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LOT-910 exam Dumps Source : IBM WebSphere Portal 7.0 Deployment and(R) Administration Update
Test Code : LOT-910
Test Name : IBM WebSphere Portal 7.0 Deployment and(R) Administration Update
Vendor Name : IBM
: 44 Real Questions
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Perficient, Inc. PRFT, +0.ninety four% (“Perficient”), a leading digital transformation consulting firm serving world 2000® and other big business consumers right through North america, introduced it has been named IBM’s 2019 Watson Commerce enterprise associate of the yr. The IBM Excellence Award, introduced during IBM’s PartnerWorld at believe 2019, acknowledges Perficient’s ongoing increase and relationships with key valued clientele, and idea leadership across the IBM Watson client Engagement Commerce platform as an integral part for digital transformation.
“Our strategy to commerce is concentrated on crafting a event, connecting with shoppers, and supplying a seamless consumer event across channels and all through the commercial enterprise, imperatives in these days’s purchaser-pushed world,” stated Steve Gatto, countrywide income director, Commerce options, Perficient Digital. “collectively, with their customers, we’re reworking businesses in a way that not handiest drives boom however strengthens their standard company, and they continually evolve their choices to preserve customers at the excellent of their game. We’re honored to be recognized by using IBM, and we’re anticipating sharing their creative solutions all over IBM believe 2019.”
Perficient Digital Takes Commerce options beyond Transactions to seriously change the client Lifecycle for a world different brand
With branded manufacturers and distributors beneath force from the dramatic shift to on-line buying, a world diverse company sought to digitally radically change its commerce company. In partnership with Perficient Digital, both organizations delivered optimized customer sales, updated product assistance (PIM), and streamlined the ordering system via building of a B2B portal. With the implementation of IBM’s Sterling Order management equipment (OMS), and Perficient’s abilities, the diverse brand is future-proofing its enterprise to align with industry tendencies and market opportunities.
additionally, the business’s OMS will provide them more advantageous flexibility in managing advanced order administration eventualities, superior reliability in order processing and fulfilment, and a cost reduction in implementing throughout its business. it'll additional allow the company to deliver service enhancements to its consumers, optimize its pricing, promotion and general supply chain, enhance sales as a result of greater inventory visibility, and in the reduction of expenses through more desirable efficiencies in order visibility.
Perficient Digital Enhances the on-line consumer event for a leading fabric Retailer
In a market that has historically trusted brick-and-mortar experiences, a leading fabric and craft retailer was challenged with extending the customer experience online. Perficient partnered with the business to put into effect an IBM Watson Commerce solution that provided up-to-date visibility of its inventory and stronger tracking of its product volume, vicinity, and availability. employing IBM Order management, Perficient additional better the solution via cloud migration that presents a single view of supply and demand, orchestrates order fulfillment processes throughout buy on-line Pickup In keep (BOPIS) and Ship-from-keep (SFS), and empowers business representatives to superior serve purchasers each in call facilities and in-save engagements.
“Perficient has been deploying IBM Commerce solutions for just about two decades, providing end-to-conclusion digital commerce solutions that embody multiple channels, and bring seamless and efficient experiences across their complete commercial enterprise,” said Sameer Peera, popular manager, Perficient’s commerce apply. “With the contemporary information that HCL took over building of IBM WebSphere Portal, IBM web content material management and internet adventure factory, their valued clientele continue to interact us for assist with their digital commerce recommendations. We’re glad to be their go-to accomplice as they navigate the changing market landscape and deliver for his or her consumers.”
Perficient abilities in action at IBM feel 2019
apart from its award-successful commerce solution potential, Perficient specialists are reachable during the IBM feel 2019 convention in booth #320 to talk about its event and talents throughout the IBM portfolio , principally cloud, cognitive, information, analytics, DevOps, IoT, content material administration, BPM, connectivity, commerce, mobile, and consumer engagement.
whereas IBM has announced its plans to sell its commerce portfolio, the information of its acquisition of crimson Hat additionally signaled the criticality cloud development and birth play in successful end-to-end digital transformations. As an IBM world Elite associate, certainly one of best seven companions with that popularity globally, and a purple Hat Premier accomplice, Perficient is well placed to work with both agencies via this transition. And, their experts can be available right through IBM consider to talk about how to navigate the cloud market, share key customer success reviews, and provide strategic capabilities on the opportunities forward for valued clientele.
“technology is altering so hastily, and agencies deserve to preserve pace or face disruption,” observed Hari Madamalla, vice chairman, rising options, Perficient. “With talents and event in all aspects of the commerce experience, to main cloud, internet hosting, managed features and aid solutions, organisations turn to Perficient as a go-to associate for their digital transformations.”
be part of a number of Perficient area matter specialists and their customers as they existing all through six IBM believe classes, including:
As a Platinum IBM company associate, Perficient holds more than 30 awards across its 20-12 months partnership historical past. The enterprise is an award-successful, licensed application value Plus answer company and some of the few partners to acquire dozens of IBM skilled level utility competency achievements.
For updates all the way through the experience and after, join with Perficient experts on-line with the aid of viewingPerficient and Perficient Digital’s blogs, or follow us on Twitter@Perficient and @PRFTDigital.
Perficient is the leading digital transformation consulting company serving world 2000® and business purchasers right through North the us. With unparalleled counsel technology, management consulting, and creative capabilities, Perficient and its Perficient Digital company deliver imaginative and prescient, execution, and cost with miraculous digital journey, company optimization, and trade solutions. Their work makes it possible for customers to increase productiveness and competitiveness; develop and toughen relationships with consumers, suppliers, and partners; and cut back charges. Perficient's gurus serve consumers from a network of workplaces across North the united states and offshore areas in India and China. Traded on the Nasdaq global opt for Market, Perficient is a member of the Russell 2000 index and the S&P SmallCap 600 index. Perficient is an award-winning Adobe Premier associate, Platinum degree IBM enterprise partner, a Microsoft country wide service company and Gold CertifiedPartner, an Oracle Platinum partner, an advanced Pivotal competent partner, a Gold Salesforce Consulting accomplice, and a Sitecore Platinum associate. For extra counsel, visitwww.perficient.com.
safe Harbor commentary
one of the most statements contained in this information unencumber that aren't merely old statements talk about future expectations or state other forward-looking assistance regarding fiscal effects and enterprise outlook for 2018. these statements are area to established and unknown hazards, uncertainties, and other factors that might cause the actual outcomes to differ materially from those reflected by the statements. The ahead-looking tips is based on administration’s existing intent, perception, expectations, estimates, and projections involving their company and their trade. remember to be conscious that these statements handiest replicate their predictions. precise routine or consequences may additionally fluctuate significantly. important elements that may cause their actual consequences to be materially different from the forward-searching statements consist of (however don't seem to be limited to) those disclosed beneath the heading “possibility components” in their annual document on kind 10-k for the year ended December 31, 2017.
