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Original research
Characterization of thrombus composition with multimodality CT-based imaging: an in-vitro study
  1. Yong-Hong Ding1,
  2. Mehdi Abbasi1,
  3. Gregory Michalak1,
  4. Shuai Leng1,
  5. Daying Dai1,
  6. Seán Fitzgerald2,
  7. Ram Kadirvel1,
  8. David F Kallmes1,
  9. Waleed Brinjikji1,3
  1. 1 Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
  2. 2 CÚRAM–Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
  3. 3 Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Waleed Brinjikji, Mayo Clinic Minnesota, Rochester, MN 55901, USA; Brinjikji.Waleed{at}


Background CT is the most commonly used imaging modality for acute ischemic stroke evaluation. There is growing interest to use pre-operative imaging to characterize clot composition in stroke. We performed an in-vitro study examining the ability of various CT techniques in differentiation between different clot types.

Methods Five clot types with varying fibrin and red blood cells (RBCs) densities (5% RBC and 95% fibrin; 25% RBC and 75% fibrin; 50% RBC and 50% fibrin; 75% RBC and 25% fibrin; 95% RBC and 5% fibrin) were prepared and scanned using various CT scanning protocols (single-energy, dual-energy, photon-counting detector CT, mixed images, and virtual monoenergetic images). Martius Scarlett Blue trichrome staining was performed to confirm the composition of each clot. Mean CT values of each type of clot under different scanning protocol were calculated and compared.

Results Mean CT values of the CT numbers in the five clot specimens for 5%, 25%, and 50% RBC clot were similar across modalities, and increased significantly for 75% and 95% RBC clots (P<0.0001). Mean CT values are highest in the Mono +50 keV images in each type of clot, and they were also significantly higher than all other imaging protocols (P<0.001). Dual-energy CT with Mono +50 keV images showed the greatest difference between attenuation in each type of clot.

Conclusion Mono +50 keV dual-energy CT scan may be helpful for differentiating between RBC-rich and fibrin-rich thrombi seen in large-vessel occlusion patients.

  • CT
  • embolic
  • stroke

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Y-HD and MA contributed equally.

  • Contributors Y-HD, MA, GM, SL, and WB designed the model and the computational framework and analyzed the data. Y-HD, MA, and GM performed the experiments. Y-HD, MA, and GM wrote the manuscript with input from the other authors (WB, SF, DD, RK, and DFK). Y-HD and GM performed the calculations. All authors discussed the results and contributed to the final manuscript.

  • Funding This work was supported by NIH grant NS105853 (Brinjikji).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.