J Stroke.  2023 May;25(2):233-241. 10.5853/jos.2022.03489.

Thrombus Enhancement Sign for Differentiation of Embolism and Arteriosclerosis-Related Acute Large Vessel Occlusion

• Zhang Y
• He G
• Lu J
• Miao G
• Liang D
• Wang J
• Wei L
• Deng J
• Zhu Y

• KMID: 2542474
• DOI: http://doi.org/10.5853/jos.2022.03489

Abstract

Background and Purpose
To evaluate whether the thrombus enhancement sign (TES) can be used to differentiate embolic large vessel occlusion (LVO) from in situ intracranial atherosclerotic stenosis (ICAS)-related LVO in the anterior circulation of patients with acute ischemic stroke (AIS).
Methods
Patients with LVO in the anterior circulation who underwent both non-contrast computed tomography (CT) and CT angiography and mechanical thrombectomy were retrospectively enrolled. Both embolic LVO (embo-LVO) and in situ ICAS-related LVO (ICAS-LVO) were confirmed by two neurointerventional radiologists after reviewing the medical and imaging data. TES was assessed to predict embo-LVO or ICAS-LVO. The associations between occlusion type and TES, along with clinical and interventional parameters, were investigated using logistic regression analysis and a receiver operating characteristic curve.
Results
A total of 288 patients with AIS were included and divided into an embo-LVO group (n=235) and an ICAS-LVO group (n=53). TES was identified in 205 (71.2%) patients and was more frequently observed in those with embo-LVO, with a sensitivity of 83.8%, specificity of 84.9%, and area under the curve (AUC) of 0.844. Multivariate analysis showed that TES (odds ratio [OR], 22.2; 95% confidence interval [CI], 9.4–53.8; P<0.001) and atrial fibrillation (OR, 6.6; 95% CI, 2.8–15.8; P<0.001) were independent predictors of embolic occlusion. A predictive model that included both TES and atrial fibrillation yielded a higher diagnostic ability for embo-LVO, with an AUC of 0.899.
Conclusion
TES is an imaging marker with high predictive value for identifying embo- and ICAS-LVO in AIS and provides guidance for endovascular reperfusion therapy.

Keyword

Acute ischemic stroke; Thrombus enhancement sign; Computed tomography angiography; Embolism; Intracranial atherosclerotic stenosis

Figure

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  Figure 1. Flow diagram of the current study. CTA, computed tomography angiography; embo-LVO, embolism-related large vessel occlusion; ICAS-LVO, intracranial atherosclerotic stenosis-related large vessel occlusion; TES, thrombus enhancement sign.

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  Figure 2. Embolism-related LVO with a positive TES. (A) NCCT reveals HAS in the M1 segment of the right MCA (white arrow). (B) Original axial slice of CTA indicates a thrombus filling defect at the M1 segment of the right MCA (red arrow). (C and D) Volume rendering and full-slab MIP image reconstruction of CTA showing the occluded site (yellow arrow). (E) Anteroposterior angiogram shows the occlusion site at the M1 segment of the right MCA (yellow arrow). (F) Thin slab MIP image reconstruction of CTA shows the TES (red arrows) at right MCA. (G) Complete recanalization of the right MCA without residual stenosis after a single attempt of stent retrieval. (H) Schematic diagram of the pathogenesis of embolism-related LVO. LVO, large vessel occlusion; TES, thrombus enhancement sign; NCCT, non-contrast computed tomography; HAS, hyperdense artery sign; MCA, middle cerebral artery; CTA, computed tomography angiography; MIP, maximum intensity projection.

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  Figure 3. ICAS-related LVO with a negative TES. (A) NCCT does not reveal HAS in the M1 segment of the left MCA (white arrow). (B) Original axial slice of CTA indicates thrombus filling defect at the M1 segment of the left MCA (red arrow). (C and D) Volume rendering and full-slab MIP image reconstruction of CTA showing the occluded site (yellow arrow). (E) Anteroposterior angiogram shows occlusion site at the M1 segment of the left MCA (yellow arrow). (F) Thin slab MIP image reconstruction of CTA shows a negative TES (red arrow) at the left MCA. (G) After attempting stent retrieval, rescued angioplasty and stenting was applied. Residual stenosis remains, but distal flow significantly improves. (H) Schematic diagram of the pathogenesis of ICAS-related LVO. ICAS, intracranial atherosclerotic stenosis; LVO, large vessel occlusion; TES, thrombus enhancement sign; NCCT, non-contrast computed tomography; HAS, hyperdense artery sign; MCA, middle cerebral artery; CTA, computed tomography angiography; MIP, maximum intensity projection.

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