Monocyte/Macrophage Infiltration in Thrombus and Outcomes of Stroke Patients with Monocyte/Macrophage-dominant Thrombus

Abstract

Background

Inflammatory cells may play a role in thrombus formation. However, the impact of monocytes in thrombosis and clinical characteristics of patients with monocyte-rich thrombus are less well understood.

Methods

A FeCl₃-induced carotid thrombosis model in mice was used to study aged thrombus by ligating the distal carotid artery for 0.5, 1, 2, 3, 6, 24, 48, or 72 hours. In stroke patients, we used thrombi that were obtained during endovascular thrombectomy. Immunohistochemistry was performed to determine thrombus composition. We investigated monocyte/macrophage recruitment to arterial thrombus over time in mice, and compared clinical outcomes between stroke patients with the higher and the lower monocyte/macrophage compositions in thrombus.

Results

In 90 mice, CD68 (monocyte/macrophage) counts increased from 3 hours in a time-dependent manner, and decreased after 48 hours (p < 0.001). In 102 stroke patients, the higher monocyte/macrophage group had higher blood platelet counts (median 228 × 10⁹/L, interquartile range [177–267] versus median 186 × 10⁹/L, interquartile range [164–225], p = 0.036), less frequently parenchymal hematoma (8.0% versus 28.8%, p = 0.007), and more frequently functional independence (54.0% versus 32.7%, p = 0.030). In multivariable logistic regression analysis, the higher monocyte/macrophage group was independently associated with functional independence (odds ratio 4.954, 95% confidence interval 1.467–16.724, p = 0.010).

Conclusion

Monocytes/macrophages increasingly infiltrated the thrombus after a few hours in mouse arterial thrombosis model, suggesting their role in later stages rather than initial stages of thrombosis. Stroke patients with higher monocyte/macrophage counts had less frequent parenchymal hematoma and more frequent functional independence, suggesting that monocyte/macrophage-rich thrombi are a predictor of better clinical outcomes.

Keywords

monocyte/macrophage - thrombosis - stroke - endovascular thrombectomy - functional outcome

