{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,11]],"date-time":"2026-07-11T18:08:32Z","timestamp":1783793312669,"version":"3.55.0"},"reference-count":39,"publisher":"MDPI AG","issue":"22","license":[{"start":{"date-parts":[[2025,11,14]],"date-time":"2025-11-14T00:00:00Z","timestamp":1763078400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100003725","name":"National Research Foundation of Korea","doi-asserted-by":"publisher","award":["RS-2024-00333653"],"award-info":[{"award-number":["RS-2024-00333653"]}],"id":[{"id":"10.13039\/501100003725","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Introduction: We aimed to clarify the influence of the thrombus composition on ischemic stroke endovascular thrombectomy (EVT) efficiency by utilizing various staining methods for patients that presented with occlusions of the middle cerebral artery (MCA). Methods: Between September 2017 and May 2021, we analyzed thrombi retrieved during endovascular thrombectomy EVT in patients with acute ischemic stroke due to middle cerebral artery (MCA) occlusion. Patients with reperfusion failure, intracranial atherosclerotic occlusions, and inadequate staining were excluded. The thrombus composition was stratified using three staining techniques\u2014Hematoxylin and Eosin (H&amp;E), Martius Scarlet Blue (MSB) staining, and immunohistochemistry (IHC) for red blood cells (RBCs), white blood cells (WBCs), fibrin (Fibrin II), and platelets (CD41). Associations between EVT efficiency outcomes and the thrombus composition were evaluated. Results: During the study period, thrombus was available for analysis in 159 patients. A total of 59 patients were included in the main analysis. Increases in the trichotomized RBS tertiles were associated with decreases in the components of various platelet\/other components but not for fibrin. A modified first pass effect (mFPE) of the modified Thrombolysis in Cerebral Infarction perfusion scale (mTICI) 2b or higher was associated with larger thrombus surface area (16.0 \u00b1 11.6 vs. 47.4 \u00b1 62.3 mm2, p = 0.005), a higher MSB fibrin content (29.8 \u00b1 10.7 vs. 21.3 \u00b1 10.9%, p = 0.002), and IHC fibrin (28.5 \u00b1 14.5 vs. 20.1 \u00b1 11.4%, p = 0.008). There was a marginal association between the mTICI 2b mFPE and lower MSB platelet\/other components (27.6 \u00b1 20.9 vs. 34.4 \u00b1 14.9%, p = 0.078). The discrepancy between MSB platelet\/others and IHC platelets was greater in the mFPE (-) group, suggesting that components other than platelets may contribute to EVT resistance. A mFPE of mTICI 2c or higher was associated with greater thrombus surface area (17.8 \u00b1 11.9 vs. 37.7 \u00b1 55.0 mm2, p = 0.015) and MSB fibrin (32.1 \u00b1 10.3 vs. 22.8 \u00b1 11.0%, p = 0.002). There was a marginal reverse association between the mTICI 2c mFPE and MSB RBCs (33.4 \u00b1 20.2% vs. 41.5 \u00b1 17.3%, p = 0.062). There was no significant association between final near-complete reperfusion and the thrombus composition. Conclusions: In patients presenting with occlusions of the MCA, a higher thrombus fibrin content is associated with better EVT efficiency. Both a higher MSB platelet\/other components and RBC content may have a negative influence on EVT efficiency. These results may help identify preprocedural biomarkers beyond the conventional assessment of RBCs, WBCs, and fibrin compositions, which could guide decision-making during mechanical thrombectomy.<\/jats:p>","DOI":"10.3390\/jcm14228088","type":"journal-article","created":{"date-parts":[[2025,11,14]],"date-time":"2025-11-14T16:46:22Z","timestamp":1763138782000},"page":"8088","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Detailed Analysis of Thrombus Composition and Endovascular Thrombectomy Efficiency in Ischemic Stroke Patients with Middle Cerebral Artery Occlusion Undergoing Thrombectomy"],"prefix":"10.3390","volume":"14","author":[{"given":"Seong-Joon","family":"Lee","sequence":"first","affiliation":[{"name":"Department of Neurology, Ajou University School of Medicine, Suwon 16499, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mai Tuyet","family":"Nguyen","sequence":"additional","affiliation":[{"name":"Department of Neurology, Ajou University School