Cerebrospinal fluid volume improves prediction of malignant edema after endovascular treatment of stroke

This prediction doesn't do one damn bit of good unless you have EXACT PROTOCOLS  to prevent this edema from happening. 

Cerebrospinal fluid volume improves prediction of malignant edema after endovascular treatment of stroke

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Frans Kauw*, Marie Louise E Bernsen, Jan W Dankbaar, ...

First Published May 12, 2022 Research Article Find in PubMed 

https://doi.org/10.1177/17474930221094693

Article information

 

Abstract

Background:

The ratio of intracranial cerebrospinal fluid (CSF) volume to intracranial volume (ICV) has been identified as a potential predictor of malignant edema formation in patients with acute ischemic stroke.

Aims:

We aimed to evaluate the added value of the CSF/ICV ratio in a model to predict malignant edema formation in patients who underwent endovascular treatment.

Methods:

We included patients from the MR CLEAN Registry, a prospective national multicenter registry of patients who were treated with endovascular treatment between 2014 and 2017 because of acute ischemic stroke caused by large vessel occlusion. The CSF/ICV ratio was automatically measured on baseline thin-slice noncontrast CT. The primary outcome was the occurrence of malignant edema based on clinical and imaging features. The basic model included the following predictors: age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT score, occlusion of the internal carotid artery, collateral score, time between symptom onset and groin puncture, and unsuccessful reperfusion. The extended model included the basic model and the CSF/ICV ratio. The performance of the basic and the extended model was compared with the likelihood ratio test.

Results:

Malignant edema occurred in 40 (6%) of 683 patients. In the extended model, a lower CSF/ICV ratio was associated with the occurrence of malignant edema (odds ratio (OR) per percentage point, 1.2; 95% confidence interval (CI) 1.1–1.3, p < 0.001). Age lost predictive value for malignant edema in the extended model (OR 1.1; 95% CI 0.9–1.5, p = 0.372). The performance of the extended model was higher than that of the basic model (p < 0.001).

Conclusions:

Adding the CSF/ICV ratio improves a multimodal prediction model for the occurrence of malignant edema after endovascular treatment.

Keywords

Ischemic stroke, computed tomography, cerebrospinal fluid, thrombectomy, malignant edema

Introduction

The occurrence of malignant edema may require timely decompressive surgery to prevent poor clinical outcomes in patients with acute ischemic stroke.^1,2 Accurate prediction of malignant edema formation may help in making prompt treatment decisions. Important factors that have been associated with malignant edema include young age, high National Institutes of Health Stroke Scale (NIHSS), extensive early ischemic changes on noncontrast CT (NCCT), large perfusion deficits on CT perfusion, proximal thrombus location on CT angiography (CTA), and poor collateral filling in the affected area on CTA.³ The incorporation of these factors in multivariable models has led to reasonable discrimination between groups of patients with and without malignant edema, but predictive values for individual patients remain moderate.³

In a previous study, we found the ratio of intracranial cerebrospinal fluid (CSF) volume to intracranial volume (ICV) to be of added value in models predicting malignant edema in patients with acute ischemic stroke.⁴ Until now, this has not been validated in another cohort.

Recently, a prediction model for malignant edema after acute supratentorial ischemic stroke for which endovascular treatment (EVT) was performed has been developed based on the Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands (MR CLEAN) Registry.⁵ In this study, we tested the additional predictive value of the CSF/ICV ratio.

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