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DOI: 10.1055/s-0041-1741095
Selecting the Appropriate First-Line Strategy Based on Hyperdense Vessel Sign in Acute Ischemic Stroke Increases First Pass Recanalization: A Tertiary Center Experience
Abstract
Background: The data pertaining to selecting an optimal first-line strategy (stent retriever [SR] vs. contact aspiration [CA]) based on noncontrast computed tomography (NCCT) in cases of acute ischemic stroke consequent to large vessel occlusion (LVO) is lacking.
Aims: This article studies the influence of hyperdense vessel sign (HVS) in selecting optimal first-line strategy, with intention of increasing first-pass recanalization (FPR).
Methods: Upfront approach at our center is SR technique with rescue therapy (CA) adoption consequent to three failed SR attempts to achieve successful recanalization. Data of patients with acute LVO who underwent mechanical thrombectomy from June 2017 to May 2020 was retrospectively analyzed. Patients were classified into HVS (+) and HVS (−) cohort. Rate of successful recanalization (first pass, early, and final) and efficacy of rescue therapy was assessed between the two cohorts.
Results: Of 52 patients included, 28 and 24 were assigned to the HVS (+) and HVS (−) cohort, respectively. FPR was observed in 50% of HVS (+) and 20.9% of HVS (−) (p = 0.029). Early recanalization was documented in 64.2% of HVS (+) and 37.5% of HVS (−) (p = 0.054). Rescue therapy need was higher in patients not demonstrating HVS (p = 0.062). Successful recanalization was achieved with rescue therapy in 50% of HVS (−) group.
Conclusion: A higher FPR is achievable following individualized first-pass strategy (based on NCCT appearance of clot), instead of a generalized SR first-pass approach. This CT imaging-based strategy is a step closer to achieving primary angiographic goal of FPR.
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Introduction
Currently, the role of mechanical thrombectomy (MT) as the standard of care in acute ischemic stroke (AIS) consequent to a large vessel occlusion (LVO) is well established.[1] With functional outcome in LVO being profoundly time dependent, achieving first-pass recanalization (FPR) holds paramount importance.[2] [3] Currently there is no robust evidence citing significant difference in terms of efficacy or safety between the first-line stent retriever (SR) and contact aspiration (CA) techniques.[4] Though recent studies have suggested that red blood cell (RBC)-rich clot shows better recanalization using SR compared with the CA as the first-line technique,[5] the debate as to the best first-line approach remains unsettled. The currently available data, as a guide to decision making in selecting an optimal first-line MT technique (SR or CA) based on noncontrast computed tomography (NCCT) imaging appearances is at the best sparse.
In this study, we evaluated the influence hyperdense vessel sign (HVS) observed on NCCT has in selecting an optimal individualized first-line approach for MT, with the intention of increasing FPR.
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Material and Methods
This retrospective study was performed at a tertiary care center equipped with a “comprehensive stroke” protocol.
Patient Selection and Characteristics
All the clinical and imaging data pertaining to patients with acute LVO who underwent MT using SR or CA approach from June 2017 to May 2020 was reviewed. Patients less than 18 years of age, occlusions involving middle cerebral artery (MCA) distal to M1 bifurcation, vertebrobasilar circulation, and tandem lesions were excluded from the study. Also, patients who underwent MT employing Solumbra technique were not included in the analysis. A total of 52 patients fulfilled the inclusion criteria and were included in the final analysis.
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Workflow for Acute Stroke at Our Tertiary Care Center
A stroke neurologist performed an initial assessment, primarily based on the National Institutes of Health Stroke Scale (NIHSS) score. The prethrombectomy evaluation to assess presence of bleed, extent of infarction, and vessel status was done using NCCT with a triple-phase CT angiogram (CTA) for neck and intracranial vessels. Cases with wake-up stroke and late presentations (beyond 6 hours from ictus) underwent MT, provided CT perfusion demonstrated significant mismatch and hence salvageability. If NIHSS score was > 4, imaging ruled out intracranial bleed, and CTA confirmed a LVO, the patient was shifted to interventional laboratory for MT procedure. The intravenous thrombolysis was initiated for patients presenting within 4.5 hours of symptom onset at the discretion of attending stroke physician, after ruling out conventional contraindications to thrombolysis. All procedures were performed by either one or two interventional neuroradiologists, using a biplane angiography system. The upfront approach at our center is SR first technique with adoption of CA technique consequent to three failed SR attempts to achieve modified treatment in cerebral infarction (mTICI) score 2b/3 recanalization. The CA technique employed placement of ACE 68 (large bore aspiration catheter) at the face of the clot and suction aspiration using a Penumbra MAX aspiration pump. The decision for conscious sedation or general anesthesia is individualized (based on patient's clinical condition) and at the discretion of interventional neuroradiologist.