of Medicine, Suwon 16499, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeong Eun","family":"Seo","sequence":"additional","affiliation":[{"name":"Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Woo Sang","family":"Jung","sequence":"additional","affiliation":[{"name":"Department of Radiology, Ajou University School of Medicine, Suwon 16499, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2396-4705","authenticated-orcid":false,"given":"Jin Wook","family":"Choi","sequence":"additional","affiliation":[{"name":"Department of Radiology, Ajou University School of Medicine, Suwon 16499, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"So Young","family":"Park","sequence":"additional","affiliation":[{"name":"Department of Neurology, Ajou University School of Medicine, Suwon 16499, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7225-6166","authenticated-orcid":false,"given":"Jin Soo","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Neurology, Ajou University School of Medicine, Suwon 16499, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,11,14]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"102","DOI":"10.5853\/jos.2015.01655","article-title":"Update of the Korean Clinical Practice Guidelines for Endovascular Recanalization Therapy in Patients with Acute Ischemic Stroke","volume":"18","author":"Hong","year":"2016","journal-title":"J. Stroke"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"606","DOI":"10.1177\/1747493017709671","article-title":"Analyses of thrombi in acute ischemic stroke: A consensus statement on current knowledge and future directions","volume":"12","author":"Andersson","year":"2017","journal-title":"Int. J. Stroke"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"529","DOI":"10.1136\/neurintsurg-2016-012391","article-title":"Correlation of imaging and histopathology of thrombi in acute ischemic stroke with etiology and outcome: A systematic review","volume":"9","author":"Brinjikji","year":"2017","journal-title":"J. Neurointerv. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"652","DOI":"10.1161\/STROKEAHA.117.019138","article-title":"Erythrocyte Fraction Within Retrieved Thrombi Contributes to Thrombolytic Response in Acute Ischemic Stroke","volume":"49","author":"Choi","year":"2018","journal-title":"Stroke"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1145","DOI":"10.1136\/neurintsurg-2018-014637","article-title":"Platelet-rich clots as identified by Martius Scarlet Blue staining are isodense on NCCT","volume":"11","author":"Fitzgerald","year":"2019","journal-title":"J. Neurointerv. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"498","DOI":"10.3324\/haematol.2019.219881","article-title":"Structural analysis of ischemic stroke thrombi: Histological indications for therapy resistance","volume":"105","author":"Staessens","year":"2020","journal-title":"Haematologica"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"65","DOI":"10.5469\/neuroint.2024.00087","article-title":"Traditional Thrombus Composition and Related Endovascular Outcomes: Catching up with the Recent Evidence","volume":"19","author":"Baek","year":"2024","journal-title":"Neurointervention"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2650","DOI":"10.1161\/STROKEAHA.113.001972","article-title":"Recommendations on angiographic revascularization grading standards for acute ischemic stroke: A consensus statement","volume":"44","author":"Zaidat","year":"2013","journal-title":"Stroke"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"394","DOI":"10.5853\/jos.2018.01627","article-title":"Prognosis of Acute Intracranial Atherosclerosis-Related Occlusion after Endovascular Treatment","volume":"20","author":"Lee","year":"2018","journal-title":"J. Stroke"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1161\/01.STR.24.1.35","article-title":"Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment","volume":"24","author":"Adams","year":"1993","journal-title":"Stroke"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"143","DOI":"10.5853\/jos.2017.00626","article-title":"Diagnostic and Therapeutic Strategies for Acute Intracranial Atherosclerosis-related