Predictive value of thrombus enhancement sign for stroke subtype and recanalization in acute basilar-artery occlusion

Background: Thrombus enhancement sign (TES) is associated with cardioembolic stroke and first-pass angiographic failure in anterior ischemic stroke. However, the relationship between TES and stroke subtype and recanalization status after endovascular treatment (EVT) in basilar artery occlusion (BAO) remains unknown. Methods: This retrospective study included consecutive patients with acute BAO who underwent EVT between January 2020 and September 2023. Each patient underwent baseline non-contrast computed tomography (CT) and CT angiography. Two independent readers assessed the presence of TES. Stroke types were classified according to the Trial of ORG 10172 for Acute Stroke Treatment. Successful recanalization was defined as a modified Thrombolysis in Cerebral Infarction score of 2b–3 after EVT. Clinical and interventional parameters, along with histopathological thrombi examination results, were compared between the TES-positive and TES-negative groups. The associations between TES and stroke subtype and recanalization status were analyzed using univariate and multivariate analyses. Results: A total of 151 patients were included in the analysis, among whom 116 (77%) exhibited TES. TES showed a significant correlation with cardioembolic and cryptogenic strokes (odds ratio OR: 8.56; 95% confidence interval: 3.49–22.4; p < 0.001), whereas the TES-positive thrombi were characterized by a higher fibrin/platelet proportion ( p = 0.002) and lower erythrocyte proportion ( p = 0.044). The TES-positive group demonstrated favorable outcomes compared to the TES-negative group, including a shorter procedure time ( p < 0.001), lower number of thrombectomy attempts ( p = 0.010), higher incidence of first pass success ( p = 0.022), and lower rate of requiring rescue angioplasty and/or stenting ( p < 0.001). In multivariate analysis, TES remained independently associated with successful recanalization (OR: 9.63; 95% CI: 2.33, 47.7; p = 0.003) after adjusting for baseline confounders. Conclusions: Visualization of TES serves as a reliable and easily accessible marker for identifying cardioembolic and cryptogenic strokes and predicting recanalization success in thrombectomy for basilar artery occlusion.