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Retrospective Evaluation of Images
All the NCCT images of 52 patients were evaluated by two neuroradiologists to assess presence or absence of the HVS in the region of LVO. The CTA data was perused to correlate the filling defect with the HVS on NCCT images, thus confirming the clot site. Initially the neuroradiologists were blinded to each other's imaging conclusions. Subsequently, following consensus meeting between the two neuroradiologists, interobserver agreement for HVS was reached in all cases (kappa: 1).
Angiographic data and follow-up NCCT were reviewed to identify occlusion site, average number of SR passes needed to achieve mTICI 2b/3, mTICI 2b/3 reperfusion after SR strategy, rate of FPR, early recanalization, rescue therapy (switch over to CA), mTICI 2b/3 reperfusion at end of procedure (following CA strategy), incidence of distal embolization using SR technique, and incidence of any or symptomatic intracerebral hemorrhage (ICH).
Postprocedure mTICI grade of ≥ 2b was defined as successful recanalization. Early recanalization was defined as recanalization with maximum of two passes of SR. Symptomatic ICH was defined as any intracranial hemorrhage associated with ≥ 4 points increase on NIHSS score at 24 hours (Electronic Consolidated Automated Support Criteria).
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Statistical Analysis
Quantitative variables were expressed as mean and standard deviation. Qualitative variable were expressed as frequency and percentage. Comparison of continuous variables between two groups was analyzed by Student's t-test. Comparison of continuous variable among more than two categories was analyzed by analysis of variance. Association between qualitative variables was analyzed by chi-square test. A p-value of < 0.05 was considered statistically significant. Interobserver agreement for HVS was calculated using kappa statistics. Data were entered in Microsoft Excel and data analysis was performed using SPSS version 22.0.
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Results
Of the 52 patients included, 28 and 24 were randomized to HVS (+) and HVS (−) cohort, respectively. Excellent interobserver agreement for HVS was noted using kappa statistics (kappa = 1). All but three patients underwent MT with onset of symptoms being within 6 hours. These three patients (2 HVS+ and 1 HVS–) presented between 6 and 10 hours of symptoms onset and underwent MT following demonstration of brain tissue salvageability on CT perfusion. MT was performed under conscious sedation in 26 (92.9%) of HVS (+) and 22 (91.7%) of HVS (−) cohort, respectively. Two cases underwent the procedure under general anesthesia in each group.
Occlusion involving the terminal internal carotid artery was documented in three patients in each cohort, but affected M1 MCA in 25 (89.3%) and 21 (87.5%) of HVS (+) and HVS (−) cohort, respectively. Intravenous tissue plasminogen activator was administered in 13 (46.4%) and 12 (50%) of HVS (+) and HVS (−) group, respectively. First-pass mTICI 2b/3 recanalization was achieved using SR in 14 (50%) of HVS (+) and 5 (20.9%) of HVS (−) cohorts. Early mTICI 2b/3 recanalization was achieved using SR in 18 (64.2%) of HVS (+) and 9 (37.5%) of HVS (−) cohorts. A total of 7 patients (25%) from HVS (+) needed the rescue therapy (switched over to CA technique) whereas 12 patients (50%) from HVS (−) needed adoption of CA technique consequent to three failed SR attempts to achieve mTICI 2b/3 recanalization. Overall, the CA technique was employed in 19 patients. Following rescue therapy with CA, mTICI 2b/3 recanalization was achieved in 2/7 (28.6%) and 6/12 (50%) of HVS (+) and HVS (−) group, respectively. The rate of distal embolization was 2 (7.1%) in the susceptibility vessel sign (SVS) (+) compared with 4 (16.7%) in the SVS (−) group ([Table 1]).
