Clot Composition Analysis as a Diagnostic Tool to Gain Insight into Ischemic Stroke Etiology: A Systematic Review

다국어 초록 (Multilingual Abstract)

Mechanical thrombectomy renders the occluding clot available for analysis. Insights into thrombus composition could help establish the stroke cause. We aimed to investigate the value of clot composition analysis as a complementary diagnostic tool in determining the etiology of large vessel occlusion (LVO) ischemic strokes (International Prospective Register of Systematic Reviews [PROSPERO] registration # CRD42020199436). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we ran searches on Medline (using the PubMed interface) and Web of Science for studies reporting analyses of thrombi retrieved from LVO stroke patients subjected to mechanical thrombectomy (January 1, 2006 to September 21, 2020). The PubMed search was updated weekly up to February 22, 2021. Reference lists of included studies and relevant reviews were hand-searched. From 1,714 identified studies, 134 eligible studies (97 cohort studies, 31 case reports, and six case series) were included in the qualitative synthesis. Physical, histopathological, biological, and microbiological analyses provided information about the gross appearance, mechanical properties, structure, and composition of the thrombi. There were non-unanimous associations of thrombus size, structure, and composition (mainly proportions of fibrin and blood formed elements) with the Trial of Org 10172 in Acute Stroke Treatment (TOAST) etiology and underlying pathologies, and similarities between cryptogenic thrombi and those of known TOAST etiology. Individual thrombus analysis contributed to the diagnosis, mainly in atypical cases. Although cohort studies report an abundance of quantitative rates of main thrombus components, a definite clot signature for accurate diagnosis of stroke etiology is still lacking. Nevertheless, the qualitative examination of the embolus remains an invaluable tool for diagnosing individual cases, particularly regarding atypical stroke causes.

참고문헌 (Reference)

• 1 Elodie O, "Whipple’s endocarditis diagnosed by thrombus analysis retrieved by successful mechanical thrombectomy" 400 : 42-43, 2019
• 2 Mereuta OM, "Von Willebrand factor expression in various subtypes of acute ischemic stroke" 51 (51): AWP268-, 2020
• 3 Wei L, "Visualization of thrombus enhancement on thin-slab maximum intensity projection of CT angiography : an imaging sign for predicting stroke source and thrombus compositions" 298 : 374-381, 2021
• 4 Funatsu N, "Vascular wall components in thrombi obtained by acute stroke thrombectomy : clinical significance and related factors" 11 : 232-236, 2019
• 5 Di Meglio L, "Two-layered susceptibility vessel sign is associated with biochemically quantified thrombus red blood cell content" 27 : 1264-1271, 2020
• 6 Berndt M, "Thrombus permeability in admission computed tomographic imaging indicates stroke pathogenesis based on thrombus histology" 49 : 2674-2682, 2018
• 7 Ducroux C, "Thrombus neutrophil extracellular traps content impair tPA-induced thrombolysis in acute ischemic stroke" 49 : 754-757, 2018
• 8 Boeckh-Behrens T, "Thrombus histology suggests cardioembolic cause in cryptogenic stroke" 47 : 1864-1871, 2016
• 9 Berndt M, "Thrombus histology of basilar artery occlusions : are there differences to the anterior circulation" 31 : 753-761, 2021
• 10 Semerano A, "Thrombus hallmarks reveal atherothrombotic stroke aetiology" 266 : 1533-1535, 2019
• 11 Elijovich L, "Thrombus composition is associated with endothelial injury and stroke etiology in patients undergoing mechanical thrombectomy for emergent large vessel occlusion" 49 (49): A145-, 2018
• 12 Simons N, "Thrombus composition in acute ischemic stroke : a histopathological study of thrombus extracted by endovascular retrieval" 42 : 86-92, 2015
• 13 Gurkas E, "Thrombus composition and success of thrombectomy in acute ischemic stroke patients : a histopathological analysis" 2019
• 14 Jolugbo P, "Thrombus composition and efficacy of thrombolysis and thrombectomy in acute ischemic stroke" 52 : 1131-1142, 2021
