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Original research
Hyperdense vessel sign as a potential guide for the choice of stent retriever versus contact aspiration as first-line thrombectomy strategy
  1. Mahmoud H Mohammaden1,2,
  2. Diogo C Haussen1,2,
  3. Catarina Perry da Camara1,2,
  4. Leonardo Pisani1,2,
  5. Marta Olive Gadea1,2,
  6. Alhamza R Al-Bayati1,2,
  7. Bernardo Liberato1,2,
  8. Srikant Rangaraju1,2,
  9. Michael R Frankel1,2,
  10. Raul G Nogueira1,2
  1. 1Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
  2. 2Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
  1. Correspondence to Dr Raul G Nogueira, Marcus Stroke & Neuroscience Center, Grady Memorial Hospita, Emory University School of Medicine, Atlanta, GA 30303, USA; raul.g.nogueira{at}


Background The first-pass effect (FPE) has emerged as a key metric for efficacy in mechanical thrombectomy (MT). The hyperdense vessel sign (HDVS) on non-contrast head CT (NCCT) indicates a higher clot content of red blood cells.

Objective To assess whether the HDVS could serve as an imaging biomarker for guiding first-line device selection in MT.

Methods A prospective MT database was reviewed for consecutive patients with anterior circulation large vessel occlusion stroke who underwent thrombectomy with stent retriever (SR) or contact aspiration (CA) as first-line therapy between January 2012 and November 2018. Pretreatment NCCT scans were evaluated for the presence of HDVS. The primary outcome was FPE (modified Thrombolysis in Cerebral Infarction score 2c/3). The primary analysis was the interaction between HDVS and thrombectomy modality on FPE. Secondary analyses aimed to evaluate the predictors of FPE.

Results A total of 779 patients qualified for the analysis. HDVS and FPE were reported in 473 (60.7%) and 286 (36.7%) patients, respectively. The presence of HDVS significantly modified the effect of thrombectomy modality on FPE (p=0.01), with patients with HDVS having a significantly higher rate of FPE with a SR (41.3% vs 22.2%, p=0.001; adjusted OR 2.11 (95% CI 1.20 to 3.70), p=0.009) and non-HDVS patients having a numerically better response to CA (41.4% vs 33.9%, p=0.28; adjusted OR 0.58 (95% CI 0.311 to 1.084), p=0.088). Age (OR 1.01 (95% CI 1.00 to 1.02), p=0.04) and balloon guide catheter (OR 2.08 (95% CI 1.24 to 3.47), p=0.005) were independent predictors of FPE in the overall population.

Conclusion Our data suggest that patients with HDVS may have a better response to SRs than CA for the FPE. Larger confirmatory prospective studies are warranted.

  • stroke
  • thrombectomy
  • technique
  • CT
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  • Contributors MHM: acquisition of data, design of the work, interpretation of data, drafting of the manuscript. DCH: interpretation of data, critical revision of the manuscript, CPdC, LP, MOG, ARA-B, BL, SR, MRF: critical revision of the manuscript. RGN: study conception, design of the work, interpretation of data, drafting of the manuscript. All authors gave final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests RGN reports potential conflicts with Stryker Neurovascular (DAWN Trial principal investigator–no compensation, Trevo Retriever Registry Steering Committee–no compensation, Trevo-2 Trial principal investigator–modest; Consultant–modest), Medtronic (SWIFT [SOLITAIRE FR With the Intention for Thrombectomy] Trial Steering Committee–modest; SWIFT-Prime Trial Steering Committee–no compensation; STAR [Solitaire Flow Restoration Thrombectomy for Acute Revascularization] Trial Angiographic Core Lab–significant), Penumbra (3D Separator Trial Executive Committee–no compensation), Cerenovus/ Neuravi (ENDOLOW Trial principal investigator, EXCELLENT Registry principal investigator, Analysis of Revascularization in Ischemic Stroke with EmboTrap (ARISE-2)-2 trial Steering Committee–no compensation, Physician Advisory Board, modest), Phenox (Physician Advisory Board, modest), Anaconda (Physician Advisory Board, modest), Genentech (Physician Advisory Board–modest), Biogen (Physician Advisory Board–modest), Prolong Pharmaceuticals (Physician Advisory Board–modest), Allm Inc. (Physician Advisory Board– no compensation), IschemaView (speaker, modest), Brainomix (Research Software Use–no compensation), Sensome (Research Device Use–no compensation), Viz.AI (Physician Advisory Board–stock options), Philips (research software use–no compensation, speaker–modest), Corindus Vascular Robotics (Physician Advisory Board–stock options), Vesalio (Physician Advisory Board–stock options), Ceretrieve (Physician Advisory Board–stock options) and Astrocyte (Physician Advisory Board–stock options). DCH is a consultant for Stryker and Vesalio and holds stock options at Viz.AI.

  • Patient consent for publication Not required.

  • Ethics approval IRB obtained through Emory University, IRB00090915.

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

  • Data availability statement The unpublished data from this dataset are held by Grady Memorial Hospital/Emory University and the corresponding author. Requests for data sharing would be required to be discussed with them directly.

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