Stroke Etiology and Thrombus Computed Tomography Characteristics in Patients With Acute Ischemic Stroke

Abstract

Background and Purpose— If a relationship between stroke etiology and thrombus computed tomography characteristics exists, assessing these characteristics in clinical practice could serve as a useful additional diagnostic tool for the identification of stroke subtype. Our purpose was to study the association of stroke etiology and thrombus computed tomography characteristics in patients with acute ischemic stroke due to a large vessel occlusion. Methods— For 1429 consecutive patients enrolled in the MR CLEAN Registry, we determined stroke cause as defined by the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria. The association of stroke etiology with the hyperdense artery sign, clot burden score, and thrombus location was estimated with univariable and multivariable binary and ordinal logistic regression. Additionally, for 367 patients with available thin-section imaging, we assessed the association of stroke etiology with absolute and relative thrombus attenuation, distance from internal carotid artery-terminus to thrombus, thrombus length, and thrombus attenuation increase with univariable and multivariable linear regression. Results— Compared with cardioembolic strokes, noncardioembolic strokes were associated with presence of hyperdense artery sign (odds ratio, 2.2 [95% CI, 1.6–3.0]), lower clot burden score (common odds ratio, 0.4 [95% CI, 0.3–0.6]), shift towards a more proximal thrombus location (common odds ratio, 0.2 [95% CI, 0.2–0.3]), higher absolute thrombus attenuation (β, 3.6 [95% CI, 0.9–6.4]), decrease in distance from the ICA-terminus (β, −5.7 [95% CI, −8.3 to −3.0]), and longer thrombi (β, 8.6 [95% CI, 6.5−10.7]), based on univariable analysis. Thrombus characteristics of strokes with undetermined cause were similar to those of cardioembolic strokes. Conclusions— Thrombus computed tomography characteristics of cardioembolic stroke are distinct from those of noncardioembolic stroke. Additionally, our study supports the general hypothesis that many cryptogenic strokes have a cardioembolic cause. Further research should focus on the use of thrombus computed tomography characteristics as a diagnostic tool for stroke cause in clinical practice.

Large vessel cardioembolic stroke and embolic stroke of undetermined source share a common profile of matrix metalloproteinase‐9 level and susceptibility vessel sign length

“…This result is in line with a recent computed tomography (CT) study conducted in ischemic stroke patients before MT that reported lower thrombus length in CE subtypes compared to non‐CE subtypes. [21] The higher rate of spontaneous thrombus lysis previously observed in CE compared to LAA subtypes may account for our finding. [22] However, it is unclear whether the thrombus length comes from a single proximal source (CE, LAA) or reflects an additional thrombus extension due to low flow effects on coagulation and thrombosis.…”

“…These results are in line with previous studies showing similar histological and CT thrombus features in strokes of undetermined etiology (UDE) and CE subtypes. [21,30] Thus, it may be worthwhile in further studies to investigate how the use of SVS length and MMP‐9 level may help to manage etiological workup, especially optimal duration of cardiac monitoring in patients with large vessel ESUS, although atrial fibrillation is not the only potential CE source in these patients. [31] Given the burden of stroke, this issue involved not only stroke specialists but all neurologists.…”

Proteomic Analysis of Cardioembolic and Large Artery Atherosclerotic Clots Using Reverse Phase Protein Array Technology Reveals Key Cellular Interactions Within Clot Microenvironments

“…A recent subgroup analysis from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry has confirmed that thrombus computed tomography characteristics of cardioembolic (CE) stroke are distinct from those of non-CE stroke. Non-CE strokes were associated with the presence of hyperdense artery sign, a higher clot burden, a shift towards a more proximal thrombus location, and longer thrombi compared with a CE cause [1]. The differences in imaging characteristics between stroke etiologies are likely a result of differences in the composition of the occlusive thrombus resulting from dissimilarities in the clotting mechanisms.…”

Relevance of Porcine Stroke Models to Bridge the Gap from Pre-Clinical Findings to Clinical Implementation

“…According to the American Heart Association, 87% of all strokes are ischemic [ 82 ], caused mainly by the obstruction of major cerebral arteries, especially the middle cerebral artery (MCA) or its branches [ 83 ]. Typically, the study of ischemic stroke in rodent models has focused in the MCA territory [ 84 ].…”