• 15 Novotny J, "Thrombus NET content is associated with clinical outcome in stroke and myocardial infarction" 94 : e2346-e2360, 2020
• 16 "Thrombus Composition in Ischemic Stroke: Analysis of the Correlation With Plasma Biomarkers, Efficacy of Treatment, Etiology and Prognosis (COMPO-CLOT)"
• 17 Wollenweber FA, "Thrombectomy recovers an aortic wall fragment from middle cerebral artery immediately after TAVI" 86 : 2111-2112, 2016
• 18 Prochazka V, "The role of von Willebrand factor, ADAMTS13, and cerebral artery thrombus composition in patient outcome following mechanical thrombectomy for acute ischemic stroke" 24 : 3929-3945, 2018
• 19 Ye G, "The role of diabetes mellitus on the thrombus composition in patients with acute ischemic stroke" 26 : 329-336, 2020
• 20 Boeckh-Behrens T, "The impact of histological clot composition in embolic stroke" 26 : 189-197, 2016
• 21 Valente M, "The diagnostic utility of routine clot analysis after endovascular thrombectomy in a patient with systemic lupus erythematosus and antiphospholipid syndrome" 70 : 247-249, 2019
• 22 Rossi R, "The administration of rtPA before mechanical thrombectomy in acute ischemic stroke patients is associated with a significant reduction of the retrieved clot area but it does not influence revascularization outcome" 51 : 545-551, 2021
• 23 Liberati A, "The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions : explanation and elaboration" 6 : e1000100-, 2009
• 24 Bain MD, "Successful recanalization of a septic embolus with a balloon mounted stent after failed mechanical thrombectomy" 21 : 170-172, 2011
• 25 Sukumaran S, "Successful mechanical thrombectomy of acute middle cerebral artery occlusion due to vegetation from infective endocarditis" 60 : 239-240, 2012
• 26 Fassa AA, "Successful endovascular stroke rescue with retrieval of an embolized calcium fragment after transcatheter aortic valve replacement" 7 : 125-126, 2014
• 27 Staessens S, "Structural analysis of ischemic stroke thrombi : histological indications for therapy resistance" 105 : 498-507, 2020
• 28 Anuwatworn A, "Stroke with valve tissue embolization during transcatheter aortic valve replacement treated with endovascular intervention" 8 : 1261-1263, 2015
• 29 Nakanishi K, "Stroke due to infective endocarditis diagnosed by the retrieved thrombus : a case report" 58 : 35-40, 2018
• 30 Sporns PB, "Small thrombus size, thrombus composition, and poor collaterals predict pre-interventional thrombus migration" 13 : 409-414, 2021
• 31 Kaesmacher J, "Risk of thrombus fragmentation during endovascular stroke treatment" 38 : 991-998, 2017
• 32 Ye G, "Risk of secondary embolism events during mechanical thrombectomy for acute ischemic stroke : a single-center study based on histological analysis" 193 : 105749-, 2020
• 33 Vidmar J, "Retrieved cerebral thrombi studied by T2 and ADC mapping : preliminary results" 53 : 427-433, 2019
• 34 Abdel-Wahed L, "Retrieved arterial clot helps guide antibiotic therapy in infective endocarditis" 132 : e795-e796, 2019
• 35 "RNA Sequencing Analysis in Large Vessel Occlusion Stroke DATA Bank (RNASA-LVOSB)"
• 36 Abbasi M, "Proteomic analysis of cardioembolic and large artery atherosclerotic clots using reverse phase protein array technology reveals key cellular interactions within clot microenvironments" 13 : e13499-, 2021
• 37 Fitzgerald S, "Platelet-rich emboli in cerebral large vessel occlusion are associated with a large artery atherosclerosis source" 50 : 1907-1910, 2019
• 38 Douglas A, "Platelet-rich emboli are associated with von Willebrand factor levels and have poorer revascularization outcomes" 12 : 557-562, 2020
• 39 Fitzgerald ST, "Platelet-rich clots as identified by Martius Scarlet Blue staining are isodense on NCCT" 11 : 1145-1149, 2019
• 40 Peña-Martínez C, "Pharmacological modulation of neutrophil extracellular traps reverses thrombotic stroke tPA(tissue-type plasminogen activator)resistance" 50 : 3228-3237, 2019
• 41 Duffy S, "Per-pass analysis of thrombus composition in patients with acute ischemic stroke undergoing mechanical thrombectomy" 50 : 1156-1163, 2019