Characteristics |
HVS positive (n = 28) n (%) |
HVS negative (n = 24) n (%) |
p-Value |
---|---|---|---|
Initial NIHSS score, mean (SD) |
13.2 (2.7)[a] |
14.4 (3.1)[a] |
0.142 |
ASPECTS, mean (SD) |
6.2 (1.3)[a] |
6.0 (1.1)[a] |
0.556 |
Occlusion site |
0.841 |
||
-ICA terminus |
3/28 (10.7) |
3/24 (12.5) |
|
-M1 MCA |
25/28 (89.3) |
21/24 (87.5) |
|
IV t-PA infusion |
13/28 (46.4) |
12/24 (50.0) |
0.797 |
Anesthesia |
0.872 |
||
Conscious sedation |
26/28 (92.9) |
22/24 (91.7) |
|
GA |
2/28 (7.1) |
2/24 (8.3) |
|
SR passes needed to achieve mTICI 2b/3: |
|||
1 |
14/28 (50.0) |
5/24 (20.9) |
0.029 |
2 |
4/28 (14.3) |
4/24 (16.7) |
0.812 |
3 |
3/28 (10.7) |
3/24 (12.5) |
0.841 |
First-pass recanalization |
14/28 (50.0) |
5/24 (20.9) |
0.029 |
Early recanalization (≤ 2 passes) |
18/28 (64.2) |
9/24 (37.5) |
0.054 |
mTICI 2b/3 reperfusion after SR strategy |
21/28 (75.0) |
12/24 (50.0) |
0.062 |
Rescue therapy[b] |
7/28 (25.0) |
12/24 (50.0) |
0.062 |
mTICI 2b/3 reperfusion post rescue strategy |
2/7 (28.6) |
6/12 (50.0) |
0.075 |
Overall mTICI 2b/3 reperfusion at end of procedure |
23/28 (82.1) |
18/24 (75%) |
0.530 |
Distal embolization |
2/28 (7.1) |
4/24 (16.7) |
0.284 |
ICH at 24 h |
2/28 (7.1) |
3/24 (12.5) |
0.514 |
Symptomatic ICH |
1/28 (3.6) |
1/24 (4.2) |
0.911 |
Abbreviations: CA, contact aspiration; GA, general anesthesia; ICA, internal carotid artery; ICH, intracerebral hemorrhage; IV, intravenous; MCA, middle cerebral artery; mTICI, modified treatment in cerebral infarction score; NIHSS, National Institutes of Health Stroke Scale; SD, standard deviation; SR, stent retriever; t-PA, tissue plasminogen activator.
a Values indicates mean (SD), rest of values in second and third columns represent numbers (percentage).
b Contact aspiration following three failed attempts at recanalization with SR.
The representative cases of HVS (+) and HVS (−) cohort, managed with SR technique and rescue therapy are depicted in [Figs. 1] and [2], respectively.
FPR was observed using SR in 50% of HVS (+) and 20.9% of HVS (−), a statistically significant difference (p = 0.029) between the two cohort. The early recanalization (≤ 2 SR passes) was documented in 64.2% of HVS (+) and 37.5% of HVS (−), a near statistically significant difference (p = 0.054) between the two cohort. The rate of rescue therapy was much lower in patients demonstrating HVS on NCCT, compared with those in the SVS (−) cohort (p = 0.062) ([Table 1] and [Fig. 3]). Also, the incidence of distal embolization was higher in the SVS (−) than in SVS (+) cohort (16.7 vs. 7.1%). No statistically significant difference was noted in the age, comorbidities, NIHSS and ASPECTS score, use of type of anesthesia, intravenous thrombolysis, and incidence of any or symptomatic ICH between HVS (+) and HVS (−) cohorts ([Table 1]).
