Differentiation of white and red thrombus with magnetic resonance imaging: a phantom study

An early identification of the composition of arterial thrombus may have diagnostic, therapeutic, and prognostic implications. The variation of magnetic resonance (MR) signal intensity between white and red thrombi, especially in the susceptibility sensitive MR sequence, remains unknown. Our research was to evaluate the feasibility of MRI in differentiating of white and red thrombi with a phantom study.

A total of 12 red and 12 white thrombi were prepared with the venous blood. Examination of the phantom was completed using a 3.0T MR unit, including fluid attenuated inversion recovery (FLAIR) T1, T2-weighted imaging (T2WI), FLAIR T2, T2 gradient echo (T2 GRE) imaging, and susceptibility weighted angiography sequences (SWAN). MR signal intensity patterns of the thrombi were objectively classified as hyperintensity, isointensity and hypointensity, compared with the background agar. The volume of thrombus was calculated and correlated with its signal intensity.

For white thrombi, 11/12 clots showed hyperintensity and 1/12 showed isointensity in FLAIR T1 images. In T2WI, 6/12 clots showed hyperintensity, 3/12 isointensity, and 3/12 hypointensity. In FLAIR T2, 8/12 clots showed hyperintensity and 4/12 showed isointensity. In T2 GRE, 3/12 clots showed hyperintensity and the remaining 9/12 clots showed isointensity. In SWAN, 5/12 clots demonstrated hyperintensity and 7/12 isointensity. For the red thrombus, 12/12 clots demonstrated hyperintensity in FLAIR T1, T2WI, and FLAIR T2 sequences. In T2 GRE and SWAN sequences, 3/12 clots displayed hypointensity and the remaining 9/12 clots showed slight hyperintensity. Thrombi with hypointensity displayed in T2 GRE and SWAN sequences were significantly larger than those with hyperintensity.

Differentiation of white and red thrombi with conventional MR sequence is unreliable, because both kinds of thrombi do not possess unique signal intensity features in these sequences. Red thrombus may or may not show hypointensity in the susceptibility sensitive MR sequences, depending on its size and time course.