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The Value of Dual-Energy Computed Tomography Angiography-Derived Parameters in the Evaluation of Clot Composition

  • Author Footnotes
    # Jingxuan Jiang, Hongmei Gu and Minda Li contribute equally to this work.
    Jingxuan Jiang
    Footnotes
    # Jingxuan Jiang, Hongmei Gu and Minda Li contribute equally to this work.
    Affiliations
    Department of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China

    Department of Radiology, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
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  • Author Footnotes
    # Jingxuan Jiang, Hongmei Gu and Minda Li contribute equally to this work.
    Hongmei Gu
    Footnotes
    # Jingxuan Jiang, Hongmei Gu and Minda Li contribute equally to this work.
    Affiliations
    Department of Radiology, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
    Search for articles by this author
  • Author Footnotes
    # Jingxuan Jiang, Hongmei Gu and Minda Li contribute equally to this work.
    Minda Li
    Footnotes
    # Jingxuan Jiang, Hongmei Gu and Minda Li contribute equally to this work.
    Affiliations
    Department of Radiology, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
    Search for articles by this author
  • Ye Hua
    Affiliations
    Department of Radiology, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
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  • Sijia Wang
    Affiliations
    Department of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
    Search for articles by this author
  • Lisong Dai
    Affiliations
    Department of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
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  • Yuehua Li
    Correspondence
    Address correspondence to: Y.L.
    Affiliations
    Department of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
    Search for articles by this author
  • Author Footnotes
    # Jingxuan Jiang, Hongmei Gu and Minda Li contribute equally to this work.
Published:December 30, 2022DOI:https://doi.org/10.1016/j.acra.2022.12.023

      Highlights

      • DE-CTA-derived parameters could be associated with thrombus composition and allow for personalized thrombectomy strategies.
      • The RBC-dominant thrombi showed significantly higher VNC values and lower IC, λHU, and Zeff values than the F/P-dominant thrombi (p < 0.05).
      • The thrombus composition was associated with DE-CTA-derived parameters.

      Objectives

      We aimed to assess the value of dual-energy computed tomography angiography (DE-CTA) derived parameters as a quantitative biomarker of thrombus composition in acute ischemic stroke (AIS).

      Methods

      AIS patients who underwent DE-CTA before thrombectomy between August 2016 and September 2022 were included in this study. We assessed the relative proportion of red blood cells (RBCs) and the fibrin/platelet ratio (F/P) of the retrieved clots and categorized the clots as RBC-dominant (RBCs > F/P) or F/P-dominant (F/P > RBCs). The thrombus based parameters were measured on polyenergetic images (PEI), virtual monoenergetic (VM), virtual non-contrast (VNC), iodine concentration (IC), and effective atomic number (Zeff) images respectively, and the slope of the spectral Hounsfield unit curve (λHU) was calculated. These parameters were compared in the DE-CTA images of RBC- and F/P-dominant thrombi. The diagnostic performance of the parameters was analyzed using the ROC curve. Correlations between thrombus composition and DE-CTA-derived parameters were assessed.

      Results

      The retrieved clots in 54 of 88 patients (61.36%) were RBC-dominant. The RBC-dominant thrombi showed significantly higher VNC values and lower IC, λHU, and Zeff values than the F/P-dominant thrombi (p < 0.05). The CT density measured on IC images showed the largest AUC value (AUC, 0.94; sensitivity, 77.78%; specificity, 100.00%). The Spearman rank-order correlation coefficient values showed that CT density measured on IC images of the thrombus showed the strongest association with the proportion of RBCs (r = -0.64, p < 0.001) and F/P (r = 0.65, p < 0.001).

      Conclusions

      DE-CTA-derived parameters, especially the CT density measured on IC images, could be associated with thrombus composition and allow for personalized thrombectomy strategies.