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Discussion
Consequent to demonstration of clinical efficacy of MT unequivocally by the multiple landmark randomized clinical trials, presently its role as the standard of care for LVO in AIS is well established.[1] [6] [7] [8] [9]
Although functional outcome for LVO with MT is definitely superior to intravenous thrombolysis, it is profoundly time dependent.[2] [3] Considering therefore the need of early recanalization, FPR is emerging as a key concept in management of AIS.[10] [11] Recent studies emphasize the importance of first-pass effect and documented it as an independent prognostic factor in achieving better functional outcome in LVO.[3] [11] [12] [13] Also, recent literature emphasize the quality of reperfusion to be an important predictor of good clinical outcome, with progressively better clinical outcomes seen from mTICI 2b to 3.[14] [15] The multiple passes not only lead to clot compaction, increased time to recanalization, but also to intimal injury and increase in procedure-related complications.[11] [16] [17] [18] [19] [20]
Therefore, the interventionist must apply a strategy which has the highest likelihood for achieving FPR, based on individual's experience and available literature.
The presence of HVS on NCCT and SVS on gradient-recalled-echo magnetic resonance imaging (MRI) suggests RBC-rich clot, whereas its absence favors a fibrin-predominant occlusive thrombi.[21] [22] [23] [24] Also, good concordance between HVS and SVS has been documented in the literature.[21]
The presence of SVS, considered to be due to T2-shortening effect of intracellular deoxyhemoglobin (acute stage of RBC clot), is documented to have a direct correlation with successful recanalization using SR.[25] [26] [27] Although studies correlating SVS with clot composition and outcomes (angiographic and clinical) following SR are available, the literature comparing HVS (on NCCT) with angiographic outcome using SR or CA strategy is scarce. Also, CT being a more commonly undertaken investigation in clinical setting of anterior circulation AIS, a first-line strategy (SR or CA) based on clot appearances on CT is more pragmatic and hence warranted. HVS in an appropriate clinical context, is a highly specific, and an early sign of AIS on NCCT.[28] In our study, the two neuroradiologists had an almost perfect interobserver agreement (kappa = 1) for HVS.
Brinjikji et al, based on their systematic review, concluded that clots with a higher mean thrombus Hounsfield unit were more likely to be RBC-rich and showed better angiographic outcome compared with those with lower values.[29] Similarly, in our study HVS presence was observed to be an independent predictor of successful, first pass, as well as early recanalization (≤ 2 SR passes). Such results are biologically plausible with recent data demonstrating improved entrapment of RBC-rich clot in a SR.[12] The favorable recanalization in the HVS (+) cohort noted in our study is in accordance with early recanalization observed in those with SVS sign on MRI.[25] [26] [27] [30] [31] Our results support the premise that RBC-rich clots manifest as HVS and SWS on plain CT and MRI, respectively, and show early recanalization using SR.
A few studies have examined the association between CT attenuation of clot and angiographic outcomes, but not the subgroup analysis to assess and compare efficiency of SR versus CA in those with absent HVS.[32] [33] [34] Similar to our results, Froehler et al documented successful recanalization in 79% of patients with HVS, but in only 36% without HVS.[34] However, the thrombectomy in this study was limited to MERCI retriever with no option to switch over to CA (rescue therapy) in those with failed recanalization.
We documented that first-pass mTICI 2b/3 recanalization was achieved using SR in 14 (50%) of HVS (+), but in only 5 (20.9%) of HVS (−) cohort, plausible explanation being the tendency of the fibrin-rich clot to roll out of the SR during retrieval.[30] [35] In our study, following rescue therapy with CA (consequent to three failed SR attempts), mTICI 2b/3 recanalization was achieved in 6 (50%) of HVS (−) cohort, with maximum of three CA passes. This observation highlights the effectiveness of aspiration technique in this subgroup of patients.
The incidence of distal embolization was 7.1% in SVS (+) compared with 16.7% in SVS (−) cohort, explained by the higher number of passes needed in the latter.
Although, a recent systematic review and meta-analysis by Boulanger et al suggest no significant difference in terms of efficacy or safety between first-line SR and CA techniques,[4] our study highlights that higher FPR can be achieved if individualized first-pass strategy is employed (based on the appearance of clot on NCCT), instead of a generalized SR first-pass approach.
