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Published on: June 4, 2021
Thrombus Permeability Is Associated With Improved Functional Outcome and Recanalization in Patients With Ischemic
Emilie M M Santos1, Henk A Marquering2, Mark D den Blanken2
1From the Departments of Radiology (E.M.M.S., H.A.M., O.A.B., A.M.M.B., L.F.B., K.M.T., C.W., K.N., C.B.M.), Biomedical Engineering and Physics (E.M.M.S., H.A.M., M.D.B., A.M.M.B.), and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (E.M.M.S., A.L., W.J.N.), Medical Informatics (E.M.M.S., W.J.N.), Neurology (O.A.B., D.W.J.D.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Robotics and Mechatronics, University of Twente, Twente, The Netherlands (A.M.M.B.); Division of Interventional Neuroradiology, Department of Radiology, Texas Stroke Institute, Plano (A.J.Y.); Departments of Radiology (W.H.Z.) and Neurology (R.J.O.), and Cardiovascular Research Institute Maastricht (W.H.Z., R.J.O.), Maastricht University MC, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands (W.H.Z.); and Faculty of Applied Sciences, Delft University of Technology, Delft, The Netherlands (W.J.N.). e.m.santos@amc.uva.nl.
Background And Purpose:
Preclinical studies showed that thrombi can be permeable and may, therefore, allow for residual blood flow in occluded arteries of patients having acute ischemic stroke. This perviousness may increase tissue oxygenation, improve thrombus dissolution, and augment intra-arterial treatment success. We hypothesize that the combination of computed tomographic angiography and noncontrast computed tomography imaging allows measurement of contrast agent penetrating a permeable thrombus, and it is associated with improved outcome.
Methods:
Thrombus and contralateral artery attenuations in noncontrast computed tomography and computed tomographic angiography images were measured in 184 Multicenter Randomized Clinical trial of Endovascular treatment of acute ischemic stroke in the Netherlands (MR CLEAN) patients with thin-slice images. Two quantitative estimators of the thrombus permeability were introduced: computed tomographic angiography attenuation increase (Δ) and thrombus void fraction (ε). Patients were dichotomized as having a pervious or impervious thrombus and associated with outcome, recanalization, and final infarct volume.
Results:
Patients with Δ≥10.9 HU (n=81 [44%]) and ε≥6.5% (n=77 [42%]) were classified as having a pervious thrombus. These patients were 3.2 (95% confidence interval, 1.7-6.4) times more likely to have a favorable outcome, and 2.5 (95% confidence interval, 1.3-4.8) times more likely to recanalyze, for Δ based classification, and similarly for ε. These odds ratios were independent from intravenous or intra-arterial treatment. Final infarct volume was negatively correlated with both perviousness estimates (correlation coefficient, -0.39 for Δ and -0.40 for ε).
Conclusions:
This study shows that simultaneous measurement of thrombus attenuation in noncontrast computed tomography and computed tomographic angiography allows for quantification of thrombus perviousness. Thrombus perviousness is strongly associated with improved functional outcome, smaller final infarct volume, and higher recanalization rate.
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