• 42 Fitzgerald S, "Per-pass analysis of acute ischemic stroke clots : impact of stroke etiology on extracted clot area and histological composition" 2020
• 43 Rao NM, "Peptide composition of stroke causing emboli correlate with serum markers of atherosclerosis and inflammation" 8 : 427-, 2017
• 44 Cline B, "Pathological analysis of extracted clots in embolectomy patients with acute ischaemic stroke" 5 (5): A15-A16, 2013
• 45 Brinjikji W, "Outcomes of the stroke thromboembolism registry of imaging and pathology : a multicenter international study" 2020
• 46 Fitzgerald S, "Orbit image analysis machine learning software can be used for the histological quantification of acute ischemic stroke blood clots" 14 : e0225841-, 2019
• 47 Patrakka O, "Oral bacterial signatures in cerebral thrombi of patients with acute ischemic stroke treated with thrombectomy" 8 : e012330-, 2019
• 48 Chapot R, "Occlusion of the middle cerebral artery due to synthetic fibers" 27 : 148-150, 2006
• 49 Meng L, "Nomogram to predict poor outcome after mechanical thrombectomy at older age and histological analysis of thrombus composition" 2020 : 8823283-, 2020
• 50 Deng J, "Neutrophil extracellular traps increased by hyperglycemia exacerbate ischemic brain damage" 738 : 135383-, 2020
• 51 Laridan E, "Neutrophil extracellular traps in ischemic stroke thrombi" 82 : 223-232, 2017
• 52 Salinas P, "Neurovascular rescue for thrombus-related embolic stroke during transcatheter aortic valve implantation" 6 : 981-982, 2013
• 53 Chen SH, "Netosis and inflammasomes in large vessel occlusion thrombi" 11 : 607287-, 2021
• 54 "Multimodal Investigation of Intracranial Clot Environment (MISO)"
• 55 Scharf EL, "Mucor thrombus" 24 : 268-272, 2016
• 56 Vajpeyee Atulabh, "Metagenomics Analysis of Thrombus Samples Retrieved from Mechanical Thrombectomy" 대한신경중재치료의학회 16 (16): 39-45, 2021
• 57 Suissa L, "Metabolome of cerebral thrombi reveals an association between high glycemia at stroke onset and good clinical outcome" 10 : 483-, 2020
• 58 Ambrosioni J, "Mechanical thrombectomy for acute ischemic stroke secondary to infective endocarditis" 66 : 1286-1289, 2018
• 59 Garcia-Ptacek S, "Mechanical endovascular treatment of acute stroke due to cardiac myxoma" 6 : e1-, 2014
• 60 Tejada J, "Mechanical endovascular procedure for the treatment of acute ischemic stroke caused by total detachment of a papillary fibroelastoma" 6 : e37-, 2014
• 61 Chueh JY, "Mechanical characterization of thromboemboli in acute ischemic stroke and laboratory embolus analogs" 32 : 1237-1244, 2011
• 62 Muñoz R, "Mass spectrometry-based proteomic profiling of thrombotic material obtained by endovascular thrombectomy in patients with ischemic stroke" 19 : 498-, 2018
• 63 Dargazanli C, "Machine learning analysis of the cerebrovascular thrombi proteome in human ischemic stroke : an exploratory study" 11 : 575376-, 2020
• 64 Genchi A, "Large vessel occlusion stroke due to dislodged aortic valve calcification revealed by imaging and histopathology" 408 : 116573-, 2020
• 65 Pisano TJ, "Large vessel occlusion secondary to COVID-19 hypercoagulability in a young patient : a case report and literature review" 29 : 105307-, 2020
• 66 Fitzgerald S, "Large artery atherosclerotic clots are larger than clots of other stroke etiologies and have poorer recanalization rates" 30 : 105463-, 2021
• 67 Sporns PB, "Ischemic stroke : what does the histological composition tell us about the origin of the thrombus" 48 : 2206-2210, 2017
• 68 Sporns PB, "Ischemic stroke : histological thrombus composition and pre-interventional CT attenuation are associated with intervention time and rate of secondary embolism" 44 : 344-350, 2017
• 69 Goebel J, "Is histologic thrombus composition in acute stroke linked to stroke etiology or to interventional parameters" 41 : 650-657, 2020
• 70 "Investigation of Clot in Ischemic Stroke and Hematoma Evacuation (INSIGHT)"
• 71 Mehta RI, "Intrathrombus polymer coating deposition: a pilot study of 91 patients undergoing endovascular therapy for acute large vessel stroke. Part I: Histologic frequency" 11 : 1191-1196, 2019