Occlusions","volume":"19","author":"Lee","year":"2017","journal-title":"J. Stroke"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1670","DOI":"10.1016\/S0140-6736(00)02237-6","article-title":"Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score","volume":"355","author":"Barber","year":"2000","journal-title":"Lancet"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Lee, S.J., Jung, W.S., Choi, M.H., Hong, J.M., Lee, J.S., and Choi, J.W. (2019). Optimal Multiphase Computed Tomographic Angiography-based Infarct Core Estimations for Acute Ischemic Stroke. Sci. Rep., 9.","DOI":"10.1038\/s41598-019-51708-6"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1111\/j.1747-4949.2008.00221.x","article-title":"Intracranial thrombus extent predicts clinical outcome, final infarct size and hemorrhagic transformation in ischemic stroke: The clot burden score","volume":"3","author":"Puetz","year":"2008","journal-title":"Int. J. Stroke"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1189","DOI":"10.1161\/STROKEAHA.118.020700","article-title":"Modified Thrombolysis in Cerebral Infarction 2C\/Thrombolysis in Cerebral Infarction 3 Reperfusion Should Be the Aim of Mechanical Thrombectomy: Insights From the ASTER Trial (Contact Aspiration Versus Stent Retriever for Successful Revascularization)","volume":"49","author":"Dargazanli","year":"2018","journal-title":"Stroke"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"660","DOI":"10.1161\/STROKEAHA.117.020315","article-title":"First Pass Effect: A New Measure for Stroke Thrombectomy Devices","volume":"49","author":"Zaidat","year":"2018","journal-title":"Stroke"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Lee, S.J., Hong, J.M., Lee, S.E., Kang, D.R., Ovbiagele, B., Demchuk, A.M., and Lee, J.S. (2017). Association of fibrinogen level with early neurological deterioration among acute ischemic stroke patients with diabetes. BMC Neurol., 17.","DOI":"10.1186\/s12883-017-0865-7"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"671","DOI":"10.1038\/nmeth.2089","article-title":"NIH Image to ImageJ: 25 years of image analysis","volume":"9","author":"Schneider","year":"2012","journal-title":"Nat. Methods"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1237","DOI":"10.1161\/STROKEAHA.110.605576","article-title":"CT and MRI early vessel signs reflect clot composition in acute stroke","volume":"42","author":"Liebeskind","year":"2011","journal-title":"Stroke"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1156","DOI":"10.1161\/STROKEAHA.118.023419","article-title":"Per-Pass Analysis of Thrombus Composition in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy","volume":"50","author":"Duffy","year":"2019","journal-title":"Stroke"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1016\/j.tjem.2018.08.001","article-title":"User\u2019s guide to correlation coefficients","volume":"18","author":"Akoglu","year":"2018","journal-title":"Turk. J. Emerg. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1136\/neurintsurg-2016-012721","article-title":"Clot friction variation with fibrin content; implications for resistance to thrombectomy","volume":"10","author":"Gunning","year":"2018","journal-title":"J. Neurointerv Surg."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Nagargoje, M.S., Fregona, V., Luraghi, G., Migliavacca, F., Pero, G., and Rodriguez Matas, J.F. (2025). The role of friction forces in arterial mechanical thrombectomy: A review. J. Biomech., 192.","DOI":"10.1016\/j.jbiomech.2025.112966"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Dumitriu LaGrange, D., Bernava, G., Reymond, P., Wanke, I., Vargas, M.I., Machi, P., and Lovblad, K.O. (2022). A high resolution scanning electron microscopy analysis of intracranial thrombi embedded along the stent retrievers. Sci. Rep., 12.","DOI":"10.1038\/s41598-022-11830-4"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"131","DOI":"10.5853\/jos.2017.00283","article-title":"Causes and Solutions of Endovascular Treatment Failure","volume":"19","author":"Kim","year":"2017","journal-title":"J. Stroke"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1131","DOI":"10.1161\/STROKEAHA.120.032810","article-title":"Thrombus Composition and Efficacy of Thrombolysis and Thrombectomy in Acute Ischemic