T2* "susceptibility vessel sign" demonstrates clot location and length in acute ischemic stroke

Olivier Naggara, Jean Raymond, Montserrat Domingo Ayllon, Fawaz Al-Shareef, Emmanuel Touzé, Meriem Chenoufi, Sophie Gerber, Charles Mellerio, Matthieu Zuber, Jean Francois Meder, Jean-Louis Mas, Catherine Oppenheim, Olivier Naggara, Jean Raymond, Montserrat Domingo Ayllon, Fawaz Al-Shareef, Emmanuel Touzé, Meriem Chenoufi, Sophie Gerber, Charles Mellerio, Matthieu Zuber, Jean Francois Meder, Jean-Louis Mas, Catherine Oppenheim

Abstract

Objectives: The aim of our study was to evaluate, in acute ischemic stroke patients, the diagnostic accuracy of the MRI susceptibility vessel sign (SVS) against catheter angiography (DSA) for the detection of the clot and its value in predicting clot location and length.

Materials and methods: We identified consecutive patients (2006-2012) admitted to our center, where 1.5 T MRI is systematically implemented as first-line diagnostic work-up, with: (1) pre-treatment 6-mm-thick multislice 2D T2* sequence; (2) delay from MRI-to-DSA <3 hrs; (3) no fibrinolysis between MRI and DSA. The location and length of SVS on T2* was independently assessed by three readers, and compared per patient, per artery and per segment, to DSA findings, obtained by two different readers. Clot length measured on T2* and DSA were compared using intra-class correlation coefficient (ICC), Bland & Altman test and Passing & Bablok regression analysis.

Results: On DSA, a clot was present in 85 patients, in 126 of 1190 (10.6%) arteries and 175 of 1870 (9.4%) segments. Sensitivity of the SVS, as sensed by the used protocol at 1.5 T, was 81.1% (69 of 85 patients) and was higher in anterior (55 of 63, 87.3%), than in posterior circulation stroke (14 of 22, 63.6%, p=0.02). Sensitivity/specificity was 69.8/99.6% (per artery) and 76.6/99.7% (per segment). Positive (PPV) and negative predictive value (NPV) and accuracy were all >94%. Inter- and intra-observer ICC was excellent for clot length as measured on T2* (ĸ ≥ 0.97) and as measured on DSA (ĸ ≥ 0.94). Correlation between T2* and DSA for clot length was excellent (ICC: 0.88, 95%CI: 0.81-0.92; Bland & Altman: mean bias of 1.6% [95%CI: -4.7 to 7.8%], Passing & Bablok: 0.91).

Conclusions: SVS is a specific marker of clot location in the anterior and posterior circulation. Clot length greater than 6 mm can be reliably measured on T2*.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Segmentation of intracranial arteries.
Figure 1. Segmentation of intracranial arteries.
Time-of-flight MR angiography of intracranial internal carotid arteries (A) and of the vertebrobasilar arteries (B). Paired arteries were: supraclinoid internal carotid artery (scICA), anterior cerebral arteries (ACA), posterior cerebral arteries (PCA), middle cerebral arteries (MCA), intracranial vertebral arteries (V4), posterior communicating arteries (PComA, not shown), postero-inferior (PICA) cerebellar arteries. Odd arteries were basilar artery (BA) and anterior communicating arteries (AComA). Each ACA was divided into 2 segments: precommunicating anterior cerebral artery (A1) and pericallosal artery (A2). Each PCA was divided into 3 segments: precommunicating PCA (P1) and distal PCA (P2, P3). MCA was divided into 4 segments: proximal part (M1) divided into two segments (M1a, proximal, M1b, distal), insular segment (M2), and opercular segment (M3). Basilar artery was divided into 3 segments (proximal, pBA; medial: mBA; distal: dBA).
Figure 2. Flowchart of patients.
Figure 2. Flowchart of patients.
Figure 3. Illustrative examples of complex internal…
Figure 3. Illustrative examples of complex internal carotid artery terminus and basilar artery occlusion.
Right internal carotid artery terminus (ICA) occlusion seen on catheter angiogram (profile projection, A). A susceptibility vessel sign (arrow) was present on T2* sequence in the right supraclinoid ICA, seen as a dramatic signal loss by comparison with contralateral ICA (dotted arrow). Clot of the basilar tip (arrow) and the left P1 segment (dotted arrow) seen on catheter angiogram (frontal projection, C). A susceptibility vessel sign (D) was seen in the same locations (basilar tip, arrow and P1 segment, dotted arrow).
Figure 4. Illustrative example of clot length…
Figure 4. Illustrative example of clot length measurement on DSA and T2*.
Occlusive MCA clot on frontal projection of catheter angiogram (A) and T2* (B).

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