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Research ArticleAdult Brain
Open Access

Whole-Brain Susceptibility-Weighted Thrombus Imaging in Stroke: Fragmented Thrombi Predict Worse Outcome

P.P. Gratz, G. Schroth, J. Gralla, H.P. Mattle, U. Fischer, S. Jung, P. Mordasini, K. Hsieh, R.K. Verma, C. Weisstanner and M. El-Koussy
American Journal of Neuroradiology July 2015, 36 (7) 1277-1282; DOI: https://doi.org/10.3174/ajnr.A4275
P.P. Gratz
aFrom the Departments of Diagnostic and Interventional Neuroradiology (P.P.G., G.S., J.G., S.J., P.M., K.H., R.K.V., C.W., M.E.-K.)
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G. Schroth
aFrom the Departments of Diagnostic and Interventional Neuroradiology (P.P.G., G.S., J.G., S.J., P.M., K.H., R.K.V., C.W., M.E.-K.)
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J. Gralla
aFrom the Departments of Diagnostic and Interventional Neuroradiology (P.P.G., G.S., J.G., S.J., P.M., K.H., R.K.V., C.W., M.E.-K.)
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H.P. Mattle
bNeurology (H.P.M., U.F., S.J.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
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U. Fischer
bNeurology (H.P.M., U.F., S.J.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
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S. Jung
aFrom the Departments of Diagnostic and Interventional Neuroradiology (P.P.G., G.S., J.G., S.J., P.M., K.H., R.K.V., C.W., M.E.-K.)
bNeurology (H.P.M., U.F., S.J.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
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P. Mordasini
aFrom the Departments of Diagnostic and Interventional Neuroradiology (P.P.G., G.S., J.G., S.J., P.M., K.H., R.K.V., C.W., M.E.-K.)
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K. Hsieh
aFrom the Departments of Diagnostic and Interventional Neuroradiology (P.P.G., G.S., J.G., S.J., P.M., K.H., R.K.V., C.W., M.E.-K.)
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R.K. Verma
aFrom the Departments of Diagnostic and Interventional Neuroradiology (P.P.G., G.S., J.G., S.J., P.M., K.H., R.K.V., C.W., M.E.-K.)
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C. Weisstanner
aFrom the Departments of Diagnostic and Interventional Neuroradiology (P.P.G., G.S., J.G., S.J., P.M., K.H., R.K.V., C.W., M.E.-K.)
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M. El-Koussy
aFrom the Departments of Diagnostic and Interventional Neuroradiology (P.P.G., G.S., J.G., S.J., P.M., K.H., R.K.V., C.W., M.E.-K.)
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    Fig 1.

    An 85-year-old man with right-sided hemiparesis and aphasia (NIHSS 13). Pretreatment SWI shows susceptibility vessel signs in the left M1 and M2 segments (A, white arrows). On TOF-MRA (MIP), diminished flow signal is seen distal to the thrombus fragment in the M1 segment with complete loss of flow signal at the site of the distal thrombus fragment (B, white arrowheads). DSA demonstrates incomplete occlusion of the vessel lumen by a thrombus in the M1 segment (C, anteroposterior projection, black arrowhead). On the lateral projection, occlusion of the temporo-occipital M2 branch by a more distal thrombus fragment is visible (D, black arrow). Although both TOF-MRA and DSA can show the distal vessel occlusion, only SWI allows estimation of the length of the distal fragment and exclusion of additional distal thrombi.

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    Fig 2.

    A 69-year-old male patient with a sudden decrease in consciousness. SWI shows susceptibility artifacts from thrombotic material in the basilar artery (A, white arrow) and the right posterior cerebral artery (B, white arrowhead). Hemorrhagic transformation of a subacute infarction in the vascular territory of the right posterior cerebral artery is seen. DSA confirms occlusion of the basilar artery (C, anteroposterior projection, black arrowhead). Following successful endovascular recanalization of the basilar artery, the occlusion in the perimesencephalic segment of the right posterior cerebral artery, already known from pretreatment SWI, becomes visible in DSA as well (D, anteroposterior projection, black arrow).