Some of the limitations of our study include the relatively small number of cases treated, a single-center experience, and the lack of direct analysis of thrombi histologically. Although our study showed high rate of successful recanalization following the rescue therapy with CA (consequent to three failed attempts with SR) in patients with absence of HVS, we cannot definitely comment on the efficacy a CA-based first-line strategy would have yielded if it was applied as the upfront approach for those demonstrating HVS. Further studies employing CA as the first-line strategy are needed to effectively comment on the efficacy the CA technique would have in those with HVS (+). However, being a single-center study, the protocol of adhering to SR as the first strategy in all cases added homogeneity to the cohort.
To our knowledge, there is no other CT-based study, evaluating the influence “HVS” has in selecting an appropriate first approach (ST vs. CA) for MT, with intention of increasing FPR.
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Conclusion
The good angiographic recanalization achieved following adoption of rescue therapy with CA technique (consequent to three failed attempts with SR) in the patients demonstrating absence of HVS, support the premise that CA may be considered as the first-line technique in such subset of patients. Our study highlights that higher FPR can be achieved if individualized first-pass strategy is employed (based on the appearance of clot on NCCT), instead of a generalized SR first-pass approach. This CT imaging-based strategy, formulated with our single tertiary center experience, is a step closer to achieving the primary angiographic goal of FPR.
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Conflict of Interest
There are no conflicts of interest.
Authors' Contributions
K.U.B.: Concept and design of study, drafting the article, analysis and interpretation of data, critical revision for important intellectual content, final approval of the version to be published.
N.J.: Analysis and interpretation of data, critical revision for important intellectual content, final approval of the version to be published.
A.M.: Analysis and interpretation of data, critical revision for important intellectual content, final approval of the version to be published.
V.M.: Concept and design of study, drafting the article, analysis and interpretation of data, manuscript editing, critical revision for important intellectual content, final approval of the version to be published.
Financial Support and Sponsorship
None.
Note
Work was primarily carried out at Armed Forces Medical College, Pune.
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References
- 1 Powers WJ, Rabinstein AA, Ackerson T. et al; American Heart Association Stroke Council. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018; 49: 46-110
- 2 Goyal M, Menon BK, van Zwam WH. et al; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387 (10029): 1723-1731
- 3 Maus V, Brehm A, Tsogkas I, Henkel S, Psychogios MN. Stent retriever placement in embolectomy: the choice of the post-bifurcational trunk influences the first-pass reperfusion result in M1 occlusions. J Neurointerv Surg 2019; 11 (03) 237-240
- 4 Boulanger M, Lapergue B, Turjman F. et al. First-line contact aspiration vs stent-retriever thrombectomy in acute ischemic stroke patients with large-artery occlusion in the anterior circulation: systematic review and meta-analysis. Interv Neuroradiol 2019; 25 (03) 244-253
- 5 Bourcier R, Mazighi M, Labreuche J. et al; ASTER Trial Investigators. Susceptibility vessel sign in the ASTER trial: higher recanalization rate and more favourable clinical outcome after first line stent retriever compared to contact aspiration. J Stroke 2018; 20 (02) 268-276
- 6 Berkhemer OA, Fransen PS, Beumer D. et al; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372 (01) 11-20