View source version on businesswire.com: https://www.businesswire.com/information/home/20190212005973/en/
supply: Perficient, Inc.
Ann Higby, PR manager, Perficient, firstname.lastname@example.org
Copyright enterprise Wire 2019
newsIBM Buffs workplace and WebSphere Portal
The solutions supply customizable business functions for certain industries or classes of enterprise projects and operations – all developed the use of IBM office products and selected third-celebration purposes.
although most likely a cliché by using now, IBM officers additionally endured to emphasize the adjustments between a “network-delivered” collaboration ambiance and one based essentially on own computers – notably Microsoft’s view. “[With Workplace Solutions] you would not have to have Microsoft workplace,” says Larry Bowden, vice chairman, of IBM place of work utility options.
IBM designed the solutions by discovering the job roles required for performing normal sets of projects or operations inside a collection of vertical markets. on the same time, it considered a way to put into effect horizontal company roles within regular businesses’ IT environments, together with procurement, finance and administration, consumer provider, and human elements. the new office solutions supply integrated software units that meet at that nexus; for example, methods to supply branch banking or retail keep administration services.
“They’ve taken training out of IBM’s services group and . . . they have designed these packages to make these people with the key business roles greater advantageous,” says Robert Mahowald, analysis supervisor at IDC. That should still, the reasoning goes, make those companies that adopt these solutions extra a success.
because the solutions and IBM workplace items guide business specifications, together with Java and XML, different items can also be integrated with different programs as neatly. IBM place of work contains Lotus place of work, WebSphere Portal, Lotus Notes and Domino, and WebSphere Everyplace, according to the company’s net site.
“Our focal point is on organizational productiveness,” says Bowden, adding, “Having a aggressive aspect is not as good as having a sustainable competitive facet.”
really, imposing whole integrated systems in keeping with the services that a company needs to function as neatly because the roles of the americans who perform the essential tasks, and presenting that to shoppers in a solution kit that is the next neatest thing – or so IBM officers hope – to a turnkey solution, offers that sustainable side, enterprise executives post.
The solutions don’t do every little thing. Implementation details remain but IBM’s intent is to take a part of the pain out of the system for small and medium-sized groups that don’t have a division committed to offering IT. “Why don’t they get you 70 percent of how?” asks Bowden rhetorically.
in one of IBM’s demonstration eventualities, a financial institution department teller receives a huge determine and wishes to acquire the approval of a customer service adult, and also must clear the deposit for regulatory compliance and auditing. The branch banking answer provides job roles for three diverse employee task sets to fulfill the necessary enterprise functions. certainly, the brand new workplace solutions embody greater than 30 job capabilities or worker roles, company spokespeople mentioned.
among the areas where IBM is providing new workplace solutions are: retail, electronics, manufacturing, finance, telecommunications, executive, life sciences, healthcare and car groups. moreover, the enterprise has updated its department Banking answer in addition to its business Controls and Reporting solution (now at version 2.5).
fundamentally, youngsters, IBM is taking a a little diverse tack on coopetition. To corporations like Oracle, SAP and PeopleSoft, “They’re saying, ‘we’re going to give the plumbing for you,’” says IDC’s Mahowald, leaving a part of the pie for different players.
IBM will also begin providing on demand net conferencing next month, officials referred to. “if you have a browser and a cellphone, that you could installation a web convention,” Bowden says. “instead of buying the application from us, which you could just buy the carrier.” This comes as an immediate try to take enterprise away from Microsoft’s reside assembly, says Mahowald.
additionally, IBM also introduced a new product within the office family unit. IBM office functions express v2.0 is a brand new product designed for small and mid-sized organizations and departments in massive corporations. It contains crew collaboration, doc administration, net kinds, project lists, and portal services as neatly person customization features. IBM workplace services categorical additionally integrates with the user's existing purposes and records, as well as electronic mail, calendar and handle publication, and offers more than a few collaboration equipment including integrated instant messaging. it'll ship in December, officers referred to.
ultimately, IBM debuted the newest free up of WebSphere Portal – version 5.1 – which adds virtual portals, company procedure workflow facets, and more advantageous content management capabilities. edition 5.1 may be attainable via the end of November.
The company will announce pricing for all of the products and functions when the items can be found, enterprise officials stated.
Stuart J. Johnston has coated expertise, primarily Microsoft, on the grounds that February 1988 for InfoWorld, Computerworld, tips Week, and workstation World, in addition to for business Developer, XML & net features, and .internet magazines.
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SharePoint Server 2007, released last fall, arrives at a time when corporations are focused on regulatory compliance and a new generation of blog and wiki users is entering the workforce. To date, most corporations use SharePoint for workgroup collaboration. But Peter O'Kelly, a senior analyst at the Burton Group, a consulting firm in Midvale, Utah, told SearchWinIT.com that IT managers working hard to get control of their content should take a fresh look at today's collaboration tools for enterprise content management.
SearchWinIT.com: SharePoint has been around for a long time. Why should IT shops pay attention now?
Peter O'Kelly: The most important change is the level of integration that has taken place. Proprietary tools today work in silos – records management, Web content management, file management. So, if you're already committed to Windows Server, SQL Server and maybe Exchange, [then adding SharePoint] will give you good synergy. Also, it's not just about IT managers working with familiar tools and services but also end users being able to use a browser and [Microsoft Office] instead of being trained on specialized tools.
But [SharePoint] is not for everybody. If you need to run Linux, if you are primarily a Java shop from an application development standpoint, then you can't play.
Has SharePoint caught up to Notes in terms of its corporate entrenchment?
