Quantitative Assessment of Hyperdense Sign Measured by Hounsfield Units is Associated with Unsuccessful Mechanical Throm
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ORIGINAL ARTICLE
Quantitative Assessment of Hyperdense Sign Measured by Hounsfield Units is Associated with Unsuccessful Mechanical Thrombectomy Fazeel M. Siddiqui1 · Cynthia B. Zevallos2 · Sudeepta Dandapat2 · Kiddy L. Ume3 · Matthew Weber3 · Andres Dajles2 · Darko Quispe-Orozco2 · Mudassir Farooqui2 · Santiago Ortega-Gutierrez2,4,5 Received: 28 September 2020 / Accepted: 2 December 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract Purpose Despite advancement in mechanical thrombectomy (MT) techniques, 10–30% of MT for large vessel occlusions (LVO) are unsuccessful. Current prediction models fail to address the association between patient-specific factors and reperfusion. We aimed to evaluate objective, easily reproducible, admission clinical and radiological biomarkers that predict unsuccessful MT. Methods We analyzed consecutive anterior LVO MT patients at two comprehensive stroke centers. The primary outcome was unsuccessful reperfusion defined by a modified thrombolysis in cerebral infarction (mTICI) score of 0–2a. We quantitatively assessed the hyperdense vessel sign by measuring Hounsfield units (HU) on admission computed tomography (CT). Receiver operating characteristic (ROC) curves were plotted to estimate the predictive value of quantitative hyperdense middle cerebral artery (MCA) measurements (delta and ratio) and of the final model for mTICI scores. We performed multivariable logistic regression to analyze associations with outcomes. Results Out of 348 patients 87 had unsuccessful MT. Smoking, difficult arch, vessel tortuosity, vessel calcification, diminutive vessels, truncal M1 occlusion, delta HU and HU ratio were significantly associated with unsuccessful MT in the univariate analysis. When we fitted two separate multivariate models including all significant variables and a HU measurement; delta HU 100, which were considered artifacts due to calcifications [13]. We utilized CTA to identify other neuroimaging biomarkers of interest including vessel calcifications in the posterior or anterior circulation, calcification and location match when the calcifications concurred at the occlusion site, diminutive vessels (observed asymmetry in the caliber of the vessel after occlusion site in comparison with the contralateral side), and the clot burden and CTA collateral scores previously described by Tan et al. [14] From DSAs we collected clot locations, presence of vessel tortuosity [15] and difficult arch (type 3) [16], type of occlusion (truncal or branch) [17], and the angiographic collateral score of Christoforidis et al. [18] Imaging data definitions are detailed in the methodology section of the supplementary material.
Biomarkers of Unsuccessful Thrombectomy
Fig. 1 Study flow chart showing included and excluded patients. LVO large vessel occlusions, MT mechanical thrombectomy, VB vertebrobasilar, ACA anterior cerebral artery, tPA tissue plasminogen activator, ICA internal carotid artery, CT computed tomography, CTA computed tomography angiography, and DSA digital subtract
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