- 7 Goyal M, Demchuk AM, Menon BK. et al; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372 (11) 1019-1030
- 8 Jovin TG, Chamorro A, Cobo E. et al; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372 (24) 2296-2306
- 9 Saver JL, Goyal M, Bonafe A. et al; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372 (24) 2285-2295
- 10 Nikoubashman O, Dekeyzer S, Riabikin A. et al. True first-pass effect: first-pass complete reperfusion improves clinical outcome in thrombectomy stroke patients. J Stroke 2019; 50: 2140-2146
- 11 Zaidat OO, Castonguay AC, Linfante I. et al. First pass effect: a new measure for stroke thrombectomy devices. Stroke 2018; 49 (03) 660-666
- 12 Angermaier A, Michel P, Khaw AV, Kirsch M, Kessler C, Langner S. Intravenous thrombolysis and passes of thrombectomy as predictors for endovascular revascularization in ischemic stroke. J Stroke Cerebrovasc Dis 2016; 25 (10) 2488-2495
- 13 Costalat V, Machi P, Lobotesis K. et al. Rescue, combined, and stand-alone thrombectomy in the management of large vessel occlusion stroke using the solitaire device: a prospective 50-patient single-center study: timing, safety, and efficacy. Stroke 2011; 42 (07) 1929-1935
- 14 Almekhlafi MA, Mishra S, Desai JA. et al. Not all “successful” angiographic reperfusion patients are an equal validation of a modified TICI scoring system. Interv Neuroradiol 2014; 20 (01) 21-27
- 15 Liebeskind DS, Bracard S, Guillemin F. et al; HERMES Collaborators. eTICI reperfusion: defining success in endovascular stroke therapy. J Neurointerv Surg 2019; 11 (05) 433-438
- 16 Arai D, Ishii A, Chihara H, Ikeda H, Miyamoto S. Histological examination of vascular damage caused by stent retriever thrombectomy devices. J Neurointerv Surg 2016; 8 (10) 992-995
- 17 Broderick JP, Palesch YY, Demchuk AM. et al; Interventional Management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013; 368 (10) 893-903
- 18 Yoo AJ, Andersson T. Thrombectomy in acute ischemic stroke: challenges to procedural success. J Stroke 2017; 19 (02) 121-130
- 19 Kim BM. Causes and solutions of endovascular treatment failure. J Stroke 2017; 19 (02) 131-142
- 20 Balasubramaian A, Mitchell P, Dowling R, Yan B. Evolution of endovascular therapy in acute stroke: implications of device development. J Stroke 2015; 17 (02) 127-137
- 21 Liebeskind DS, Sanossian N, Yong WH. et al. CT and MRI early vessel signs reflect clot composition in acute stroke. Stroke 2011; 42 (05) 1237-1243
- 22 Kim J, Park JE, Nahrendorf M, Kim DE. Direct thrombus imaging in stroke. J Stroke 2016; 18 (03) 286-296
- 23 Park MG, Oh SJ, Baik SK, Jung DS, Park KP. Susceptibility weighted imaging for detection of thrombus in acute cardioembolic stroke. J Stroke 2016; 18 (01) 73-79
- 24 Kim BJ, Kang HG, Kim HJ. et al. Magnetic resonance imaging in acute ischemic stroke treatment. J Stroke 2014; 16 (03) 131-145
- 25 Soize S, Batista AL, Rodriguez Regent C. et al. Susceptibility vessel sign on T2* magnetic resonance imaging and recanalization results of mechanical thrombectomy with stent retrievers: a multicentre cohort study. Eur J Neurol 2015; 22 (06) 967-972
- 26 Bourcier R, Volpi S, Guyomarch B. et al. Susceptibility vessel sign on MRI predicts favorable clinical outcome in patients with anterior circulation acute stroke treated with mechanical thrombectomy. AJNR Am J Neuroradiol 2015; 36 (12) 2346-2353
- 27 Bae YJ, Jung C, Kim JH. et al. Potential for the use of the Solitaire stent for recanalization of middle cerebral artery occlusion without a susceptibility vessel sign. AJNR Am J Neuroradiol 2014; 35 (01) 149-155
- 28 Jensen-Kondering U, Riedel C, Jansen O. Hyperdense artery sign on computed tomography in acute ischemic stroke. World J Radiol 2010; 2 (09) 354-357
- 29 Brinjikji W, Duffy S, Burrows A. et al. Correlation of imaging and histopathology of thrombi in acute ischemic stroke with etiology and outcome: a systematic review. J Neurointerv Surg 2017; 9 (06) 529-534