• 72 Donnerstag F, "Interventional stroke treatment : is it also safe for arteries? : looking at thrombectomy wall damage through clot histology" 27 : 404-410, 2021
• 73 Bacigaluppi M, "Insights from thrombi retrieved in stroke due to large vessel occlusion" 39 : 1433-1451, 2019
• 74 Baek BH, "Inflammatory mediator expression within retrieved clots in acute ischemic stroke" 5 : 273-279, 2018
• 75 Patel TR, "Increased perviousness on CT for acute ischemic stroke is associated with fibrin/platelet-rich clots" 42 : 57-64, 2021
• 76 Itsekson Hayosh Z, "In-thrombus thrombin secretion : a new diagnostic marker of atrial fibrillation in cryptogenic stroke" 13 : 799-804, 2021
• 77 Horie N, "Impact of mechanical thrombectomy device on thrombus histology in acute embolic stroke" 132 : e418-e422, 2019
• 78 Maegerlein C, "Impact of histological thrombus composition on preinterventional thrombus migration in patients with acute occlusions of the middle cerebral artery" 24 : 70-75, 2018
• 79 Essig F, "Immunohistological analysis of neutrophils and neutrophil extracellular traps in human thrombemboli causing acute ischemic stroke" 21 : 7387-, 2020
• 80 López-Cancio E, "Immunohistochemical study of clot composition in thrombi retrieved from MCA with mechanical thrombectomy" 35 : 255-, 2013
• 81 Singh P, "Immunohistochemical analysis of thrombi retrieved during treatment of acute ischemic stroke : does stent-retriever cause intimal damage" 44 : 1720-1722, 2013
• 82 Schuhmann MK, "Immunohistochemical analysis of cerebral thrombi retrieved by mechanical thrombectomy from patients with acute ischemic stroke" 17 : 298-, 2016
• 83 Uta Hanning, "Imaging-based prediction of histological clot composition from admission CT imaging" BMJ 13 (13): 1053-1057, 2021
• 84 Qureshi AI, "Histopathological characteristics of IV recombinant tissue plasminogen-resistant thrombi in patients with acute ischemic stroke" 8 : 38-45, 2016
• 85 Hernández-Fernández F, "Histopathological and bacteriological analysis of thrombus material extracted during mechanical thrombectomy in acute stroke patients" 40 : 1851-1860, 2017
• 86 Niesten JM, "Histopathologic composition of cerebral thrombi of acute stroke patients is correlated with stroke subtype and thrombus attenuation" 9 : e88882-, 2014
• 87 Hashimoto T, "Histopathologic analysis of retrieved thrombi associated with successful reperfusion after acute stroke thrombectomy" 47 : 3035-3037, 2016
• 88 Salam KA, "Histology of thrombectomy specimen reveals cardiac tumor embolus in cryptogenic young stroke" 27 : e70-e72, 2018
• 89 Staessens S, "Histological stroke clot analysis after thrombectomy : technical aspects and recommendations" 15 : 467-476, 2020
• 90 Sallustio F, "Histological features of intracranial thrombo-emboli predict response to endovascular therapy for acute ischemic stroke" 3 : 1105-, 2015
• 91 Park H, "Histological features of intracranial thrombi in stroke patients with cancer" 86 : 143-149, 2019
• 92 Matsumoto N, "Histological examination of trousseau syndrome-related thrombus retrieved through acute endovascular thrombectomy : report of 2 cases" 25 : e227-, 2016
• 93 Sporns PB, "Histological clot composition is associated with preinterventional clot migration in acute stroke patients" 50 : 2065-2071, 2019
• 94 Ahn SH, "Histologic features of acute thrombi retrieved from stroke patients during mechanical reperfusion therapy" 11 : 1036-1044, 2016
• 95 Kim SK, "Histologic analysis of retrieved clots in acute ischemic stroke : correlation with stroke etiology and gradient-echo MRI" 36 : 1756-1762, 2015
• 96 Mereuta OM, "High-resolution scanning electron microscopy for the analysis of three-dimensional ultrastructure of clots in acute ischemic stroke" 13 : 906-911, 2021
• 97 Shin JW, "High red blood cell composition in clots is associated with successful recanalization during intra-arterial thrombectomy" 13 : e0197492-, 2018
• 98 Dargazanli C, "High CD3+ cells in intracranial thrombi represent a biomarker of atherothrombotic stroke" 11 : e0154945-, 2016