O'Kelly: SharePoint may be 'stealthy,' but it is well used. There are two elements to SharePoint: One is Windows SharePoint Services, which is free, although you do need a SQL Server CAL [client-access license] to do anything meaningful. Then there is the product you pay for, which until 2007 was called SharePoint Portal Server 2003. Now it's called Microsoft Office SharePoint Server 2007. Microsoft says it has sold more than 85 million CALs. Notes is the most broadly deployed incumbent today with about 130 million [CALs], but Notes has been out there since 1989.
There is a series of major advances with [SharePoint] 2007. With [SharePoint] 2003, most people thought of it as a department-level portal. They use it for basic workspaces, document libraries and team discussions. With 2007, the product is more credible for enterprise content management. SharePoint is really the server side component for Microsoft Office. Instead of using file servers, you will capture content [in SharePoint].
So you can replace a lot of individual tools by using these platforms?
O'Kelly: There are things you can do with SharePoint, such as records management and workflow. Organizations use file servers to share files among applications. But file servers are not good for people. With people, it's better to go with a Web-centric view where you don't have to copy files to a file server. It's not a replacement for a file system like SQL Server.
There is a stark reality for a lot of organizations and that is large, publicly traded companies are out of compliance. Like Y2K, you have to inventory and fix this stuff. But the reality is companies don't have control over their content -- and not just documents.
There are things in database management systems, but historically those are more transaction-oriented document management systems. The vast majority of content today is on file servers, or local hard disks or email and email with file attachments. All of that needs to get under control. [Regulatory] compliance is helping.
What about the corporate cultural barriers that might keep companies from adopting these tools?
O'Kelly: This has been the biggest challenge. If you don't work in an organization that fosters collaboration, then you are wasting your money. You see this sort of thing in sales where the person who sits next to you would just as soon kill you than give you information. It's easier for people who are new to the workforce who are already doing this stuff. Some of them will find their way to SharePoint.They come to work and want to use blogs and wikis and would rather not have a rogue open source project under their desk.
Will IT shops have to invest a lot of time in training end users?
O'Kelly: What they need to do is get people to unlearn some things. In the past they've had to copy and paste, but people naturally default to email and file attachments. That's why blogs and wikis are so popular. They are consistent with the way people work. It's a breakthrough of simplicity.
Compare IBM and Microsoft collaboration strategies. How do you choose between them?
O'Kelly: Start at the top. How much do you care about things like Java and support for non-Microsoft platforms? Do you care about non-Microsoft server platforms and non-Microsoft developer tools? If you do, you need to look at more competitive alternatives.
So take that out of the equation. What I'm looking for is browser-oriented content and collaboration, and I have an email strategy so I'm not looking for an email strategy with content and collaboration. So then it's SharePoint versus [IBM] WebSphere Portal. WebSphere Portal will soon be extended with QuickR [file sharing software], which is an easy to work with browser-based experience. There is also Oracle WebCenter, though it has almost zero brand and market awareness.
[Now, take] it further. I need to support multiple rich client platforms. I have Windows, Mac and Linux and I need to take work offline. Then you have to go down a path where Notes looks unique. Notes and [Microsoft] Groove are the only products now that can take things offline for content management.
If I'm leaning toward IBM, do I go with a WebSphere core or a Notes/Domino core? IBM's biggest challenge is market perception of its products. Notes is not seen as obsolete but a late-in-life product. With the release of Notes 8, IBM needs to get people to take a look so they can see it's not a 1990s piece of software.
Where there’s victory, there’s also opportunity…
This Presidential election was profound in its results. Obama won both the Electoral College vote 364 to 163 and the popular vote 53% to 46% with roughly 120,000,000 votes cast. This election was the first in 50 years, in which there was no incumbent President or Vice President from either party competing for the Presidential nomination. Close to 65% of the American population voted in this election, its highest turnout since the election of 1908.
With Obama’s wins in key “swing states” including Ohio, Florida, Colorado, and Pennsylvania, this election was nothing short of a landslide victory that fundamentally redrew America’s political dynamics. A Democrat had not won Virginia and Indiana in a generation.
But let’s examine the election another way, one that may bring to life a different picture of how Obama earned his place in history. His campaign both redrew political lines and also forever changed the way candidates reach out to constituents.
Online tools such as Facebook, MySpace, and Twitter contributed to the netting of record-breaking campaign funding and the staggering galvanization of a younger generation of first-time voters who truly made an impact and a difference. The Obama campaign, for example, outspent McCain nearly three-to-one, which was a testament to the capabilities of technology and the corresponding impact of sociology let loose on the Web. The Obama campaign leveraged multiple technology platforms and social immersion strategies to engage constituents directly, raising an astounding $660 million in campaign contributions.
They went directly to the people.
The Obama team, for example befriended almost 130,000 friends on Twitter with an almost equal amount following him.
On Facebook, the Obama page boasted over three million fans compared to McCain’s 618,000.
YouTube also swayed towards Obama with a network of 358,000 to 191,000, with the Obama camp posting over 1,800 videos compared to McCain’s 330. These videos accounted for 110 million views.
If you compare the other social networks and communities from FriendFeed to MySpace to Flickr, the stats are asymmetrical in Obama’s partiality.
Many of these two-way tools however, were simply used as broadcast mechanisms to send updates, solicit contributions, provide updates, and to also rally and unite supporters, albeit successfully.
Reaching the other 46%
My question is: What if these same social media tools where deployed to not only communicate “to” constituents, but also to listen and interact with supporters as well as those who don’t currently endorse the President-elect?
Over 46% of America voted against Barrack Obama, with 22 states going to John McCain, regardless of weight in the Electoral College. Either way you look at it, that’s still a significant portion of America who didn’t believe #change or #hope were attributes of the Obama campaign. These voters believed their future lay with another candidate.
Whether you’re a Democrat, Republican, Independent or member of the Green Party, you cannot overlook the power of real world community relations combined with the reach and engagement of online social communities and networks to change politics as usual.
If Obama dedicates a team aside from the outbound crew that “pushes” content through social channels in order to strategically reach, listen to, and embrace the 46% who voted against him, he might be able to run a truly democratic term. It could also curtail the necessity to campaign as much while in office in order to focus on the issues they elected him to fix
All signs and words emanating from the Obama camp and Mr. Obama himself, point to a strategy of leveraging today’s powerful, two-way bridges of communication.