- 30 Machi P, Jourdan F, Ambard D. et al. Experimental evaluation of stent retrievers' mechanical properties and effectiveness. J Neurointerv Surg 2017; 9 (03) 257-263
- 31 Bourcier R, Brecheteau N, Costalat V. et al. MRI quantitative T2* mapping on thrombus to predict recanalization after endovascular treatment for acute anterior ischemic stroke. J Neuroradiol 2017; 44 (04) 241-246
- 32 Moftakhar P, English JD, Cooke DL. et al. Density of thrombus on admission CT predicts revascularization efficacy in large vessel occlusion acute ischemic stroke. Stroke 2013; 44 (01) 243-245
- 33 Mokin M, Morr S, Natarajan SK. et al. Thrombus density predicts successful recanalization with Solitaire stent retriever thrombectomy in acute ischemic stroke. J Neurointerv Surg 2015; 7 (02) 104-107
- 34 Froehler MT, Tateshima S, Duckwiler G. et al; UCLA Stroke Investigators. The hyperdense vessel sign on CT predicts successful recanalization with the Merci device in acute ischemic stroke. J Neurointerv Surg 2013; 5 (04) 289-293
- 35 Gunning GM, McArdle K, Mirza M, Duffy S, Gilvarry M, Brouwer PA. Clot friction variation with fibrin content; implications for resistance to thrombectomy. J Neurointerv Surg 2018; 10 (01) 34-38
Address for correspondence
Publication History
Article published online:
10 January 2022
© 2022. Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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References
- 1 Powers WJ, Rabinstein AA, Ackerson T. et al; American Heart Association Stroke Council. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018; 49: 46-110
- 2 Goyal M, Menon BK, van Zwam WH. et al; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387 (10029): 1723-1731
- 3 Maus V, Brehm A, Tsogkas I, Henkel S, Psychogios MN. Stent retriever placement in embolectomy: the choice of the post-bifurcational trunk influences the first-pass reperfusion result in M1 occlusions. J Neurointerv Surg 2019; 11 (03) 237-240
- 4 Boulanger M, Lapergue B, Turjman F. et al. First-line contact aspiration vs stent-retriever thrombectomy in acute ischemic stroke patients with large-artery occlusion in the anterior circulation: systematic review and meta-analysis. Interv Neuroradiol 2019; 25 (03) 244-253
- 5 Bourcier R, Mazighi M, Labreuche J. et al; ASTER Trial Investigators. Susceptibility vessel sign in the ASTER trial: higher recanalization rate and more favourable clinical outcome after first line stent retriever compared to contact aspiration. J Stroke 2018; 20 (02) 268-276
- 6 Berkhemer OA, Fransen PS, Beumer D. et al; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372 (01) 11-20
- 7 Goyal M, Demchuk AM, Menon BK. et al; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372 (11) 1019-1030
- 8 Jovin TG, Chamorro A, Cobo E. et al; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372 (24) 2296-2306
- 9 Saver JL, Goyal M, Bonafe A. et al; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372 (24) 2285-2295
- 10 Nikoubashman O, Dekeyzer S, Riabikin A. et al. True first-pass effect: first-pass complete reperfusion improves clinical outcome in thrombectomy stroke patients. J Stroke 2019; 50: 2140-2146
- 11 Zaidat OO, Castonguay AC, Linfante I. et al. First pass effect: a new measure for stroke thrombectomy devices. Stroke 2018; 49 (03) 660-666
- 12 Angermaier A, Michel P, Khaw AV, Kirsch M, Kessler C, Langner S. Intravenous thrombolysis and passes of thrombectomy as predictors for endovascular revascularization in ischemic stroke. J Stroke Cerebrovasc Dis 2016; 25 (10) 2488-2495
- 13 Costalat V, Machi P, Lobotesis K. et al. Rescue, combined, and stand-alone thrombectomy in the management of large vessel occlusion stroke using the solitaire device: a prospective 50-patient single-center study: timing, safety, and efficacy. Stroke 2011; 42 (07) 1929-1935