• 99 Hund HM, "Foreign bodies are present in thrombi mechanically extracted from patients suffering acute ischemic stroke and who underwent endovascular treatment" 39 : 261-, 2019
• 100 Kim JM, "Forced arterial suction thrombectomy of septic embolic middle cerebral artery occlusion due to infective endocarditis : an illustrative case and review of the literature" 9 : 101-105, 2014
• 101 Kan P, "First reported use of retrievable stent technology for removal of a large septic embolus in the middle cerebral artery" 77 : 591-, 2012
• 102 Roessler FC, "First approach to distinguish between cardiac and arteriosclerotic emboli of individual stroke patients applying the histological THROMBEX-classification rule" 11 : 8433-, 2021
• 103 Krajíčková D, "Fibrin clot architecture in acute ischemic stroke treated with mechanical thrombectomy with stent-retrievers : cohort study" 82 : 866-873, 2018
• 104 Fu CH, "Fibrin and platelet-rich composition in retrieved thrombi hallmarks stroke with active cancer" 51 : 3723-3727, 2020
• 105 Xue Y, "Exploration of thrombus histological composition and clinical effect in mechanical thrombectomy of acute ischemic stroke" 98 : 3697-3700, 2018
• 106 Fitzpatrick N, "Expanding the role of stent-retriever endovascular thrombectomy : a case series of free-floating thrombus" 10 : 1164-1167, 2018
• 107 Juega J, "Etiology of stroke based on early analysis of clot cytometry obtained through first pass technique for mechanical thrombectomy" 50 (50): AWMP70-, 2019
• 108 Maekawa K, "Erythrocyte-rich thrombus is associated with reduced number of maneuvers and procedure time in patients with acute ischemic stroke undergoing mechanical thrombectomy" 8 : 39-49, 2018
• 109 Liu M, "Erythrocyte-rich thrombi related to serum iron contribute to single stent retrieval and favorable clinical outcomes in acute ischemic stroke by endovascular treatment" 195 : 8-15, 2020
• 110 Choi MH, "Erythrocyte fraction within retrieved thrombi contributes to thrombolytic response in acute ischemic stroke" 49 : 652-659, 2018
• 111 Scharf EL, "Endovascular management of cerebral septic embolism : three recent cases and review of the literature" 9 : 463-465, 2017
• 112 Wolpert F, "Embolization of tumor cells is rare in patients with systemic cancer and cerebral large vessel occlusion" 27 : 2041-2046, 2020
• 113 Biraschi F, "Effective ADAPT thrombectomy in a patient with acute stroke due to cardiac papillary elastofibroma : histological thrombus confirmation" 25 : e185-e187, 2016
• 114 Hinman JD, "Drip, ship, and grip, then slice and dice:comprehensive stroke center management of cervical and intracranial emboli" 4 : 104-, 2013
• 115 Liao Y, "Differences in pathological composition among large artery occlusion cerebral thrombi, valvular heart disease atrial thrombi and carotid endarterectomy plaques" 11 : 811-, 2020
• 116 Bourcier R, "Diagnostic performances of the susceptibility vessel sign on MRI for the prediction of macroscopic thrombi features in acute ischemic stroke" 29 : 105245-, 2020
• 117 Kim B, "Development of a predictive scale for cardioembolic stroke using extracted thrombi and angiographic findings" 73 : 224-230, 2020
• 118 Di Meglio L, "DNA content in ischemic stroke thrombi can help identify cardioembolic strokes among strokes of undetermined cause" 51 : 2810-2816, 2020
• 119 Bhaskar S, "Cryptogenic stroke is linked to cardioembolic aetiology : a histopathological study of thrombus retrieved after endovascular thrombectomy" 26 : 20-, 2019
• 120 Brinjikji W, "Correlation of imaging and histopathology of thrombi in acute ischemic stroke with etiology and outcome : a systematic review" 9 : 529-534, 2017
• 121 Suissa L, "Combined omic analyzes of cerebral thrombi : a new molecular approach to identify cardioembolic stroke origin" 52 : 2892-2901, 2021
• 122 Khashim Z, "Clots retrieved by mechanical thrombectomy from acute ischemic stroke patients show no evidence of bacteria" 25 : 502-507, 2019
• 123 Benson JC, "Clot permeability and histopathology : is a clot’s perviousness on CT imaging correlated with its histologic composition" 12 : 38-42, 2020
