We retrospectively evaluated the composition of retrieved clots from ischemic stroke patients to study the association between histological composition and stroke etiology METHODS: Consecutive ...patients enrolled in the Stroke Thromboembolism Registry of Imaging and Pathology (STRIP) were included in this study. All patients underwent mechanical thrombectomy and retrieved clots were sent to a central core lab for processing. Histological analysis was performed using martius scarlet blue (MSB) staining, and quantification for red blood cells (RBCs), white blood cells (WBCs), fibrin and platelets was performed using Orbit Image Software. A Wilcoxon test was used for continuous variables and χ
test for categorical variables.
1350 patients were included in this study. The overall rate of Thrombolysis In Cerebral Infarction (TICI) 2c/3 was 68%. 501 patients received tissue plasminogen activator (tPA) (37%). 267 patients (20%) had a large artery atherosclerosis (LAA) source, 662 (49%) a cardioembolic (CE) source, 301 (22%) were cryptogenic, and the remainder had other identifiable sources including hypercoagulable state or dissection. LAA thrombi had a higher mean RBC density (46±23% vs 42±22%, p=0.01) and a lower platelet density (24±18% vs 27±18%, p=0.03) than CE thrombi. Clots from dissection patients had the highest mean RBC density (50±24%) while clots from patients with a hypercoagulable state had the lowest mean RBC density (26±21%).
Our study found statistically significant but clinically insignificant differences between clots of CE and LAA etiologies. Future studies should emphasize molecular, proteomic and immunohistochemical characteristics to determine links between clot composition and etiology.
Background and Purpose- Nearly 30% of large vessel occlusion acute ischemic stroke clots are from an unknown source. We assessed histological clot composition in a series of patients with large ...vessel occlusion and investigated correlations between clot composition and stroke pathogenesis. Methods- As part of the multi-institutional STRIP registry (Stroke Thromboembolism Registry of Imaging and Pathology), consecutive emboli retrieved during mechanical thrombectomy were stained using Martius Scarlett Blue and analyzed using machine learning software. We assessed proportions of red blood cells, fibrin, platelets, and white blood cells. Correlations between clot components and stroke pathogenesis (large artery atherosclerosis, cardioembolism, and stroke of undetermined pathogenesis) were assessed using SPSS22. Results- One hundred five patients were included. The proportion of platelet-rich clots (55.0% versus 21.2%; P=0.005) and percentage of platelet content (22.1±4.2% versus 13.9±14.2%; P=0.03) was significantly higher in the large artery atherosclerosis group compared with the cardioembolic group. The proportion of platelet-rich clots (50.0% versus 21.2%; P=0.024) was also significantly higher in the cryptogenic group compared with cardioembolic cases. Large artery atherosclerosis and cryptogenic cases had a similar proportion of platelet-rich clots (55.0% versus 50.0%; P=0.636). There was no significant difference between stroke pathogenesis and the other major clot components. Conclusions- High platelet content of emboli is associated with a large artery atherosclerosis etiology of large vessel occlusion.
Current studies on clot characterization in acute ischemic stroke focus on fibrin and red blood cell composition. Few studies have examined platelet composition in acute ischemic stroke clots. We ...characterize clot composition using the Martius Scarlet Blue stain and assess associations between platelet density and CT density.
Histopathological analysis of the clots collected as part of the multi-institutional STRIP registry was performed using Martius Scarlet Blue stain and the composition of the clots was quantified using Orbit Image Analysis (www.orbit.bio) machine learning software. Prior to endovascular treatment, each patient underwent non-contrast CT (NCCT) and the CT density of each clot was measured. Correlations between clot components and clinical information were assessed using the χ
test.
Eighty-five patients were included in the study. The mean platelet density of the clots was 15.7% (2.5-72.5%). There was a significant correlation between platelet-rich clots and the absence of hyperdensity on NCCT, (ρ=0.321, p=0.003*, n=85). Similarly, there was a significant inverse correlation between the percentage of platelets and the mean Hounsfield Units on NCCT (ρ=-0.243, p=0.025*, n=85).
Martius Scarlet Blue stain can identify patients who have platelet-rich clots. Platelet-rich clots are isodense on NCCT.
Size of an unruptured intracranial aneurysm (UIA) may be an important risk factor for rupture. Accordingly, serial noninvasive imaging is commonly used to assess untreated UIA for enlargement. Few ...data exist regarding the frequency and predictors of enlargement. We obtained this information from a group of patients followed with serial MR angiography (MRA).
We retrospectively identified 165 patients with 191 UIA followed with serial MRA. Fusiform aneurysms, UIA <2 mm, and UIA that were surgically or endovascularly treated before the first MRA were excluded. MRA was performed using 1.5-T and 3-T MRI. Maximal diameter was determined on MRA source images. Multivariate regression analysis was used to determine independent risk factors for growth.