In a text message sent to supporters on the eve of the election, he reaffirmed that they will be part of the Presidency moving forward, “We have a lot of work to do to get their country back on track, and I’ll be in touch soon about what comes next.”
But perhaps the most revealing promise that showed Mr. Obama will run his office for all the people of the United States, not just those who voted for him, was shared through his words on November 4th:
I will listen to you, especially when they disagree…and to those Americans whose support I have yet to earn, I may not have won your vote tonight, but I hear your voices. I need your help. And I will be your President, too.
His first step towards bringing the vision of running a cross-party campaign is the launch of Change.gov, a portal for transparency and interaction during, and hopefully past, the transition.
In a sense, Change.gov is a simple and engaging site, but also highly intricate in its goals to give voters a voice. It is a resource center for sharing information, updates, jobs, and also provides a channel for people who share their vision, concern, and ideas with the President and his advisors through text, images or video.
Mr. Obama offers this message to visitors:
I ask you to believe - not just in my ability to bring about change, but in yours. I know this change is possible…because in this campaign, I have had the privilege to witness what is best in America.
Change.gov is the first step in a long road of reshaping the dynamics of politics and communication with voters.
They’re on the right track however.
Obama’s history-making campaign that fused community relations with social sciences, after all, carried him to the Democratic nomination and also the Oval Office. Mr. Obama and his team have cultivated and collaborated with a database of millions of people that spans a sophisticated contact relationship management infrastructure that spans across the real world to all popular social networks.
With an elaborate and revolutionary channel that will only grow with his Presidency, Obama takes office with a powerful new medium that may eclipse the reach and drive of traditional broadcast media.
But, what about those who voted against him?
What’s the channel for Obama to ask, “Why didn’t I get your vote?” Is it Change.gov or is it through the combination of inbound and outbound engagement that will unearth the key concerns that offer genuine potential for not just listening, but also intelligent response and earned support?
It’s a two way street.
This isn’t just about broadcasting content through new channels or merely soliciting feedback, participating in popular networks or actively listening. It’s the ability to identify and internalize themes to precipitate change and earn support through action—not just words.
For the first time, the U.S. President can cultivate grassroots communities directly where people create, discover, and share information online. He is already thinking in this direction, as evidenced by his intention to record the weekly Presidential address on Youtube, in addition to broadcasting it over the radio. The videos will be hosted on Change.gov, with the first one already recorded.
Other opportunities to engage with citizens online include:
- Launch a social network at Change.gov and/or whitehouse.gov
- Create a citizen feedback and collaboration page at GetSatisfaction
-Solicit policy proposals that people can vote up or down on Change For Us.
- Open the blog to comments on Change.gov (with community moderation).
- Address the country on YouTube with updates, polls, and also address issues in between official State of the Union broadcasts.
- Capture behind-the-scenes footage of the inner workings of the White House and share across all video networks.
- Create a user-generated channel on Magnify.net that features content from constituents.
-Create an @obamacares or @whitehousecares account on Twitter and other micro-blogging communities to listen and respond directly within each network.
- Complement the Presidential radio show with a regular podcast or livecast on uStream.tv or BlogTalkRadio and also interact with the people online, in real time.
- Publish speeches and important policy documents on document networks such as Scribd and Docstoc to be shared and disseminated throughout blogs and personal social profile pages.
(What other ideas do you have? Add them to comments).
This is how a President, or any politician or business for that matter, can authentically connect with the people formerly known as the audience—in the real world.
Treat us like customers
Most, successful businesses around the world place customers at the center of everything. Before the Web, for instance, Nordstrom built its engendering foundation on world-class, and now world famous, customer care.
There’s an extraordinary opportunity here for the White House to leverage these new and influential channels of conversation to embrace and cultivate voters as if they were customers, winning market share, one person at a time.
This is an era in which information is democratized. The Web potentially offers a live and unfiltered looking glass into the office of the Presidency and also the thoughts, insights, support, satisfaction, and grievances of the American people.
The Web cuts through political tape to spotlight the issues that matter most to the electorate. It creates the foundation for people to participate in a truly democratic, crowd-sourced Government that can directly channel their discontent or new ideas.
It’s through this collaboration that any public official, particularly the President, could continually maintain a real-time pulse of the country to learn from the very human effects and responses to government actions to run a more in-tune and effective administration.
People shouldn’t only have a voice during an election time; listening and responding should be an ongoing practice and process of any office. This is a political ecology rooted in sociology and conversations. It’s the art and science of stripping down the politics to reveal the truth.
The President can’t satisfy everyone, that’s just the reality. It’s human nature to disagree. This President-elect is not purporting to be perfect, but it seems he’s honestly willing to learn. With a national chief technology officer in place, combined with an informed engagement team versed in social sciences and psychology, he can use technology and two-way channels to not only increase economic efficiencies and boost education and media literacy, but also to “listen” to those influential beacons in order to continue to redraw, or potentially erase, party lines.
In my techtopian dreams, I hope that these incredible networks remain a constant source of conversation to extend beyond campaigning, but also collaborative governance that unites people.
It’s not about being Republican or a Democrat, it’s about representing the majority of the people, their views, passions, ambitions and struggles, in order to be a representative of the people for the people. This is Obama’s opportunity to use the tools and channels of today’s emerging voter demographics to rewrite the future of politics, while serving the best interests of the American people in the process.
Sometimes the best advisors and cabinet members are the very people who elected that person into office, and maybe, just maybe, also those who voted against him in the first place.
If the Obama camp reads this, I’m more than happy to release @obamacares and @whitehouse cares on Twitter. I held them for you.
Crunch Network: MobileCrunch Mobile Gadgets and Applications, Delivered Daily.
BACKGROUND AND PURPOSE: The prevalence and clinical importance of primarily fragmented thrombi in patients with acute ischemic stroke remains elusive. Whole-brain SWI was used to detect multiple thrombus fragments, and their clinical significance was analyzed.
MATERIALS AND METHODS: Pretreatment SWI was analyzed for the presence of a single intracranial thrombus or multiple intracranial thrombi. Associations with baseline clinical characteristics, complications, and clinical outcome were studied.