• 124 Bhaskar S, "Clot histopathology in ischemic stroke with infective endocarditis" 46 : 331-336, 2019
• 125 Nouh A, "Clot composition of embolic strokes of undetermined source : a feasibility study" 20 : 383-, 2020
• 126 Koneru S, "Clot composition in retrieved thrombi after mechanical thrombectomy in strokes due to carotid web" 13 : 530-533, 2021
• 127 Salom JB, "Clot composition analysis as complementary diagnostic tool to gain insight into ischemic stroke etiology: A systematic review of clinical studies and case reports"
• 128 Saver JL, "Clinical practice : cryptogenic stroke" 374 : 2065-2074, 2016
• 129 Matsumoto N, "Cholesterol crystal in thrombus removed by mechanical thrombectomy should be a strong marker for aortogenic embolic stroke" 29 : 105178-, 2020
• 130 Lopez-Pedrera C, "Characterization of the protein profile in thrombi of patients with ischemic stroke and identification of potential biomarkers as predictors of negative clinical evolution" 4 (4): OC08.5-, 2020
• 131 Almekhlafi MA, "Calcification and endothelialization of thrombi in acute stroke" 64 : 344-348, 2008
• 132 Liebeskind DS, "CT and MRI early vessel signs reflect clot composition in acute stroke" 42 : 1237-1243, 2011
• 133 Smith WS, "Brief history of endovascular acute ischemic stroke treatment" 47 : e23-e26, 2016
• 134 Gong L, "Bridging therapy versus direct mechanical thrombectomy in patients with acute ischemic stroke due to middle cerebral artery occlusion : a clinical-histological analysis of retrieved thrombi" 28 : 684-690, 2019
• 135 "Blood And Clot Thrombectomy Registry And Collaboration (BACTRAC)"
• 136 Brinjikji W, "Association between clot composition and stroke origin in mechanical thrombectomy patients : analysis of the Stroke Thromboembolism Registry of Imaging and Pathology" 13 : 594-598, 2021
• 137 Sgreccia A, "Association between acute ischemic stroke etiology and macroscopic aspect of retrieved clots : is a clot’s color a warning light for underlying pathologies" 11 : 1197-1200, 2019
• 138 Berndt M, "Artificial stroke clots : how wide is the gap to the real world" 110 : e90-e99, 2018
• 139 Usui G, "Aortogenic embolic stroke diagnosed by a pathological examination of endovascularly removed thrombus : an autopsy report" 58 : 2851-2855, 2019
• 140 Mönch S, "Angiographic baseline proximal thrombus appearance of M1/M2 occlusions in mechanical thrombectomy" 31 : 189-196, 2021
• 141 Marder VJ, "Analysis of thrombi retrieved from cerebral arteries of patients with acute ischemic stroke" 37 : 2086-2093, 2006
• 142 Meher V, "Analysis of retrieved stroke thrombi from mechanical thrombectomy using X-ray fluorescence imaging and fourier transform infrared spectroscopy" 13 : 150-, 2018
• 143 Jeong-Min Kim, "Analysis of microRNA signatures in ischemic stroke thrombus" BMJ 2021
• 144 Liu Y, "Analysis of human emboli and thrombectomy forces in large-vessel occlusion stroke" 134 : 893-901, 2020
• 145 De Meyer SF, "Analyses of thrombi in acute ischemic stroke : a consensus statement on current knowledge and future directions" 12 : 606-614, 2017
• 146 Khismatullin RR, "Agedependent differential staining of fibrin in blood clots and thrombi" 10 : 370-374, 2020
• 147 Sgreccia A, "Acute ischemic stroke treated with mechanical thrombectomy and fungal endocarditis : a case report and systematic review of the literature" 47 : 386-392, 2020
• 148 Di Meglio L, "Acute ischemic stroke thrombi have an outer shell that impairs fibrinolysis" 93 : e1686-e1698, 2019
• 149 Jean Darcourt, "Absence of susceptibility vessel sign is associated with aspiration-resistant fibrin/platelet-rich thrombi" SAGE Publications 16 (16): 972-980, 2021
• 150 Distefano M, "A puzzling case of cryptogenic stroke" 28 : e33-e35, 2019
• 151 Katano T, "A fungus in a thrombus by mechanical thrombectomy in acute cerebral infarction : a case report" 60 : 340-345, 2020
• 152 Li Y, "A case report of thrombolysis resistance : thrombus ultrastructure in an ischemic stroke patient" 20 : 135-, 2020
• 153 Thomas MC, "A case of right middle cerebral artery ‘tendonectomy’ following mitral valve replacement surgery" 9 : e35-, 2017