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Original research
High-resolution scanning electron microscopy for the analysis of three-dimensional ultrastructure of clots in acute ischemic stroke
  1. Oana Madalina Mereuta1,2,
  2. Seán Fitzgerald1,2,
  3. Trace A Christensen3,
  4. Adam L Jaspersen3,
  5. Daying Dai1,
  6. Mehdi Abbasi1,
  7. Tejaswini Puttappa1,
  8. Ram Kadirvel1,
  9. David F Kallmes1,4,
  10. Karen M Doyle2,
  11. Waleed Brinjikji1,4
  1. 1Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Department of Physiology, CÚRAM–SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland
  3. 3Microscopy and Cell Analysis Core, Mayo Clinic, Rochester, Minnesota, USA
  4. 4Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Oana Madalina Mereuta, Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; mereuta.oana{at}


Background Characterization of acute ischemic stroke (AIS) clots has typically focused on two-dimensional histological analysis of the thrombus. The three-dimensional (3D) architecture and distribution of components within emboli have not been fully investigated. The aim of this study was to examine the composition and microstructure of AIS clots using histology and serial block-face scanning electron microscopy (SBFSEM).

Methods As part of the multi-institutional STRIP registry, 10 consecutive AIS emboli were collected from 10 patients treated by mechanical thrombectomy. Histological and immunohistochemical analysis was performed to determine clot composition. SBFSEM was used to assess the ultrastructural organization of the clots and specific features of individual components.

Results Quantification of Martius Scarlett Blue stain identified fibrin (44.4%) and red blood cells (RBCs, 32.6%) as the main components. Immunohistochemistry showed a mean platelet and von Willebrand factor content of 23.9% and 11.8%, respectively. The 3D organization of emboli varied greatly depending on the region analyzed. RBC-rich areas were composed mainly of tightly packed RBCs deformed into polyhedrocytes with scant fibrin fibers interwoven between cells. The regions with mixed composition showed thick fibrin fibers along with platelets, white blood cells and RBC clusters. Fibrin-rich areas contained dense fibrin masses with sparse RBC. In three cases, the fibrin formed a grid-like or a sponge-like pattern, likely due to thrombolytic treatment. Segmentation showed that fibrin fibers were thinner and less densely packed in these cases.

Conclusions 3D-SEM provides novel and potentially clinically relevant information on clot components and ultrastructure which may help to inform thrombolytic treatment and medical device design.

  • stroke
  • thrombectomy
  • thrombolysis
  • embolic
  • technology

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  • Contributors OMM and WB were involved in all stages of the manuscript from concept design to drafting the manuscript. TAC and ALJ were responsible for the serial block-face scanning electron microscopy of clots. SF, DD, MA and TP were responsible for collecting and recording the clinical and procedural information from patients and were involved in the histological analysis of clots. All authors reviewed, edited, and approved the final manuscript prior to submission.

  • Funding This work was supported by the National Institutes of Health (R01 NS105853), the European Regional Development Fund and Science Foundation Ireland (grant number 13/RC/2073).

  • Competing interests RK reports NIH funding (R01 NS076491, R43 NS110114 and R44 NS107111), is a research consultant for Cerenovus, Insera Therapeutics LLC, Marblehead Medical LLC, MicroVention Inc, MIVI Neuroscience Inc, Neurogami Medical Inc and Triticum Inc, and has stock in Neurosigma Inc (money paid to institution). DFK is President of Marblehead Medical and has a patent pending in balloon catheter technologies, and receives research support from Cerenovus, Insera Therapeutics LLC, Medtronic, MicroVention Inc, MIVI Neuroscience Inc, NeuroSave, Neurogami Medical Inc, Sequent Medical and Insera, and has stock in Neurosigma Inc (money paid to institution). He is on the Scientific Advisory Board of Triticum Inc and previously served on a SAB for Boston Scientific. WB is CMO of Marblehead Medical and has a patent pending in balloon catheter technologies, and he is a consultant for Cerenovus and MicroVention Inc. He reports NIH funding (R01 NS105853).

  • Patient consent for publication Not required.

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

  • Data availability statement Data are available from the corresponding author upon reasonable request.

  • 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.

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