Tables

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    Table 1:

    Baseline clinical characteristics

    Fragmented Thrombus (n = 24) (7.4%)Single Thrombus (n = 300) (92.6%)P
    Age (yr) (mean) (SD)73.1 (11.3)68.6 (14.0).109
    Women (No.) (%)9 (37.5)139 (46.3).403
    Baseline NIHSS score (median) (range)15 (6–36)11 (1–36).014
    Vascular risk factors
        Hypertension (No.) (%)15 (62.5)192 (64.0).883
        Diabetes mellitus (No.) (%)5 (20.8)45/298 (15.1).395
        Atrial fibrillation (No.) (%)13/23 (56.5)123/263 (46.8).392
        Current smoking (No.) (%)2/22 (9.1)57/286 (19.9).271
        Hypercholesterolemia (No.) (%)14/23 (60.9)161/296 (54.4).548
        Coronary artery disease (No.) (%)5 (20.8)58/298 (19.5).794
        Previous stroke (No.) (%)2 (8.3)31/298 (10.4)1.00
    Stroke etiology.558
        Large artery disease (No.) (%)3 (12.5)31 (10.3)
        Cardioembolic stroke (No.) (%)14 (58.3)135 (45.0)
        Other determined etiology (No.) (%)2 (8.3)38 (12.7)
        Unknown etiology (No.) (%)5 (20.8)96 (32.0)
    • View popup
    Table 2:

    Imaging characteristics and treatment

    Fragmented Thrombus (n = 24) (7.4%)Single Thrombus (n = 300) (92.6%)P
    Affected vascular territory.739
        Anterior circulation (No.) (%)21 (87.5)267 (89.0)
        Posterior circulation (No.) (%)3 (12.5)33 (11.0)
    Occlusion site.372
        Tandem occlusion (No.) (%)3 (12.5)29 (9.7)
        Carotid-T (No.) (%)3 (12.5)14 (4.7)
        MCA M1 (No.) (%)8 (33.3)123 (41.0)
        MCA M2 (No.) (%)6 (25.0)74 (24.7)
        MCA M3/4 (No.) (%)1 (4.2)23 (7.7)
        Anterior cerebral artery (No.) (%)0 (0.0)4 (1.3)
        Basilar artery (No.) (%)3 (12.5)16 (5.3)
        Posterior cerebral artery (No.) (%)0 (0.0)17 (5.7)
    Primary thrombus length on SWI (mm) (mean) (SD)10.3 (6.4) (n = 18)10.3 (5.6) (n = 248).699
    Total clot length (mm) (mean) (SD)20.1 (10.7) (n = 18)10.3 (5.6) (n = 248)<.001
    DWI ASPECTS (media) (range)5 (0–8) (n = 21)7 (0–10) (n = 263).006
    Leptomeningeal collateralsn = 19n = 199.051
        Good (No.) (%)4 (21.1)88 (44.2)
        Moderate/poor (No.) (%)15 (78.9)111 (55.8)
    Treatment.625
        Intravenous thrombolysis only (No.) (%)6 (25.0)102 (34.0)
        Bridging thrombolysis (No.) (%)7 (29.2)69 (23.0)
        Endovascular intervention only (No.) (%)11 (45.8)129 (43.0)
    • View popup
    Table 3:

    Intracranial bleeding complications and clinical outcome

    Fragmented Thrombus (n = 24) (7.4%)Single Thrombus (n = 300) (92.6%)P
    Symptomatic intracranial hemorrhage (No.) (%)3 (12.5)17 (5.7).176
    Asymptomatic intracranial hemorrhage (No.) (%)6 (25.0)34 (11.3).097
    Favorable outcome (mRS 0–2) at 3 months (No.) (%)6/23 (26.1)171/286 (59.8).002
    Death at 3 months (No.) (%)7/23 (30.4)43/292 (14.7).069
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American Journal of Neuroradiology: 36 (7)
American Journal of Neuroradiology
Vol. 36, Issue 7
1 Jul 2015
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Cite this article
P.P. Gratz, G. Schroth, J. Gralla, H.P. Mattle, U. Fischer, S. Jung, P. Mordasini, K. Hsieh, R.K. Verma, C. Weisstanner, M. El-Koussy
Whole-Brain Susceptibility-Weighted Thrombus Imaging in Stroke: Fragmented Thrombi Predict Worse Outcome
American Journal of Neuroradiology Jul 2015, 36 (7) 1277-1282; DOI: 10.3174/ajnr.A4275

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Whole-Brain Susceptibility-Weighted Thrombus Imaging in Stroke: Fragmented Thrombi Predict Worse Outcome
P.P. Gratz, G. Schroth, J. Gralla, H.P. Mattle, U. Fischer, S. Jung, P. Mordasini, K. Hsieh, R.K. Verma, C. Weisstanner, M. El-Koussy
American Journal of Neuroradiology Jul 2015, 36 (7) 1277-1282; DOI: 10.3174/ajnr.A4275
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