The hyperdense vessel sign on CT predicts successful recanalization with the Merci device in acute ischemic stroke

Abstract

Background: The success of mechanical clot retrieval for acute ischemic stroke may be influenced by the characteristics of the occlusive thrombus. The thrombus can be partly characterized by CT, as the hyperdense vessel sign (HVS) suggests erythrocyte-rich clot whereas fibrin-rich clot may be isodense. We hypothesized that the physical clot characteristics that determine CT density may also determine likelihood of retrieval with the Merci device.

Methods: We reviewed all acute stroke cases initially imaged with non-contrast CT before attempted Merci clot retrieval at a single center between 2004 and 2010. Each CT was blindly assessed for the presence or absence of the HVS, and post-retrieval angiograms were blindly assessed for reperfusion using the TICI scale.

Results: Of 67 patients analyzed (mean age 69; median NIHSS 19; 61% female), the HVS was seen in 42, and no HVS was present in 25. Successful recanalization was achieved in 79% of patients with the HVS (33/42), but in only 36% (9/25) of patients without HVS (p=0.001). The HVS was the only significant predictor of recanalization while accounting for age, treatment with IV-tPA, clot location, stroke etiology, time to treatment, and number of retrieval attempts.

Conclusion: The HVS in acute ischemic stroke was strongly predictive of successful recanalization using the Merci device. The HVS may indicate thrombi that are less adhesive compared with isodense clots that are more resistant to mechanical retrieval. The absence of HVS on pre-treatment CT may thus suggest the need for a more aggressive or alternative therapeutic approach.

Keywords: Hyperdense vessel sign; acute ischemic stroke; aneurysm; angiography; angioplasty; arteriovenous malformation; artery; atherosclerosis; balloon; brain; catheter; clot retrieval; coil; complication; embolic; flow diverte r; intervention; malformation; recanalization; stenosis; stent; stroke; subarachnoid; thrombectomy; thrombolysis; thrombus; vasculitis; vein.

Figure 1

(A) An example of the hypderdense vessel sign (HVS) in the right middle cerebral artery seen on non-contrast CT. The arrow indicates the clot seen in the proximal portion of the middle cerebral artery, but additional clot can also be seen as hyperdensity near the M1–M2 junction on this scan. (B) Patients that exhibited the HVS had a 79% likelihood of successful recanalization (right side). In contrast, when the HVS was not observed (isodense vessel; left side), mechanical recanalization was much more likely to fail. Only 36% of patients without the HVS experienced successful recanalization.