      Key Words

      Abbreviations:

      λHU (Slope of the spectral Hounsfield unit curve), AIS (Acute ischemic stroke), DE-CTA (Dual-energy computed tomography angiography), F/P (Fibrin/platelet), H&E (Hematoxylin & eosin), IC (Iodine concentration), ICA (Internal carotid artery), ICC (Intraclass correlation coefficient), LVO (Large vessel occlusion), MCA (Middle cerebral artery), PEI (Polyenergetic images), RBC (Red blood cell), VNC (Virtual non-contrast), VM (Virtual monoenergetic), Zeff (Effective atomic number), NCCT (Non-contrast computed tomography), DECT (Dual-energy computed tomography)
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      References

      1. Feigin VL, Nichols E, Alam T, et al., regional, and national burden of neurological disorders, 1990-2016: a systematic analysis for the global burden of disease study 2016. Lancet Neurol 2019; 18:459–480.

        • Prabhakaran S
        • Ruff I
        • Bernstein RA
        Acute stroke intervention: a systematic review.
        JAMA. 2015; 313: 1451-1462
        • Kaesmacher J
        • Boeckh-Behrens T
        • Simon S
        • et al.
        Risk of thrombus fragmentation during endovascular stroke treatment.
        AJNR Am J Neuroradiol. 2017; 38: 991-998
        • He G
        • Deng J
        • Lu H
        • et al.
        Thrombus enhancement sign on CT angiography is associated with the first pass effect of stent retrievers.
        J Neurointerv Surg. 2022; https://doi.org/10.1136/neurintsurg-2021-018447
        • Fereidoonnezhad B
        • Dwivedi A
        • Johnson S
        • et al.
        Blood clot fracture properties are dependent on red blood cell and fibrin content.
        Acta Biomater. 2021; 127: 213-228
        • Joundi RA
        • Menon BK.
        Thrombus composition, imaging, and outcome prediction in acute ischemic stroke.
        Neurology. 2021; 97: S68-S78
        • Liebeskind DS
        • Sanossian N
        • Yong WH
        • et al.
        CT and MRI early vessel signs reflect clot composition in acute stroke.
        Stroke. 2011; 42: 1237-1243
        • Hund H
        • Boodt N
        • Arrarte TN
        • et al.
        Quantitative thrombus characteristics on thin-slice computed tomography improve prediction of thrombus histopathology: results of the MR CLEAN Registry.
        Eur Radiol. 2022; 32: 7811-7823
        • Benson JC
        • Fitzgerald ST
        • Kadirvel R
        • et al.
        Clot permeability and histopathology: is a clot's perviousness on CT imaging correlated with its histologic composition?.
        J Neurointerv Surg. 2020; 12: 38-42
        • Berndt M
        • Friedrich B
        • Maegerlein C
        • et al.
        Thrombus permeability in admission computed tomographic imaging indicates stroke pathogenesis based on thrombus histology.
        Stroke. 2018; 49: 2674-2682
        • Wei L
        • Zhu Y
        • Deng J
        • et al.
        Visualization of thrombus enhancement on thin-slab maximum intensity projection of ct angiography: an imaging sign for predicting stroke source and thrombus compositions.
        Radiology. 2021; 298: 374-381
        • Alvarez RE
        • Macovski A.
        Energy-selective reconstructions in X-ray computerized tomography.
        Phys Med Biol. 1976; 21: 733-744
        • Kessner R
        • Sommer J
        • Grosse HN
        • et al.
        Virtual versus true non-contrast images of the brain from spectral detector CT: comparison of attenuation values and image quality.
        Acta Radiol. 2022; https://doi.org/10.1177/02841851221093763
        • Schneider D
        • Apfaltrer P
        • Sudarski S
        • et al.
        Optimization of kiloelectron volt settings in cerebral and cervical dual-energy CT angiography determined with virtual monoenergetic imaging.
        Acad Radiol. 2014; 21: 431-436
        • Ding YH
        • Abbasi M
        • Michalak G
        • et al.
        Characterization of thrombus composition with multimodality CT-based imaging: an in-vitro study.
        J Neurointerv Surg. 2021; 13: 738-740
        • Brinjikji W
        • Michalak G
        • Kadirvel R
        • et al.
        Utility of single-energy and dual-energy computed tomography in clot characterization: An in-vitro study.
        Interv Neuroradiol. 2017; 23: 279-284
        • Borggrefe J
        • Kottlors J
