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Correlation of imaging and histopathology of thrombi in acute ischemic stroke with etiology and outcome: a systematic review
  1. Waleed Brinjikji1,
  2. Sharon Duffy2,
  3. Anthony Burrows1,
  4. Werner Hacke3,
  5. David Liebeskind4,
  6. Charles B L M Majoie5,
  7. Diederik W J Dippel6,
  8. Adnan H Siddiqui7,
  9. Pooja Khatri8,
  10. Blaise Baxter9,
  11. Raul Nogeuira10,
  12. Matt Gounis11,
  13. Tudor Jovin12,
  14. David F Kallmes1
  1. 1Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Department of Engineering, Galway-Mayo Institute of Technology, Galway, Ireland
  3. 3Department of Neurology, University of Heidelberg, Heidelberg, Germany
  4. 4Department of Neurology, University of California, Los Angeles, California, USA
  5. 5Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
  6. 6Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
  7. 7Department of Neurosurgery, University of Buffalo, Buffalo, New York, USA
  8. 8Department of Neurology, University of Cincinatti, Cincinatti, Ohio, USA
  9. 9Department of Radiology, University of Tennessee Medical Center, Chatanooga, Tennessee, USA
  10. 10Department of Neurology, Emory University, Atlanta, Georgia, USA
  11. 11Department of Radiology, New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts, USA
  12. 12Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  1. Correspondence to Dr Waleed Brinjikji, Department of Radiology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA; Brinjikji.waleed{at}


Background and purpose Studying the imaging and histopathologic characteristics of thrombi in ischemic stroke could provide insights into stroke etiology and ideal treatment strategies. We conducted a systematic review of imaging and histologic characteristics of thrombi in acute ischemic stroke.

Materials and methods We identified all studies published between January 2005 and December 2015 that reported findings related to histologic and/or imaging characteristics of thrombi in acute ischemic stroke secondary to large vessel occlusion. The five outcomes examined in this study were (1) association between histologic composition of thrombi and stroke etiology; (2) association between histologic composition of thrombi and angiographic outcomes; (3) association between thrombi imaging and histologic characteristics; (4) association between thrombi imaging characteristics and angiographic outcomes; and (5) association between imaging characteristics of thrombi and stroke etiology. A meta-analysis was performed using a random effects model.

Results There was no significant difference in the proportion of red blood cell (RBC)-rich thrombi between cardioembolic and large artery atherosclerosis etiologies (OR 1.62, 95% CI 0.1 to 28.0, p=0.63). Patients with a hyperdense artery sign had a higher odds of having RBC-rich thrombi than those without a hyperdense artery sign (OR 9.0, 95% CI 2.6 to 31.2, p<0.01). Patients with a good angiographic outcome had a mean thrombus Hounsfield unit (HU) of 55.1±3.1 compared with a mean HU of 48.4±1.9 for patients with a poor angiographic outcome (mean standard difference 6.5, 95% CI 2.7 to 10.2, p<0.001). There was no association between imaging characteristics and stroke etiology (OR 1.13, 95% CI 0.32 to 4.00, p=0.85).

Conclusions The hyperdense artery sign is associated with RBC-rich thrombi and improved recanalization rates. However, there was no association between the histopathological characteristics of thrombi and stroke etiology and angiographic outcomes.

  • CT
  • Intervention
  • Stroke
  • Thrombolysis
  • Thrombectomy

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