Stroke","volume":"52","author":"Jolugbo","year":"2021","journal-title":"Stroke"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"64","DOI":"10.5853\/jos.2019.03440","article-title":"Pathophysiologic and Therapeutic Perspectives Based on Thrombus Histology in Stroke","volume":"22","author":"Heo","year":"2020","journal-title":"J. Stroke"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"106127","DOI":"10.1016\/j.jstrokecerebrovasdis.2021.106127","article-title":"Characterization of the \u2018White\u2019 Appearing Clots that Cause Acute Ischemic Stroke","volume":"30","author":"Mereuta","year":"2021","journal-title":"J. Stroke Cerebrovasc. Dis."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"938","DOI":"10.1056\/NEJMra0801082","article-title":"Mechanisms of thrombus formation","volume":"359","author":"Furie","year":"2008","journal-title":"N. Engl. J. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"153","DOI":"10.14366\/usg.24175","article-title":"Thrombus stiffness as an independent predictor of endovascular treatment success in hemodialysis fistulas: A study using ultrasound elastography","volume":"44","author":"Zirek","year":"2025","journal-title":"Ultrasonography"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"160","DOI":"10.1161\/ATVBAHA.122.318715","article-title":"Circulating Tumor Cells and Cancer-Associated Venous Thrombosis: A Missing Link","volume":"43","author":"Mackman","year":"2023","journal-title":"Arterioscler. Thromb. Vasc. Biol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"223","DOI":"10.1002\/ana.24993","article-title":"Neutrophil extracellular traps in ischemic stroke thrombi","volume":"82","author":"Laridan","year":"2017","journal-title":"Ann. Neurol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1055\/a-1522-4507","article-title":"An Older Thrombus Delays Reperfusion after Mechanical Thrombectomy for Ischemic Stroke","volume":"122","author":"Kitano","year":"2022","journal-title":"Thromb. Haemost."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"454","DOI":"10.5853\/jos.2024.00787","article-title":"Thrombi with a Higher Erythrocyte Composition Are More Fragile in Acute Stroke","volume":"26","author":"Baek","year":"2024","journal-title":"J. Stroke"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"991","DOI":"10.3174\/ajnr.A5105","article-title":"Risk of Thrombus Fragmentation during Endovascular Stroke Treatment","volume":"38","author":"Kaesmacher","year":"2017","journal-title":"AJNR Am. J. Neuroradiol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1016\/j.actbio.2021.03.052","article-title":"Blood clot fracture properties are dependent on red blood cell and fibrin content","volume":"127","author":"Fereidoonnezhad","year":"2021","journal-title":"Acta Biomater."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Santo, B.A., Patel, T.R., Mousavi Janbeh Sarayi, S.M., Poppenberg, K.E., Balghonaim, S., Scotti, A., Jenkins, T.D., Levy, E.I., Siddiqui, A.H., and Kolega, J. (2025). CT Radiomic Signatures of Neutrophil Extracellular Traps in Ischemic Stroke Thrombi. bioRxiv.","DOI":"10.1101\/2025.08.11.669792"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1136\/neurintsurg-2018-013918","article-title":"Longer stent retrievers enhance thrombectomy performance in acute stroke","volume":"11","author":"Haussen","year":"2019","journal-title":"J. Neurointerventional Surg."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1107","DOI":"10.1161\/STROKEAHA.117.020125","article-title":"Primary Results of the Multicenter ARISE II Study (Analysis of Revascularization in Ischemic Stroke with EmboTrap)","volume":"49","author":"Zaidat","year":"2018","journal-title":"Stroke"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/22\/8088\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,14]],"date-time":"2025-11-14T17:06:17Z","timestamp":1763139977000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/22\/8088"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,14]]},"references-count":39,"journal-issue":{"issue":"22","published-online":{"date-parts":[[2025,11]]}},"alternative-id":["jcm14228088"],"URL":"https:\/\/doi.org\/10.3390\/jcm14228088","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,14]]}}}