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Abstract/Summary
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<jats:title>Abstract</jats:title><jats:sec>
<jats:title>Background</jats:title>
<jats:p>Nowadays, there is no method to quantitatively characterize the material composition of acute ischemic stroke thrombi prior to intervention, but dual-energy CT (DE-CT) offers imaging-based multimaterial decomposition. We retrospectively investigated the material composition of thrombi <jats:italic>ex vivo</jats:italic> using DE-CT with histological analysis as a reference.</jats:p>
</jats:sec><jats:sec>
<jats:title>Methods</jats:title>
<jats:p>Clots of 70 patients with acute ischemic stroke were extracted by mechanical thrombectomy and scanned <jats:italic>ex vivo</jats:italic> in formalin-filled tubes with DE-CT. Multimaterial decomposition in the three components, <jats:italic>i.e.</jats:italic>, red blood cells (RBC), white blood cells (WBC), and fibrin/platelets (F/P), was performed and compared to histology (hematoxylin/eosin staining) as reference. Attenuation and effective <jats:italic>Z</jats:italic> values were assessed, and histological composition was compared to stroke etiology according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria.</jats:p>
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<jats:title>Results</jats:title>
<jats:p>Histological and imaging analysis showed the following correlation coefficients for RBC (<jats:italic>r</jats:italic> = 0.527, <jats:italic>p</jats:italic> < 0.001), WBC (<jats:italic>r</jats:italic> = 0.305, <jats:italic>p</jats:italic> = 0.020), and F/P (<jats:italic>r</jats:italic> = 0.525, <jats:italic>p</jats:italic> < 0.001). RBC-rich thrombi presented higher clot attenuation in Hounsfield units than F/P-rich thrombi (51 HU <jats:italic>versus</jats:italic> 42 HU, <jats:italic>p</jats:italic> < 0.01). In histological analysis, cardioembolic clots showed less RBC (40% <jats:italic>versus</jats:italic> 56%, <jats:italic>p</jats:italic> = 0.053) and more F/P (53% <jats:italic>versus</jats:italic> 36%, <jats:italic>p</jats:italic> = 0.024), similar to cryptogenic clots containing less RBC (34% <jats:italic>versus</jats:italic> 56%, <jats:italic>p</jats:italic> = 0.006) and more F/P (58% <jats:italic>versus</jats:italic> 36%, <jats:italic>p</jats:italic> = 0.003) than non-cardioembolic strokes. No difference was assessed for the mean WBC portions in all TOAST groups.</jats:p>
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<jats:title>Conclusions</jats:title>
<jats:p>DE-CT has the potential to quantitatively characterize the material composition of ischemic stroke thrombi.</jats:p>
</jats:sec><jats:sec>
<jats:title>Relevance statement</jats:title>
<jats:p>Using DE-CT, the composition of ischemic stroke thrombi can be determined. Knowledge of histological composition prior to intervention offers the opportunity to define personalized treatment strategies for each patient to accomplish faster recanalization and better clinical outcomes.</jats:p>
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<jats:title>Key points</jats:title>
<jats:p>• Acute ischemic stroke clots present different recanalization success according to histological composition.</jats:p>
<jats:p>• Currently, no method can determine clot composition prior to intervention.</jats:p>
<jats:p>• DE-CT allows quantitative material decomposition of thrombi <jats:italic>ex vivo</jats:italic> in red blood cells, white blood cells, and fibrin/platelets.</jats:p>
<jats:p>• Histological clot composition differs between stroke etiology.</jats:p>
<jats:p>• Insights into the histological composition <jats:italic>in situ</jats:italic> offer personalized treatment strategies.</jats:p>
</jats:sec><jats:sec>
<jats:title>Graphical Abstract</jats:title>
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