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What is a Challenging Clot? : A DELPHI Consensus Statement from the CLOTS 7.0 Summit.

Johanna M Ospel1, Mahmood Mirza2, Frédéric Clarençon3

  • 1Departments of Diagnostic Imaging and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, T2N2T9, Calgary, AB, Canada. johannaospel@gmail.com.

Clinical Neuroradiology
|June 7, 2023
PubMed
Summary

Identifying challenging clots during mechanical thrombectomy for acute stroke is difficult. Experts identified 8 features of challenging clots, including white color, calcification, stiffness, and adherence, aiding in better patient treatment.

Keywords:
Acute ischemic strokeIntracranial vessel occlusionNeurovascular diseaseThrombectomyThrombus

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Area of Science:

  • Neurology
  • Interventional Radiology
  • Clot Research

Background:

  • Mechanical thrombectomy is a crucial treatment for acute stroke.
  • Predicting and defining challenging clots for endovascular approaches remains difficult due to a lack of expert consensus.
  • This study aimed to define challenging clots and identify indicative features through expert opinion.

Purpose of the Study:

  • To establish a consensus definition of challenging clots in acute stroke.
  • To identify specific clot and patient features indicative of difficult-to-recanalize clots.
  • To improve the accuracy of identifying challenging occlusions before endovascular treatment (EVT).

Main Methods:

  • A modified DELPHI technique was employed with stroke thrombectomy and clot research experts.
  • The study involved three rounds of questioning, starting with open-ended and progressing to closed-ended questions.
  • Consensus was defined as agreement among ≥50% of panelists, with features rated ≥3 out of 4 on certainty being included.

Main Results:

  • Consensus was reached on 16 out of 30 questions.
  • Eight features were identified with consensus and high certainty: white-colored clots, calcified clots (histology and imaging), stiff clots, sticky/adherent clots, hard clots, difficult-to-pass clots, and clots resistant to pulling.
  • Most experts agreed on switching endovascular treatment techniques after 2-3 failed attempts.

Conclusions:

  • A consensus definition of challenging clots was established, highlighting 8 distinct features.
  • The identified features provide a basis for a priori identification of challenging occlusions.
  • Further pragmatic studies are needed to validate these findings and enhance predictive accuracy for EVT outcomes.