Twenty aneurysms (10%) grew over a median follow-up period of 47 months. Frequency of enlargement was 6.9%, 25%, and 83% for aneurysms <8 mm, 8 to 12 mm, and >or=13 mm, respectively (P<0.001 for trend). Of the variables we evaluated, original aneurysm diameter (OR, 1.28 per mm; 95% CI, 1.07 to 1.58) was the only independent predictor of enlargement. Aneurysms >or=8 mm in diameter were at highest risk for enlargement (OR, 7.25; 95% CI, 1.96 to 27.1). There was a trend toward increased risk of enlargement in patients with multiple aneurysms (OR, 2.50; 95% CI, 0.86 to 7.53).
Over a median follow-up period of 47 months, 10% of UIA enlarged. Larger aneurysms had a significantly increased risk of enlargement. The likelihood of enlargement was highest in aneurysms with diameters >or=8 mm. However, a clinically significant proportion of small aneurysms grow, and this growth can be detected by serial MRA.
We present the results of a randomized controlled trial evaluating the efficacy of vertebroplasty versus kyphoplasty in treating vertebral body compression fractures.
Patients with vertebral body ...compression fractures were randomly assigned to treatment with kyphoplasty or vertebroplasty. Primary endpoints were pain (0-10 scale) and disability assessed using the Roland-Morris Disability Questionnaire (RMDQ). Outcomes were assessed at 3 days, 1 month, 6 months, and 1 year following the procedure.
115 subjects were enrolled in the trial with 59 (51.3%) randomly assigned to kyphoplasty and 56 (48.7%) assigned to vertebroplasty. Mean (SD) pain scores at baseline, 3 days, 30 days, and 1 year for kyphoplasty versus vertebroplasty were 7.4 (1.9) vs 7.9 (2.0), 4.1 (2.8) vs 3.7 (3.0), 3.4 (2.5) vs 3.6 (2.9), and 3.0 (2.8) vs 2.3 (2.6), respectively (p>0.05 at all time points). Mean (SD) RMDQ scores at baseline, 3 days, 30 days, 180 days, and 1 year were 17.3 (6.6) vs 16.3 (7.4), 11.8 (7.9) vs 10.9 (8.2), 8.6 (7.2) vs 8.8 (8.5), 7.9 (7.4) vs 7.3 (7.7), 7.5 (7.2) vs 6.7 (8.0), respectively (p>0.05 at all time points). For baseline to 12-month assessment in average pain and RMDQ scores, the standardized effect size between kyphoplasty and vertebroplasty was small at -0.36 (95% CI -1.02 to 0.31) and -0.04 (95% CI -1.68 to 1.60), respectively.
Our study indicates that vertebroplasty and kyphoplasty appear to be equally effective in substantially reducing pain and disability in patients with vertebral body compression fractures.
NCT00279877.
Background
Initial reports of the FUNC score suggest that it may accurately identify those patients suffering from intracerebral hemorrhage (ICH) with an ultra low chance of functional neurologic ...recovery. This study’s aim is to validate the FUNC score and determine if it accurately identifies the cohort of patients with an ultra low chance of survival with good neurologic recovery.
Methods
Retrospective review of 501 consecutive primary ICH patients admitted from the Emergency Department to a large healthcare system. Performance of the FUNC, ICH-GS, and oICH scores was determined by calculating areas under the receiver-operator-characteristic curves. Patients with a predicted 100 % chance of poor neurologic outcome (PNO) (FUNC
<
4 and ICH-GS
>
10) scores were evaluated to determine if DNR impacted 90 day survival or rate of survival with a Glasgow Outcome Score of
<
3.
Results
In 366 cases of primary ICH who presented during the study period, 222(61 %) survived to discharge. Both the FUNC (AUC: 0.873) and ICH-GS (AUC: 0.888) outperformed the oICH (AUC: 0.743) in predicting 90-day mortality (
p
= <0.001). Of 68 patients with a FUNC score
<
4, 67 (98.5 %) had PNO at discharge. The presence of DNR was not associated with a significant difference in the rate of PNO at discharge (40/40 = 100 % vs. 27/28 = 96.4 %
p
= 0.42) or 90-day mortality (40/40 = 100 % vs. 21/28 = 75 %,
p
= 0.06).
Conclusion
The FUNC and ICH-GS appear superior to the oICH in predicting outcome in patients with primary ICH. In addition, the FUNC score appears to accurately identify patients with low chance of functional neurologic recovery at discharge.
Several animal studies have demonstrated that mechanical thrombectomy (MT) for acute ischemic stroke (AIS) may cause vessel wall injury (VWI). However, the histological changes in human cerebral ...arteries following MT are difficult to determine.
To investigate the occurrence of VWI during MT by histological and immunohistochemical evaluation of AIS clots.
As part of the multicenter STRIP registry, 277 clots from 237 patients were analyzed using Martius Scarlett Blue stain and immunohistochemistry for CD34 (endothelial cells) and smooth muscle actin (smooth muscle cells).