- 14 Almekhlafi MA, Mishra S, Desai JA. et al. Not all “successful” angiographic reperfusion patients are an equal validation of a modified TICI scoring system. Interv Neuroradiol 2014; 20 (01) 21-27
- 15 Liebeskind DS, Bracard S, Guillemin F. et al; HERMES Collaborators. eTICI reperfusion: defining success in endovascular stroke therapy. J Neurointerv Surg 2019; 11 (05) 433-438
- 16 Arai D, Ishii A, Chihara H, Ikeda H, Miyamoto S. Histological examination of vascular damage caused by stent retriever thrombectomy devices. J Neurointerv Surg 2016; 8 (10) 992-995
- 17 Broderick JP, Palesch YY, Demchuk AM. et al; Interventional Management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013; 368 (10) 893-903
- 18 Yoo AJ, Andersson T. Thrombectomy in acute ischemic stroke: challenges to procedural success. J Stroke 2017; 19 (02) 121-130
- 19 Kim BM. Causes and solutions of endovascular treatment failure. J Stroke 2017; 19 (02) 131-142
- 20 Balasubramaian A, Mitchell P, Dowling R, Yan B. Evolution of endovascular therapy in acute stroke: implications of device development. J Stroke 2015; 17 (02) 127-137
- 21 Liebeskind DS, Sanossian N, Yong WH. et al. CT and MRI early vessel signs reflect clot composition in acute stroke. Stroke 2011; 42 (05) 1237-1243
- 22 Kim J, Park JE, Nahrendorf M, Kim DE. Direct thrombus imaging in stroke. J Stroke 2016; 18 (03) 286-296
- 23 Park MG, Oh SJ, Baik SK, Jung DS, Park KP. Susceptibility weighted imaging for detection of thrombus in acute cardioembolic stroke. J Stroke 2016; 18 (01) 73-79
- 24 Kim BJ, Kang HG, Kim HJ. et al. Magnetic resonance imaging in acute ischemic stroke treatment. J Stroke 2014; 16 (03) 131-145
- 25 Soize S, Batista AL, Rodriguez Regent C. et al. Susceptibility vessel sign on T2* magnetic resonance imaging and recanalization results of mechanical thrombectomy with stent retrievers: a multicentre cohort study. Eur J Neurol 2015; 22 (06) 967-972
- 26 Bourcier R, Volpi S, Guyomarch B. et al. Susceptibility vessel sign on MRI predicts favorable clinical outcome in patients with anterior circulation acute stroke treated with mechanical thrombectomy. AJNR Am J Neuroradiol 2015; 36 (12) 2346-2353
- 27 Bae YJ, Jung C, Kim JH. et al. Potential for the use of the Solitaire stent for recanalization of middle cerebral artery occlusion without a susceptibility vessel sign. AJNR Am J Neuroradiol 2014; 35 (01) 149-155
- 28 Jensen-Kondering U, Riedel C, Jansen O. Hyperdense artery sign on computed tomography in acute ischemic stroke. World J Radiol 2010; 2 (09) 354-357
- 29 Brinjikji W, Duffy S, Burrows A. et al. Correlation of imaging and histopathology of thrombi in acute ischemic stroke with etiology and outcome: a systematic review. J Neurointerv Surg 2017; 9 (06) 529-534
- 30 Machi P, Jourdan F, Ambard D. et al. Experimental evaluation of stent retrievers' mechanical properties and effectiveness. J Neurointerv Surg 2017; 9 (03) 257-263
- 31 Bourcier R, Brecheteau N, Costalat V. et al. MRI quantitative T2* mapping on thrombus to predict recanalization after endovascular treatment for acute anterior ischemic stroke. J Neuroradiol 2017; 44 (04) 241-246
- 32 Moftakhar P, English JD, Cooke DL. et al. Density of thrombus on admission CT predicts revascularization efficacy in large vessel occlusion acute ischemic stroke. Stroke 2013; 44 (01) 243-245
- 33 Mokin M, Morr S, Natarajan SK. et al. Thrombus density predicts successful recanalization with Solitaire stent retriever thrombectomy in acute ischemic stroke. J Neurointerv Surg 2015; 7 (02) 104-107
- 34 Froehler MT, Tateshima S, Duckwiler G. et al; UCLA Stroke Investigators. The hyperdense vessel sign on CT predicts successful recanalization with the Merci device in acute ischemic stroke. J Neurointerv Surg 2013; 5 (04) 289-293
- 35 Gunning GM, McArdle K, Mirza M, Duffy S, Gilvarry M, Brouwer PA. Clot friction variation with fibrin content; implications for resistance to thrombectomy. J Neurointerv Surg 2018; 10 (01) 34-38