy classification. RESULTS: A total of 91 patients with 94 ruptured intracranial aneurysms were included (mean age 57.7±15.2 years; 68.1% women; 82.9% wide-necked). Aneurysms were located in the anterior communicating artery (42/94, 44.6%), middle cerebral artery (16/94, 17%), and basilar artery (15/94, 16%). Adequate occlusion was achieved in 48.8% (41/84) and 80.0% (40/50) at discharge and last follow-up (mean of 3.4 months), respectively. At discharge, procedural-related morbidity was 3.3% (3/91) and there was no procedure-related mortality. No re-rupture or delayed aneurysm rupture was observed. CONCLUSIONS: This study demonstrates the perioperative safety and effectiveness of the WEB device for the treatment of patients with ruptured intracranial aneurysms in the setting of SAH, with low periprocedural morbidity and mortality. Long-term follow-up is warranted.
Assuntos
Aneurisma Roto , Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Adulto , Idoso , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/cirurgia , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: We retrospectively evaluated the composition of retrieved clots from ischemic stroke patients to study the association between histological composition and stroke etiology METHODS: Consecutive patients enrolled in the Stroke Thromboembolism Registry of Imaging and Pathology (STRIP) were included in this study. All patients underwent mechanical thrombectomy and retrieved clots were sent to a central core lab for processing. Histological analysis was performed using martius scarlet blue (MSB) staining, and quantification for red blood cells (RBCs), white blood cells (WBCs), fibrin and platelets was performed using Orbit Image Software. A Wilcoxon test was used for continuous variables and χ2 test for categorical variables. RESULTS: 1350 patients were included in this study. The overall rate of Thrombolysis In Cerebral Infarction (TICI) 2c/3 was 68%. 501 patients received tissue plasminogen activator (tPA) (37%). 267 patients (20%) had a large artery atherosclerosis (LAA) source, 662 (49%) a cardioembolic (CE) source, 301 (22%) were cryptogenic, and the remainder had other identifiable sources including hypercoagulable state or dissection. LAA thrombi had a higher mean RBC density (46±23% vs 42±22%, p=0.01) and a lower platelet density (24±18% vs 27±18%, p=0.03) than CE thrombi. Clots from dissection patients had the highest mean RBC density (50±24%) while clots from patients with a hypercoagulable state had the lowest mean RBC density (26±21%). CONCLUSIONS: Our study found statistically significant but clinically insignificant differences between clots of CE and LAA etiologies. Future studies should emphasize molecular, proteomic and immunohistochemical characteristics to determine links between clot composition and etiology.