        • Mirza M
        • et al.
        Differentiation of clot composition using conventional and dual-energy computed tomography.
        Clin Neuroradiol. 2018; 28: 515-522
        • Shin JW
        • Jeong HS
        • Kwon HJ
        • et al.
        High red blood cell composition in clots is associated with successful recanalization during intra-arterial thrombectomy.
        Plos One. 2018; 13e197492
        • Macovski A
        • Alvarez RE
        • Chan JL
        • et al.
        Energy dependent reconstruction in X-ray computerized tomography.
        Comput Biol Med. 1976; 6: 325-336
        • Ye G
        • Cao R
        • Lu J
        • et al.
        Histological composition behind CT-based thrombus density and perviousness in acute ischemic stroke.
        Clin Neurol Neurosurg. 2021; 207106804
        • Brinjikji W
        • Duffy S
        • Burrows A
        • et al.
        Correlation of imaging and histopathology of thrombi in acute ischemic stroke with etiology and outcome: a systematic review.
        J Neurointerv Surg. 2017; 9: 529-534
        • Simons N
        • Mitchell P
        • Dowling R
        • et al.
        Thrombus composition in acute ischemic stroke: a histopathological study of thrombus extracted by endovascular retrieval.
        J Neuroradiol. 2015; 42: 86-92
        • Niesten JM
        • van der Schaaf IC
        • van Dam L
        • et al.
        Histopathologic composition of cerebral thrombi of acute stroke patients is correlated with stroke subtype and thrombus attenuation.
        Plos One. 2014; 9: e88882
        • Wu J
        • Lv Y
        • Wang N
        • et al.
        The value of single-source dual-energy CT imaging for discriminating microsatellite instability from microsatellite stability human colorectal cancer.
        Eur Radiol. 2019; 29: 3782-3790
        • Johnson TR
        • Krauss B
        • Sedlmair M
        • et al.
        Material differentiation by dual energy CT: initial experience.
        Eur Radiol. 2007; 17: 1510-1517
        • Garcia LI
        • Azorin JF
        • Almansa JF.
        A new method to measure electron density and effective atomic number using dual-energy CT images.
        Phys Med Biol. 2016; 61: 265-279
        • Landry G
        • Reniers B
        • Granton PV
        • et al.
        Extracting atomic numbers and electron densities from a dual source dual energy CT scanner: experiments and a simulation model.
        Radiother Oncol. 2011; 100: 375-379
        • Deniffel D
        • Sauter A
        • Fingerle A
        • Rummeny EJ
        • Makowski MR
        • Pfeiffer D.
        Improved differentiation between primary lung cancer and pulmonary metastasis by combining dual-energy CT-derived biomarkers with conventional CT attenuation.
        Eur Radiol. 2021; 31: 1002-1010
        • Chandarana H
        • Megibow AJ
        • Cohen BA
        • et al.
        Iodine quantification with dual-energy CT: phantom study and preliminary experience with renal masses.
        AJR Am J Roentgenol. 2011; 196: W693-W700
        • Mileto A
        • Marin D
        • Alfaro-Cordoba M
        • et al.
        Iodine quantification to distinguish clear cell from papillary renal cell carcinoma at dual-energy multidetector CT: a multireader diagnostic performance study.
        Radiology. 2014; 273: 813-820
        • Ascenti G
        • Sofia C
        • Mazziotti S
        • et al.
        Dual-energy CT with iodine quantification in distinguishing between bland and neoplastic portal vein thrombosis in patients with hepatocellular carcinoma.
        Clin Radiol. 2016; 71: 931-938
        • Choi MH
        • Park GH
        • Lee JS
        • et al.
        Erythrocyte fraction within retrieved thrombi contributes to thrombolytic response in acute ischemic stroke.
        Stroke. 2018; 49: 652-659
        • Goebel J
        • Gaida BJ
        • Wanke I
        • et al.
        Is histologic thrombus composition in acute stroke linked to stroke etiology or to interventional parameters?.
        AJNR Am J Neuroradiol. 2020; 41: 650-657
        • Javadi S
        • Elsherif S
        • Bhosale P
        • et al.
        Quantitative attenuation accuracy of virtual non-enhanced imaging compared to that of true non-enhanced imaging on dual-source dual-energy CT.
        Abdom Radiol (NY). 2020; 45: 1100-1109