Prognostic Value of Thrombus Volume and Interaction With First-Line Endovascular Treatment Device Choice

Abstract

Background: A larger thrombus in patients with acute ischemic stroke might result in more complex endovascular treatment procedures, resulting in poorer patient outcomes. Current evidence on thrombus volume and length related to procedural and functional outcomes remains contradicting. This study aimed to assess the prognostic value of thrombus volume and thrombus length and whether this relationship differs between first-line stent retrievers and aspiration devices for endovascular treatment. Methods: In this multicenter retrospective cohort study, 670 of 3279 patients from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) for endovascularly treated large vessel occlusions were included. Thrombus volume (0.1 mL) and length (0.1 mm) based on manual segmentations and measurements were related to reperfusion grade (expanded Treatment in Cerebral Infarction score) after endovascular treatment, the number of retrieval attempts, symptomatic intracranial hemorrhage, and a shift for functional outcome at 90 days measured with the reverted ordinal modified Rankin Scale (odds ratio >1 implies a favorable outcome). Univariable and multivariable linear and logistic regression were used to report common odds ratios (cORs)/adjusted cOR and regression coefficients (B/aB) with 95% CIs. Furthermore, a multiplicative interaction term was used to analyze the relationship between first-line device choice, stent retrievers versus aspiration device, thrombus volume, and outcomes. Results: Thrombus volume was associated with functional outcome (adjusted cOR, 0.83 [95% CI, 0.71–0.97]) and number of retrieval attempts (aB, 0.16 [95% CI, 0.16–0.28]) but not with the other outcome measures. Thrombus length was only associated with functional independence (adjusted cOR, 0.45 [95% CI, 0.24–0.85]). Patients with more voluminous thrombi had worse functional outcomes if endovascular treatment was based on first-line stent retrievers (interaction cOR, 0.67 [95% CI, 0.50–0.89]; P =0.005; adjusted cOR, 0.74 [95% CI, 0.55–1.0]; P =0.04). Conclusions: In this study, patients with a more voluminous thrombus required more endovascular thrombus retrieval attempts and had a worse functional outcome. Patients with a lengthier thrombus were less likely to achieve functional independence at 90 days. For more voluminous thrombi, first-line stent retrieval compared with first-line aspiration might be associated with worse functional outcome.

Value of Automatically Derived Full Thrombus Characteristics: An Explorative Study of Their Associations with Outcomes in Ischemic Stroke Patients

“…We found a significant association between the thrombus volume and functional outcome in the Registry population. This association was also reported by Baek et al (2017) [ 22 ] and van Voorst et al (2023) [ 9 ], but it was not found by Borst et al (2017) [ 23 ]. Unlike Baek et al (2017) [ 22 ], we did not find a significant association between the thrombus volume and successful reperfusion.…”

“…Imaging characteristics, on the other hand, are more rapidly and consistently available and contain pertinent information about the patient’s present condition. In LVO stroke patients, certain radiological imaging characteristics of the thrombus on CT scans, such as length, volume, perviousness, and density, have been shown to be related to various outcome measures of stroke treatment [ 5 , 6 , 7 , 8 , 9 , 10 ]. However, thrombus location is the only thrombus imaging characteristic that is currently taken into account during the triage of ischemic stroke patients [ 11 ].…”

Priorities for Advancements in Neuroimaging in the Diagnostic Workup of Acute Stroke

“…16 A recent analysis of the MR CLEAN registry performed manual segmentations and measurements of thrombi using a 3-dimensional imaging software. 17 Larger volume thrombi were associated with a lower probability of functional independence defined as a modified Rankin Scale score ≤2 (odds ratio [OR], 0.78 [95% CI, 0.64-0.96]) and a higher number of retrieval attempts (OR, 0.16 [95% CI, 0.04-0.28]). 18 A recent study by Santo et al 19…”

Water content for clot composition prediction in acute ischemic stroke

“…An in-vitro study showed that the combined technique achieved the highest success rates in removing stiff, calcified clots [17]. Consequently, determining clot pathology prior to MT could be useful for selecting the most effective initial treatment strategy [18][19][20][21].…”