RESULTS: Single intracranial thrombi were detected in 300 (92.6%), and multiple thrombi, in 24 of 324 patients (7.4%). In 23 patients with multiple thrombi, all thrombus fragments were located in the vascular territory distal to the primary occluding thrombus; in 1 patient, thrombi were found both in the anterior and posterior circulation. Only a minority of thrombus fragments were detected on TOF-MRA, first-pass gadolinium-enhanced MRA, or DSA. Patients with multiple intracranial thrombi presented with more severe symptoms (median NIHSS scores, 15 versus 11; P = .014) and larger ischemic areas (median DWI ASPECTS, 5 versus 7; P = .006); good collaterals, rated on DSA, were fewer than those in patients with a single thrombus (21.1% versus 44.2%, P = .051). The presence of multiple thrombi was a predictor of unfavorable outcome at 3 months (P = .040; OR, 0.251; 95% CI, 0.067–0.939).
CONCLUSIONS: Patients with multiple intracranial thrombus fragments constitute a small subgroup of patients with stroke with a worse outcome than patients with single thrombi.ABBREVIATION: SVS susceptibility vessel sign
Little is known about the proportion of acute ischemic strokes caused by multiple intracranial thrombi. Rarely, distal thrombus fragments that are separate from the primary occluding thrombus can be detected on DSA. Incomplete vessel occlusion by the primary thrombus with distal passage of contrast is required for this observation. Therefore, the true prevalence of multiple intracranial thrombi in the stroke population and the implications for clinical outcome remain unknown.
Advanced gradient-echo-based MR imaging sequences, such as SWI, are highly sensitive in distinguishing structures that have different susceptibility values than their surroundings (eg, deoxygenated blood, hemosiderin, ferritin, or calcium).1 SWI offers the possibility to directly visualize thrombotic material, commonly referred to as the susceptibility vessel sign (SVS), independent of the presence of blood flow or contrast media.2⇓–4 Recent studies confirmed that 1.5T and 3T SWI is a fast, robust, and highly sensitive imaging technique in acute stroke without relevant image interference following gadolinium application.5,6 They performed SWI, covering the whole brain in patients with acute ischemic stroke of the anterior or posterior circulation to determine the prevalence of multiple intracranial thrombi before thrombolytic treatment and to study the associations between the presence of fragmented thrombi and baseline clinical and imaging characteristics, stroke etiology, and clinical outcome.Materials and Methods Patients and Clinical Data
Five hundred fifty-seven patients with acute ischemic stroke treated at their stroke unit from January 2010 to August 2013 underwent MR imaging after admission. Of these, 442 patients had MR imaging including SWI before initiation of thrombolytic therapy. Patients with anterior or posterior circulation stroke due to tandem occlusions (ICA and MCA), carotid-T occlusions, isolated occlusions of the MCA (M1, M2, or M3/4 segments), occlusions of the anterior cerebral artery, occlusions of the basilar artery either isolated or in combination with the vertebral artery, and occlusions of the posterior cerebral artery were considered for the final analysis. Three hundred forty-seven patients fulfilled all inclusion criteria. Following the imaging, all patients underwent recanalization therapy with IV rtPA, endovascular techniques, or a combination of both.
Clinical data were continuously recorded in the data base of their stroke center. The Trial of Org 10172 in Acute Stroke Treatment criteria were used for the categorization of stroke etiology.7 The occurrence of symptomatic and asymptomatic intracranial hemorrhage, within 72 hours from stroke onset, was recorded according to the Prolyse in Acute Cerebral Thromboembolism II criteria.8 Clinical outcome was assessed 3 months after stroke by using the modified Rankin Scale. The study was approved by their institutional review board.Imaging
Standard stroke MR imaging protocol was performed, which included diffusion-weighted imaging, T2-weighted imaging, TOF-MRA, SWI, first-pass gadolinium-enhanced MRA of the cervical and intracranial arteries, and perfusion imaging. The scans were acquired on 1.5T and 3T MR imaging systems (Magnetom Avanto and Magnetom Verio; Siemens, Erlangen, Germany).
For the 1.5T scanner, the SWI parameters were the following: TR, 49 ms; TE, 40 ms; number of averages, 1; FOV read, 230 mm; FOV phase, 75.0%; voxel size, 0.9 × 0.7 × 1.8 mm; flip angle, 15°; acquisition time, 2 minutes 59 seconds. For the 3T scanner, the parameters were as follows: TR, 28 ms; TE, 20 ms; number of averages, 1; FOV read, 230 mm; FOV phase, 75.0%; voxel size, 0.9 × 0.9 × 2.0 mm; flip angle, 15°; acquisition time, 2 minutes 59 seconds. The SWI and minimum-intensity-projection images were generated automatically by the scanner software.
DSA was performed via a transfemoral approach by using a biplane, high-resolution angiographic system (Axiom Artis zee; Siemens).Image Analysis
MR images were interpreted in consensus by a neuroradiologist and a radiologist in training. SWI was analyzed for the presence of the SVS in the supraclinoid segment of the ICA, the MCA, the anterior cerebral artery, the intradural segment of the vertebral artery, the basilar artery, and the posterior cerebral artery. The SVS was defined as an area of signal drop within the course of an artery that either exceeded the diameter of the contralateral nonoccluded vessel or that of the adjacent vessel segment on both the SWI and minimum-intensity-projection series.3 The length of the main thrombus and distal thrombus fragments, if applicable, was measured on SWI. In case of carotid-T, tandem, and combined basilar artery and vertebral artery occlusions, total clot length could not be determined because of either susceptibility artifacts in the proximity of the skull base or thrombi located partially outside the FOV.
A distal thrombus fragment was defined as an SVS being separated from the more proximal SVS by >2 mm—that is, the largest dimension of a voxel in SWI (Figs 1 and 2). The distance between the primary occluding thrombus and distal thrombus fragments was measured on a reconstructed plane, including both the distal part of the primary occluding thrombus and the proximal part of the thrombus fragment.Fig 1.
