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Automated quantitative lesion water uptake in acute stroke is a predictor of malignant cerebral edema

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An Editorial Comment to this article was published on 01 February 2022

Abstract

Objectives

Net water uptake (NWU) has been shown to have a linear relationship with brain edema. Based on an automated-Alberta Stroke Program Early Computed Tomography Score (ASPECTS) technique, we automatically derived NWU from baseline multimodal computed tomography (CT), namely ASPECTS-NWU. We aimed to determine if ASPECTS-NWU can predict the development of malignant cerebral edema (MCE).

Methods

One hundred and forty-six patients with large-vessel occlusion were retrospectively enrolled. Quantitative NWU based on automated-ASPECTS was measured both on nonenhanced CT (NECT) and CT angiography (CTA), namely NECT-ASPECT-NWU and CTA-ASPECTS-NWU. The correlation between ASPECTS-NWU and cerebral edema (CED) grades was calculated using Spearman rank correlation. Univariate logistic regression was used to assess the effect of radiological and clinical features on MCE, and a multivariable model with significant factors from the univariate regression analysis was built. Receiver operating characteristic (ROC) was obtained and area under curve (AUC) was compared.

Results

CTA-ASPECTS-NWU had a moderate positive correlation with CED grades (r = 0.62; 95% confidence interval [CI], 0.51–0.71; p < 0.001). The CTA-ASPECTS-NWU performed better than the NECT-ASPECTS-NWU with AUC: 0.88 vs. 0.71 (p < 0.001). Multivariable logistic regression model integrating CTA-ASPECTS-NWU, collateral score, and age showed the CTA-ASPECTS-NWU was an independent predictor of MCE with an AUC of 0.94 (95% CI: 0.90–0.98; p < 0.001).

Conclusions

This study demonstrates that ASPECTS-NWU is a quantitative predictor of MCE after large-vessel occlusion of the middle cerebral artery territory. The multivariable logistic regression model may enhance the identification of patients with MCE needing anti-edematous treatment.

Key Points

• The automated-ASPECTS technique can automatically detect the affected regions with early ischemic changes and NWU could be manually calculated.

• The CTA-ASPECTS-NWU performs better than the NECT-ASPECTS-NWU on predicting the development of MCE.

• The multivariable logistic regression model may enhance the identification of patients with MCE needing anti-edematous treatment.

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Abbreviations

AIS:

Acute ischemic stroke

ASPECTS:

Alberta Stroke Program Early CT Score

ASPECTS-NWU:

ASPECTS-Net water uptake

BBB:

Blood-brain barrier

CED:

Cerebral edema

CS:

Collateral score

CTA-SI:

CT angiography source images

CTP:

CT perfusion

IQR:

Interquartile range

LVO:

Large-vessel occlusion

MCA:

Middle cerebral artery

MCE:

Malignant cerebral edema

MLS:

Midline shift

mRS:

Modified RanKin scale

mTICI:

Modified thrombolysis in cerebral infarction

NECT:

Nonenhanced CT

NIHSS:

National Institutes of Health Stroke Scale scores

NWU:

Net water uptake

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Acknowledgements

We thank MengJie Lu for contributing to the statistical analysis.

Funding

The authors state that this work has not received any funding.

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Author notes

  1. JiaQian Shi and Hang Wu contributed equally to this work.

Authors and Affiliations

  1. Department of Medical Imaging, Xuzhou Medical University, Xuzhou, Jiangsu, China

    JiaQian Shi, Zheng Dong, XianXian Liang & GuangMing Lu

  2. Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China

    Hang Wu & Wusheng Zhu

  3. Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, 305 Zhongshan East Road, Nanjing, 210002, Jiangsu, China

    QuanHui Liu, ChangSheng Zhou, MengJie Lu, Jia Liu, XiaoQin Su, GuangMing Lu & XiaoQing Cheng

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  1. JiaQian Shi
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Corresponding authors

Correspondence to GuangMing Lu or XiaoQing Cheng.

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The scientific guarantor of this publication is GuangMing Lu.

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The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and Biometry

One of the authors has significant statistical expertise.

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Written informed consent was waived.

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• performed at one institution

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Shi, J., Wu, H., Dong, Z. et al. Automated quantitative lesion water uptake in acute stroke is a predictor of malignant cerebral edema. Eur Radiol 32, 2771–2780 (2022). https://doi.org/10.1007/s00330-021-08443-2

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  • DOI: https://doi.org/10.1007/s00330-021-08443-2

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