• References

• 1 Engelmann B, Massberg S. Thrombosis as an intravascular effector of innate immunity. Nat Rev Immunol 2013; 13 (01) 34-45
• 2 Laridan E, Martinod K, De Meyer SF. Neutrophil extracellular traps in arterial and venous thrombosis. Semin Thromb Hemost 2019; 45 (01) 86-93
• 3 Goyal M, Menon BK, van Zwam WH. et al; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387 (10029): 1723-1731
• 4 Heo JH, Nam HS, Kim YD. et al. Pathophysiologic and therapeutic perspectives based on thrombus histology in stroke. J Stroke 2020; 22 (01) 64-75
• 5 Riegger J, Byrne RA, Joner M. et al; Prevention of Late Stent Thrombosis by an Interdisciplinary Global European Effort (PRESTIGE) Investigators. Histopathological evaluation of thrombus in patients presenting with stent thrombosis. A multicenter European study: a report of the prevention of late stent thrombosis by an interdisciplinary global European effort consortium. Eur Heart J 2016; 37 (19) 1538-1549
• 6 Cha MJ, Ha J, Lee H. et al. Neutrophil recruitment in arterial thrombus and characteristics of stroke patients with neutrophil-rich thrombus. Yonsei Med J 2022; 63 (11) 1016-1026
• 7 Boeckh-Behrens T, Schubert M, Förschler A. et al. The impact of histological clot composition in embolic stroke. Clin Neuroradiol 2016; 26 (02) 189-197
• 8 Radzyukevich YV, Kosyakova NI, Prokhorenko IR. Participation of monocyte subpopulations in progression of experimental endotoxemia (EE) and systemic inflammation. J Immunol Res 2021; 2021: 1762584
• 9 Tutwiler V, Madeeva D, Ahn HS. et al. Platelet transactivation by monocytes promotes thrombosis in heparin-induced thrombocytopenia. Blood 2016; 127 (04) 464-472
• 10 von Brühl ML, Stark K, Steinhart A. et al. Monocytes, neutrophils, and platelets cooperate to initiate and propagate venous thrombosis in mice in vivo. J Exp Med 2012; 209 (04) 819-835
• 11 Kwon I, Hong SY, Kim YD. et al. Thrombolytic effects of the snake venom disintegrin saxatilin determined by novel assessment methods: a FeCl3-induced thrombosis model in mice. PLoS One 2013; 8 (11) e81165
• 12 Shim Y, Kwon I, Park Y. et al. Characterization of ferric chloride-induced arterial thrombosis model of mice and the role of red blood cells in thrombosis acceleration. Yonsei Med J 2021; 62 (11) 1032-1041
• 13 Park H, Kim J, Ha J. et al. Histological features of intracranial thrombi in stroke patients with cancer. Ann Neurol 2019; 86 (01) 143-149
• 14 Heo J, Seog Y, Lee H. et al. Automated composition analysis of thrombus from endovascular treatment in acute ischemic stroke using computer vision. J Stroke 2022; 24 (03) 433-435
• 15 Heo J, Lee H, Seog Y. et al. Cancer prediction with machine learning of thrombi from thrombectomy in stroke: multicenter development and validation. Stroke 2023; 54 (08) 2105-2113
• 16 Rittersma SZ, van der Wal AC, Koch KT. et al. Plaque instability frequently occurs days or weeks before occlusive coronary thrombosis: a pathological thrombectomy study in primary percutaneous coronary intervention. Circulation 2005; 111 (09) 1160-1165
• 17 Adams Jr HP, Bendixen BH, Kappelle LJ. et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24 (01) 35-41
• 18 Higashida RT, Furlan AJ, Roberts H. et al; Technology Assessment Committee of the American Society of Interventional and Therapeutic Neuroradiology, Technology Assessment Committee of the Society of Interventional Radiology. Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 2003; 34 (08) e109-e137
• 19 Yaghi S, Willey JZ, Cucchiara B. et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Quality of Care and Outcomes Research. Treatment and outcome of hemorrhagic transformation after intravenous alteplase in acute ischemic stroke: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2017; 48 (12) e343-e361
• 20 Yang J, Zhang L, Yu C, Yang XF, Wang H. Monocyte and macrophage differentiation: circulation inflammatory monocyte as biomarker for inflammatory diseases. Biomark Res 2014; 2 (01) 1
• 21 Han Z, Liu Q, Li H. et al. The role of monocytes in thrombotic diseases: a review. Front Cardiovasc Med 2023; 10: 1113827
• 22 Frantz S, Hofmann U, Fraccarollo D. et al. Monocytes/macrophages prevent healing defects and left ventricular thrombus formation after myocardial infarction. FASEB J 2013; 27 (03) 871-881
• 23 Lambert JM, Lopez EF, Lindsey ML. Macrophage roles following myocardial infarction. Int J Cardiol 2008; 130 (02) 147-158
• 24 Troidl C, Möllmann H, Nef H. et al. Classically and alternatively activated macrophages contribute to tissue remodelling after myocardial infarction. J Cell Mol Med 2009; 13 (9B): 3485-3496
• 25 Mantovani A, Biswas SK, Galdiero MR, Sica A, Locati M. Macrophage plasticity and polarization in tissue repair and remodelling. J Pathol 2013; 229 (02) 176-185
• 26 Medzhitov R. Origin and physiological roles of inflammation. Nature 2008; 454 (7203): 428-435
• 27 Nicklas JM, Gordon AE, Henke PK. Resolution of deep venous thrombosis: proposed immune paradigms. Int J Mol Sci 2020; 21 (06) 2080
• 28 Bystrom J, Evans I, Newson J. et al. Resolution-phase macrophages possess a unique inflammatory phenotype that is controlled by cAMP. Blood 2008; 112 (10) 4117-4127
• 29 Ali T, Humphries J, Burnand K. et al. Monocyte recruitment in venous thrombus resolution. J Vasc Surg 2006; 43 (03) 601-608
• 30 Kaesmacher J, Boeckh-Behrens T, Simon S. et al. Risk of thrombus fragmentation during endovascular stroke treatment. AJNR Am J Neuroradiol 2017; 38 (05) 991-998
• 31 Ye G, Qi P, Chen K. et al. Risk of secondary embolism events during mechanical thrombectomy for acute ischemic stroke: a single-center study based on histological analysis. Clin Neurol Neurosurg 2020; 193: 105749
• 32 Baek J-H, Kwon I, Kim S. et al. Histological determination of thrombus fragility in endovascular thrombectomy for acute stroke. J Stroke 2024
• 33 Mestas J, Hughes CC. Of mice and not men: differences between mouse and human immunology. J Immunol 2004; 172 (05) 2731-2738
• 34 Chistiakov DA, Killingsworth MC, Myasoedova VA, Orekhov AN, Bobryshev YV. CD68/macrosialin: not just a histochemical marker. Lab Invest 2017; 97 (01) 4-13