An 85-year-old man with right-sided hemiparesis and aphasia (NIHSS 13). Pretreatment SWI shows susceptibility vessel signs in the left M1 and M2 segments (A, white arrows). On TOF-MRA (MIP), diminished flow signal is seen distal to the thrombus fragment in the M1 segment with complete loss of flow signal at the site of the distal thrombus fragment (B, white arrowheads). DSA demonstrates incomplete occlusion of the vessel lumen by a thrombus in the M1 segment (C, anteroposterior projection, black arrowhead). On the lateral projection, occlusion of the temporo-occipital M2 branch by a more distal thrombus fragment is visible (D, black arrow). Although both TOF-MRA and DSA can show the distal vessel occlusion, only SWI allows estimation of the length of the distal fragment and exclusion of additional distal thrombi.Fig 2.
A 69-year-old male patient with a sudden decrease in consciousness. SWI shows susceptibility artifacts from thrombotic material in the basilar artery (A, white arrow) and the right posterior cerebral artery (B, white arrowhead). Hemorrhagic transformation of a subacute infarction in the vascular territory of the right posterior cerebral artery is seen. DSA confirms occlusion of the basilar artery (C, anteroposterior projection, black arrowhead). Following successful endovascular recanalization of the basilar artery, the occlusion in the perimesencephalic segment of the right posterior cerebral artery, already known from pretreatment SWI, becomes visible in DSA as well (D, anteroposterior projection, black arrow).
In patients with anterior circulation stroke, with the exception of the 4 patients with isolated anterior cerebral artery occlusion, the extent of ischemic lesions was assessed on pretreatment DWI by using the Alberta Stroke Program Early CT Score.9
Leptomeningeal collaterals were assessed on DSA as described previously.10Statistical Analysis
Categoric variables were compared with the χ2 test and the Fisher exact test as appropriate, and continuous variables, with the Mann-Whitney U test. To determine the predictors of clinical outcome, they performed a forward stepwise logistic regression, including all variables with a P < .2 in univariate analysis. These variables were age, sex, baseline NIHSS score, occlusion site, degree of collaterals, DWI ASPECTS, atrial fibrillation, diabetes mellitus, arterial hypertension, hypercholesterolemia, coronary artery disease, current smoking, and the presence of multiple intracranial thrombi on pretreatment imaging. Clinical outcome was dichotomized into favorable (mRS 0–2) and poor outcome (mRS 3–6). Collateral status was dichotomized into good and moderate/poor collaterals. A P value < .05 was considered significant. Statistics were performed with SPSS, Version 21 (IBM, Armonk, New York).Results
The SVS was detected in 324 of 347 patients (93.4%) on pretreatment SWI. Multiple intracranial thrombi were found in 24 patients (7.4% of all patients with visible SVSs). Fragmented thrombi occurred with a similar frequency in anterior and posterior circulation strokes (3/36 [8.3%] versus 21/288 [7.3%], P = .739). Nineteen patients had 1 distal fragment, 3 had 2 fragments, and 2 had 3 fragments. One of 31 fragments was located in the M1 segment of the MCA; 15, in the M2 segment; 11, in the M3 or M4 segment; 2, in the P2 segment of the posterior cerebral artery, and 2, in the P3 segment. Thirty thrombus fragments were found in the vascular territory distal to the primary occluding thrombus. One patient with a carotid-T occlusion was found to have a thrombus fragment in the P3 segment of the ipsilateral posterior cerebral artery, most likely by distal migration through a fetal variant of the posterior cerebral artery.
The mean distance of thrombus fragments from the primary occluding thrombus was 19.6 ± 15.6 mm. The mean length of thrombus fragments was 7.1 ± 4.0 mm.
TOF-MRA and first-pass gadolinium-enhanced MRA detected distal thrombus fragments in 8 and 11 of 24 patients (25.0% and 33.3%, respectively), with multiple intracranial thrombi on SWI. Nineteen of the 24 patients with multiple intracranial thrombi on SWI underwent DSA. In this group, thrombus fragments were confirmed in 8 patients (42.1%) on DSA.
Baseline clinical characteristics of patients with fragmented and single thrombi are shown in Table 1. Patients with multiple intracranial thrombi presented with a significantly higher median NIHSS score on admission (15 versus 11, P = .014). No significant difference in vascular risk factors or stroke etiology was found between the 2 groups. The prestroke use of antiplatelet drugs or anticoagulants did not differ between the groups. Imaging characteristics and treatment are compared in Table 2. In patients with isolated MCA, anterior cerebral artery, basilar artery, and posterior cerebral artery occlusions, total clot length was determined. Clot length in patients with fragmented thrombi was significantly higher than that in patients with a solitary thrombus (20.1 ± 10.7 versus 10.3 ± 5.6 mm, P < .001).Table 1:
Baseline clinical characteristicsTable 2:
Imaging characteristics and treatment
Patients with fragmented thrombi had significantly lower median DWI ASPECTS, meaning larger ischemic areas on DWI, than patients with a solitary thrombus (5 versus 7, P = .006). Good collaterals as assessed on DSA were found in fewer patients with fragmented thrombi than in those without, but the difference was not significant (4/19 [21.1%] versus 88/199 [44.2%], P = .051). One hundred eight patients (33.3%) were treated with IV rtPA alone, 140 (43.2%) underwent endovascular treatment, and 76 (23.5%) had a combination of both. Treatment was similar in both groups. Clinical outcome at 3 months was worse in patients with fragmented thrombi (mRS 0–2: 6/23 [26.1%] versus 171/286 [59.8%]; P = .002; Table 3).Table 3:
Intracranial bleeding complications and clinical outcome
The following variables showed P < .2 in univariate analysis and were included in the binary logistic regression analysis: NIHSS, age, DWI ASPECTS, multiple intracranial thrombi on pretreatment imaging, occlusion site, atrial fibrillation, diabetes mellitus, arterial hypertension, coronary artery disease, and current smoking. In their stepwise regression model, NIHSS was included as the first variable, followed by age, DWI ASPECTS, and finally the presence of multiple thrombi. The absence of multiple thrombus fragments (P = .040; OR, 0.251; 95% CI, 0.067–0.939), higher DWI ASPECTS (P = .004; OR, 1.328; 95% CI, 1.093–1.614), younger age (P < .001; OR, 0.919; 95% CI, 0.889–0.950), and lower NIHSS score (P < .001; OR, 0.832; 95% CI, 0.773–0.894) predicted good outcome.Discussion
Using whole-brain SWI, they found multiple intracranial thrombi in 24 of 324 patients with acute stroke with the SVS (7.4%) before initiation of any thrombolytic therapy. Most distal thrombus fragments (95.8%) affected the same vascular territory distal to the proximal occluding thrombus and were therefore a priori invisible with normal angiographic techniques. They found significant associations between the presence of multiple intracranial thrombi and a higher NIHSS score on admission as well as larger ischemic areas on pretreatment DWI. The presence of fragmented thrombi was a predictor of unfavorable clinical outcome at 3 months.