MT devices used were aspiration catheters (100 cases), stentriever (101 cases), and both (36 cases). VWI was found in 33/277 clots (12%). There was no significant correlation between VWI and MT device. The degree of damage varied from grade I (mild intimal damage, 24 clots), to grade II (relevant intimal and subintimal damage, 3 clots), and III (severe injury, 6 clots). VWI clots contained significantly more erythrocytes (p=0.006*) and less platelets/other (p=0.005*) than non-VWI clots suggesting soft thrombus material.Thrombolysis correlated with a lower rate of VWI (p=0.04*). VWI cases showed a significantly higher number of passes (2 1-4 vs 1 1-3, p=0.028*) and poorer recanalization outcome (p=0.01*) than cases without VWI.
Histological markers of VWI were present in 12% of AIS thrombi, suggesting that VWI might be related to MT. VWI was associated with soft thrombus consistency, higher number of passes and poorer revascularization outcome. There was no significant correlation between VWI and MT device.
Mechanical thrombectomy (MT) has become standard for large vessel occlusions, but rates of complete recanalization are suboptimal. Previous reports correlated radiographic signs with clot composition ...and a better response to specific techniques. Therefore, understanding clot composition may allow improved outcomes.
Clinical, imaging, and clot data from patients enrolled in the STRIP Registry from September 2016 to September 2020 were analyzed. Samples were fixed in 10% phosphate-buffered formalin and stained with hematoxylin-eosin and Martius Scarlett Blue. Percent composition, richness, and gross appearance were evaluated. Outcome measures included the rate of first-pass effect (FPE, modified Thrombolysis in Cerebral Infarction 2c/3) and the number of passes.
A total of 1430 patients of mean±SD age 68.4±13.5 years (median (IQR) baseline National Institutes of Health Stroke Scale score 17.2 (10.5-23), IV-tPA use 36%, stent-retrievers (SR) 27%, contact aspiration (CA) 27%, combined SR+CA 43%) were included. The median (IQR) number of passes was 1 (1-2). FPE was achieved in 39.3% of the cases. There was no association between percent histological composition or clot richness and FPE in the overall population. However, the combined technique resulted in lower FPE rates for red blood cell (RBC)-rich (P<0.0001), platelet-rich (P=0.003), and mixed (P<0.0001) clots. Fibrin-rich and platelet-rich clots required a higher number of passes than RBC-rich and mixed clots (median 2 and 1.5 vs 1, respectively; P=0.02). CA showed a trend towards a higher number of passes with fibrin-rich clots (2 vs 1; P=0.12). By gross appearance, mixed/heterogeneous clots had lower FPE rates than red and white clots.
Despite the lack of correlation between clot histology and FPE, our study adds to the growing evidence supporting the notion that clot composition influences recanalization treatment strategy outcomes.
Oculomotor nerve palsy (ONP) is a rare neurological deficit associated with numerous underlying pathologies. Of these, aneurysm of the posterior communicating artery (PCOM) has been described due to ...the intimate association with the third cranial nerve in the basal cistern. Less described are other vascular abnormalities and their contribution to ONP. We describe a case of ONP thought to result from a PCOM aneurysm, per the associated magnetic resonance imaging (MRI) scan, yet found intraoperatively to be caused by a congenital vascular aberrancy. This is the first case, to our knowledge, of this presentation.
Vertebroplasty alters spinal biomechanics and may lead to incident vertebral fractures. The endplate localization of prevalent and incident fractures was evaluated in 86 patients. In the absence of ...vertebroplasty, superior endplate fractures predominate. After the procedure, inferior endplate fractures are disproportionately common in adjacent vertebrae immediately above the treated level, potentially supporting a causative relationship between vertebroplasty and incident fractures.
Introduction: To determine retrospectively whether new‐onset fractures after vertebroplasty tend to cluster in the endplate immediately adjacent to the cemented vertebra.
Materials and Methods: Institutional Review Board approval and patient consent for use the use of medical records were obtained for this study. We performed a retrospective review of patients with new (incident) vertebral fractures after vertebroplasty. The median age for these patients was 72.5 years, and 58 (67.4%) were women. Fractures were diagnosed on the basis of MRI or bone scan and were catalogued based on their location within the vertebral body (superior endplate, inferior endplate, or holo‐vertebral). χ2 and generalized estimating equation (GEE) analyses were used to compare the distribution of fracture subtypes among pre‐existing (prevalent) and incident fractures.
Results: The patients had 313 prevalent osteoporotic vertebral fractures and were treated at 137 vertebral levels. Among prevalent fractures, superior endplate fractures predominated (57% superior, 11% inferior; p < 0.0001). After vertebroplasty, 186 incident fractures developed in these 86 patients. Seventy‐seven (41%) of these incident fractures occurred adjacent to treated vertebrae. Nonadjacent, incident fractures, like prevalent fractures, occurred predominantly along superior endplate. Incident fractures immediately above treated levels, however, localized disproportionately to the inferior endplate (30% superior, 57% inferior; p < 0.0001).
Conclusions: There are an increased number of inferior endplate fractures of the vertebral body immediately cephalad to the treated level.
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