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Thrombus Characteristics Are Related to Collaterals and Angioarchitecture in Acute Stroke

  • Emmad M. Qazi (a1), Sung Il Sohn (a2), Sachin Mishra (a1), Mohammed A. Almekhlafi (a1) (a3) (a4), Muneer Eesa (a1) (a3), Christopher D. d’Esterre (a1), Abdul A. Qazi (a1), Josep Puig (a5), Mayank Goyal (a1) (a3), Andrew M. Demchuk (a1) (a3) and Bijoy K. Menon (a1) (a3) (a6)...

Abstract

Background

We have theorized that clots with stasis are longer. We therefore explored the relationship between thrombus imaging characteristics on noncontrast computed tomography (NCCT) and magnetic resonance imaging (MRI) with clot length and pial collaterals on baseline computed tomography angiography (CTA).

Methods

Prospective study of acute ischemic stroke patients (2005-2009) from Keimyung University. Patients with known stroke symptom onset time, baseline CTA, MRI, and with M1-Middle Cerebral Artery (MCA)±intracranial internal carotid artery (ICA) occlusions were included. Clot length and pial collaterals were measured on baseline CTA.

Results

A total of 104 patients (mean age 65.1±12.28 years, 56.7% male, median baseline National Institutes of Health Stroke Scale 13) with intracranial ICA + MCA (n=50) or isolated M1-MCA (n=54) occlusions were included. Hyperdense sign on NCCT had a median clot length of 42.3 mm versus 29.5 mm when hyperdense negative (p=0.02). Clots showing blooming artifact on gradient recall echo MRI had a median length of 39.1 mm versus 24.5 mm without blooming (p=0.005). Patients with poor baseline collaterals on CTA had longer clots than those with intermediate/good collaterals (median clot length 49.4 mm vs 34.9 mm vs 20.5 mm respectively, p<0.001). In censored logistic regression modeling, clot length was an independent predictor of hyperdense sign (p=0.05) and of the presence of blooming artifact (p=0.006).

Conclusions

Clot length and baseline collateral status are independent predictors of clot hyperdensity on NCCT and blooming artifact on gradient recall echo. Longer clots are more likely to be hyperdense and to bloom more, probably because portions of these clots are freshly formed locally due to of stasis of blood around the original clot. This stasis could be because of poor collaterals and inefficient angio-architecture within the cerebral arterial tree.

Les caractéristiques du thrombus sont associées aux collatérales et à l’architecture vasculaire dans l’accident vasculaire cérébral aigu. Contexte: Nous avons émis l’hypothèse que les caillots avec stase sont plus longs. Nous avons donc exploré la relation entre les caractéristiques du caillot, à l’imagerie par tomodensitométrie (CT) sans agent de contraste (CTSAC) et à l’imagerie par résonance magnétique (IRM), et la longueur du caillot et les vaisseaux collatéraux pie-mériens à l’angiographie CT initiale (CTA). Méthode: Cette étude prospective porte sur des patients ayant subi un accident vasculaire cérébral ischémique entre 2005 et 2009 qui ont consulté à l’Université Keinyung. Les patients dont le moment du début des symptômes d’AVC était connu, dont le CTA initial et l’IRM étaient au dossier et qui présentaient une occlusion de l’artère cérébrale moyenne M1 (ACM) ± de la carotide interne intracrânienne (CIIC), ont été inclus dans l’étude. La longueur du caillot et les collatérales pie-mériennes ont été mesurées sur le CTA initial. Résultats: Cent quatre patients, dont l’âge moyen était de 65,1 ans ± 12,28 ans et dont 56,7% étaient des hommes, ont été inclus dans l’étude. Ils présentaient une occlusion de la CIIC avec occlusion de l’ACM-M1 (n=50) ou une occlusion isolée de l’ACM-M1 (n=54). La longueur médiane du caillot était de 42,3 mm lorsqu’il y avait présence de signe d’hyperdensité au CTSAC et de 29,5 mm lorsqu’il n’y en avait pas (p=0,02). Les caillots ayant l’aspect d’un artéfact à l’aspect efflorescent (blooming artifact) à l’IRM gradient recall echo avaient une longueur médiane de 39,1 mm par rapport à 24,5 mm pour ceux qui ne présentaient pas cet aspect (p=0,005). Les patients qui avaient des collatérales médiocres au CTA initial avaient des caillots plus longs que ceux qui avaient des collatérales intermédiaires ou de bonnes collatérales (longueur médiane du caillot 49,4 mm par rapport à 34,9 mm et 20,5 respectivement, p < 0,001). Le modèle de régression logistique censuré a permis de constater que la longueur du caillot était un facteur de prédiction indépendant de la présence du signe d’hyperdensité (p=0,05) et de la présence d’un artéfact efflorescent (p=0,006). Conclusions: La longueur du caillot et l’état initial des collatérales sont des facteurs de prédiction indépendants de l’hyperdensité du caillot au CTSAC et d’un artéfact à l’aspect efflorescent au gradient recall echo. Les caillots plus longs sont plus susceptible d’être hyperdense et de présenter plus d’efflorescence, probablement parce que la formation locale de certaines parties de ces caillots est récente à cause de la stase du sang autour du caillot original. Cette stase pourrait être due à des collatérales médiocres et à une architecture vasculaire inefficace du réseau artériel cérébral.

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Copyright

Corresponding author

Correspondence to: Bijoy K. Menon, 1079 A, 29th Street NW, Calgary, AB, T3H4J2 Canada. Email: Bijoy.Menon@Albertahealthservices.ca

References

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