A study that analyzed the histologic structure of clots extracted by endovascular means by using the Merci retriever (Concentric Medical, Mountain View, California) reported that in 64% of cases, thrombi were retrieved in multiple fragments.11 It is likely that the prevalence of fragmented thrombi had been lower before mechanical disruption of the clot during deployment and retraction of the thrombectomy device. This supposition is supported by their in vivo studies demonstrating thrombus fragmentation and distal embolization during retrieval of the initially single thrombus with distal thrombectomy devices.12
Although their results are based purely on thrombus fragmentation before thrombolytic treatment, it could be speculated that iatrogenic thrombus fragmentation might have a similarly negative impact on outcome. This may, among other contributing factors, explain the disappointing clinical outcome in studies that used thrombus fragmentation techniques exclusively (Multi Mechanical Embolus Removal in Cerebral Ischemia, Penumbra Pivotal Stroke Trial, Mechanical Retrieval and REcanalization of Stroke Clots Using Embolectomy trials)13⇓–15 or in part (Interventional Management of Stroke III, SYNTHESIS Expansion [A randomized controlled trial between loco-regional intra-arterial and systemic intravenous thrombolysis with Alteplase in acute ischemic stroke]).16,17 The SYNTHESIS Expansion study reported that thrombus fragmentation with a microguidewire was performed in approximately two-thirds of patients.17 In contrast, the goal of current mechanical thrombectomy in acute stroke is removal of the thrombus en bloc with the lowest possible rate of thrombus fragmentation, as applied and improved in experienced stroke centers.10,18,19
In their series, good collaterals as assessed on DSA were found in fewer patients with multiple intracranial thrombi, though the difference was not significant. No additional differences in other well-known predictors of outcome were found between patients with and without multiple thrombi. There is evidence from multiple studies that good leptomeningeal collaterals reduce and slow penumbral tissue loss, resulting in better clinical outcome.20,21 When one considers the differences in collateral status between patients with and without multiple fragments, the probable role of autolysis should be discussed. Zanette et al22 reported that spontaneous lysis occurs in a high percentage of patients with distal MCA occlusions, similar to the sites where most of the distal thrombus fragments were found in their cohort. Because good collaterals were seen less often in patients with multiple thrombus fragments than in those with a single thrombus, one could hypothesize that fewer endogenous thrombolytic factors may have reached the distal thrombus fragments in patients with poor collateralization, resulting in the persistence of these fragments.
Thrombus burden must be taken into account when looking for factors that could explain the differences in outcome. Total clot length, defined as the combined length of the primary occluding thrombus and the distal thrombus fragments, was significantly higher in patients with fragmented thrombi compared with those with a solitary thrombus. It remains unclear whether longer thrombi are more likely to fragment or distal fragments lead to secondary clot formation due to stagnation of blood flow, thus increasing total clot length. A recent study assessed clot burden in patients with anterior circulation stroke on T2*-weighted imaging by using a scoring system based on the vessel segments that were affected by thrombotic material. Patients with fewer and more distal vessel segments involved had a higher revascularization rate and were more likely to have favorable clinical outcome.23 Because absolute thrombus length was not part of the scoring system, the comparability with their results is limited. One has to consider that assessment of thrombus burden by measuring the total length of thrombus fragments could result in overestimation in patients with multiple thrombi. Migration of distal thrombus fragments to smaller-sized vessels may result in reorientation and elongation of distal thrombi, resulting in a total clot length disproportionate to total clot volume.
TOF-MRA, first-pass gadolinium-enhanced MRA, and DSA detected only a minority of distal thrombus fragments seen on SWI. The lower yield of these imaging techniques in the detection of distal thrombus fragments most likely results from their dependence on the presence of blood flow or contrast media, both of which are usually reduced or absent distal to the primary vessel occlusion. Besides DWI and imaging of the whole angioarchitecture from the aortic arch up to distal branches of the cerebral arteries, imaging of the thrombus and its fragments with SWI has become a standard sequence of their stroke protocol due to its high therapeutic relevance.5
Our study has some limitations. Image analysis was only performed in consensus. In their experience, the SVS and distal thrombus fragments are easily detectable and they did not deem it necessary to additionally assess interobserver variability. Furthermore, each MR imaging study was routinely evaluated by a neuroradiologist and radiologist in training, and the findings were documented in their PACS. In 16 of the 24 patients (66.7%) with multiple thrombi on SWI, a distal vessel occlusion or thrombus fragment or both separate from the primary occlusion had already been described in the radiology report. Most interesting, in the 8 patients in whom distal thrombus fragments were not described initially, the fragments were located in closer proximity to the primary thrombus than in those in whom the distal occlusion was mentioned (7.0 ± 4.0 versus 24.2 ± 15.9 mm). One could speculate that these fragments were either harder to detect or had not been considered important enough to be described in the radiology report. In this single-center study, data from imaging were partly analyzed retrospectively. The small size of the patient group with fragmented thrombi limits the generalizability of the results. Evaluation of ICA and basilar artery thrombi on SWI was greatly limited by the extensive susceptibility artifacts in the proximity of the skull base.Conclusions
Multiple intracranial thrombi were detected on pretreatment SWI in 7.4% of patients with acute ischemic stroke of the anterior or posterior circulation. The presence of fragmented thrombi was a predictor of worse outcome. Patients with multiple thrombus fragments presented with more severe symptoms on admission, had more extensive ischemic areas on pretreatment DWI, and demonstrated worse collaterals as seen on biplane angiography. To know that multiple thrombi are present not only helps in planning the endovascular treatment, especially mechanical thrombectomy because distal fragments render the intervention more difficult, but may also be of use in prognostication of functional outcome.Acknowledgments
We thank Pietro Ballinari for statistical advice.Footnotes
Disclosures: Jan Gralla—UNRELATED: Consultancy: Covidien,* Comments: Global Principal Investigator of the Solitaire FR Thrombectomy for Acute Revascularization Study and consultant for Covidien. Heinrich P. Mattle—UNRELATED: Consultancy: Bayer, Biogen, Boehringer Ingelheim, Daiichi-Sankyo, Genzyme, Merck, Neuravi, Novartis, Pfizer, Teva; Grants/Grants Pending: Swiss Heart Foundation,* Swiss National Science Foundation*; Payment for Lectures (including service on Speakers Bureaus): Bayer, Biogen, Boehringer Ingelheim, Covidien, Daiichi Sankyo, Genzyme, Neuravi, Novartis, Pfizer; Royalties: for textbooks on neurology I have written. *Money paid to the institution.
Paper previously presented in part at: XXIII European Stroke Conference, May 12–15, 2014; Nice, France.
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Hyperion [10 Certification Exam(s) ]
IAAP [1 Certification Exam(s) ]
IAHCSMM [1 Certification Exam(s) ]
IBM [1532 Certification Exam(s) ]
IBQH [1 Certification Exam(s) ]
ICAI [1 Certification Exam(s) ]
ICDL [6 Certification Exam(s) ]
IEEE [1 Certification Exam(s) ]
IELTS [1 Certification Exam(s) ]
IFPUG [1 Certification Exam(s) ]
IIA [3 Certification Exam(s) ]
IIBA [2 Certification Exam(s) ]
IISFA [1 Certification Exam(s) ]
Intel [2 Certification Exam(s) ]
IQN [1 Certification Exam(s) ]
IRS [1 Certification Exam(s) ]
ISA [1 Certification Exam(s) ]
ISACA [4 Certification Exam(s) ]
ISC2 [6 Certification Exam(s) ]
ISEB [24 Certification Exam(s) ]
Isilon [4 Certification Exam(s) ]
ISM [6 Certification Exam(s) ]
iSQI [7 Certification Exam(s) ]
ITEC [1 Certification Exam(s) ]
Juniper [64 Certification Exam(s) ]
LEED [1 Certification Exam(s) ]
Legato [5 Certification Exam(s) ]
Liferay [1 Certification Exam(s) ]
Logical-Operations [1 Certification Exam(s) ]
Lotus [66 Certification Exam(s) ]
LPI [24 Certification Exam(s) ]
LSI [3 Certification Exam(s) ]
Magento [3 Certification Exam(s) ]
Maintenance [2 Certification Exam(s) ]
McAfee [8 Certification Exam(s) ]
McData [3 Certification Exam(s) ]
Medical [69 Certification Exam(s) ]
Microsoft [374 Certification Exam(s) ]
Mile2 [3 Certification Exam(s) ]
Military [1 Certification Exam(s) ]
Misc [1 Certification Exam(s) ]
Motorola [7 Certification Exam(s) ]
mySQL [4 Certification Exam(s) ]
NBSTSA [1 Certification Exam(s) ]
NCEES [2 Certification Exam(s) ]
NCIDQ [1 Certification Exam(s) ]
NCLEX [2 Certification Exam(s) ]
Network-General [12 Certification Exam(s) ]
NetworkAppliance [39 Certification Exam(s) ]
NI [1 Certification Exam(s) ]
NIELIT [1 Certification Exam(s) ]
Nokia [6 Certification Exam(s) ]
Nortel [130 Certification Exam(s) ]
Novell [37 Certification Exam(s) ]
OMG [10 Certification Exam(s) ]
Oracle [279 Certification Exam(s) ]
P&C [2 Certification Exam(s) ]
Palo-Alto [4 Certification Exam(s) ]
PARCC [1 Certification Exam(s) ]
PayPal [1 Certification Exam(s) ]
Pegasystems [12 Certification Exam(s) ]
PEOPLECERT [4 Certification Exam(s) ]
PMI [15 Certification Exam(s) ]
Polycom [2 Certification Exam(s) ]
PostgreSQL-CE [1 Certification Exam(s) ]
Prince2 [6 Certification Exam(s) ]
PRMIA [1 Certification Exam(s) ]
PsychCorp [1 Certification Exam(s) ]
PTCB [2 Certification Exam(s) ]
QAI [1 Certification Exam(s) ]
QlikView [1 Certification Exam(s) ]
Quality-Assurance [7 Certification Exam(s) ]
RACC [1 Certification Exam(s) ]
Real-Estate [1 Certification Exam(s) ]
RedHat [8 Certification Exam(s) ]
RES [5 Certification Exam(s) ]
Riverbed [8 Certification Exam(s) ]
RSA [15 Certification Exam(s) ]
Sair [8 Certification Exam(s) ]
Salesforce [5 Certification Exam(s) ]
SANS [1 Certification Exam(s) ]
SAP [98 Certification Exam(s) ]
SASInstitute [15 Certification Exam(s) ]
SAT [1 Certification Exam(s) ]
SCO [10 Certification Exam(s) ]
SCP [6 Certification Exam(s) ]
SDI [3 Certification Exam(s) ]
See-Beyond [1 Certification Exam(s) ]
Siemens [1 Certification Exam(s) ]
Snia [7 Certification Exam(s) ]
SOA [15 Certification Exam(s) ]
Social-Work-Board [4 Certification Exam(s) ]
SpringSource [1 Certification Exam(s) ]
SUN [63 Certification Exam(s) ]
SUSE [1 Certification Exam(s) ]
Sybase [17 Certification Exam(s) ]
Symantec [134 Certification Exam(s) ]
Teacher-Certification [4 Certification Exam(s) ]
The-Open-Group [8 Certification Exam(s) ]
TIA [3 Certification Exam(s) ]
Tibco [18 Certification Exam(s) ]
Trainers [3 Certification Exam(s) ]
Trend [1 Certification Exam(s) ]
TruSecure [1 Certification Exam(s) ]
USMLE [1 Certification Exam(s) ]
VCE [6 Certification Exam(s) ]
Veeam [2 Certification Exam(s) ]
Veritas [33 Certification Exam(s) ]
Vmware [58 Certification Exam(s) ]
Wonderlic [2 Certification Exam(s) ]
Worldatwork [2 Certification Exam(s) ]
XML-Master [3 Certification Exam(s) ]
Zend [6 Certification Exam(s) ]
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