Net water uptake combined with neutrophil-to-lymphocyte ratio predictive value after successful recanalization in acute large vessel occlusion stroke

And somehow you didn't check all this earlier research to see if the answer was already there! Predicting poor outcome is totally fucking useless! SOLVE THE DAMN PROBLEM; YOU'RE FIRED!

Neutrophil-to-Lymphocyte Ratio (16 posts to September 2015)

Net Water Uptake (4 posts to March 2021)

 Net water uptake combined with neutrophil-to-lymphocyte ratio predictive value after successful recanalization in acute large vessel occlusion stroke

Xu Jing¹Xiang Liangxu¹Li Zhide¹Zhao Yue¹Tian Yanghua^2*

• ¹Department of Neurology, Ma'anshan People's Hospital, Maanshan, Anhui, China
• ²Anhui Medical University, Hefei, Anhui, China

Objective: Despite successful recanalization after endovascular thrombectomy (EVT), some patients with acute large vessel occlusion stroke (ALVOS) have poor clinical outcomes. This study employed 

Xu Jing¹Xiang Liangxu¹Li Zhide¹Zhao Yue¹Tian Yanghua^2*

• ¹Department of Neurology, Ma'anshan People's Hospital, Maanshan, Anhui, China
• ²Anhui Medical University, Hefei, Anhui, China

Objective: Despite successful recanalization after endovascular thrombectomy (EVT), some patients with acute large vessel occlusion stroke (ALVOS) have poor clinical outcomes. This study employed net water uptake (NWU) which was calculated based on the cranial CT on admission, to investigate the factors associated with the clinical outcomes of ALVOS patients with successful EVT recanalization.

Methods: ALVOS patients in anterior circulation with successful EVT recanalization were consecutively enrolled. NWU was measured in the middle cerebral artery territory based on the preoperative cranial CT, calculated by (1 − affected hemisphere density/ contralateral hemisphere density) × 100%. The neutrophil-to-lymphocyte ratio (NLR) was calculated from the blood routine test on admission. A poor 90-day outcome was defined as a modified Rankin Scale (mRS) > 2 points at 90-day after the index stroke.

Results: A total of 113 participants were enrolled. NLR (odds ratio [OR] = 1.31, 95% confidence interval [CI] = 1.09–1.58, p = 0.004) and NWU (OR = 1.48, 95% CI = 1.21–1.81, p < 0.001) were independently associated with poor 90-day outcomes. In the restricted cubic spline analysis, a significant nonlinear relationship was observed between NWU and an increased risk of 90-day poor functional outcome (p for nonlinear = 0.018). All participants were categorized into three grades based on 90-day mRS: complete independence (mRS 0–1 point), partial dependence (mRS 2–3 points), and complete dependence or mortality (mRS 4–6 points). In the multivariate ordinal logistic regression, both NLR (OR = 1.32, 95% CI = 1.12–1.56, p = 0.001) and NWU (OR = 1.29, 95% CI = 1.10–1.51, p = 0.002) were independently associated with the 90-day functional outcome grade. Receiver operating characteristic analysis demonstrated that the combination of NWU and NLR had the highest indicative value of poor outcome (area under the curve [AUC] = 0.800, 95% CI = 0.718–0.881, p < 0.001), followed by sole NWU (AUC = 0.764, 95% CI = 0.674–0.855, p < 0.001) and NLR (AUC = 0.662, 95% CI = 0.563–0.762, p = 0.003).

Conclusion: The combination of NWU and NLR provides stronger indicative value of poor outcome compared to either marker alone. (NWU) which was calculated based on the cranial CT on admission, to investigate the factors associated with the clinical outcomes of ALVOS patients with successful EVT recanalization.

Methods: ALVOS patients in anterior circulation with successful EVT recanalization were consecutively enrolled. NWU was measured in the middle cerebral artery territory based on the preoperative cranial CT, calculated by (1 − affected hemisphere density/ contralateral hemisphere density) × 100%. The neutrophil-to-lymphocyte ratio (NLR) was calculated from the blood routine test on admission. A poor 90-day outcome was defined as a modified Rankin Scale (mRS) > 2 points at 90-day after the index stroke.

Results: A total of 113 participants were enrolled. NLR (odds ratio [OR] = 1.31, 95% confidence interval [CI] = 1.09–1.58, p = 0.004) and NWU (OR = 1.48, 95% CI = 1.21–1.81, p < 0.001) were independently associated with poor 90-day outcomes. In the restricted cubic spline analysis, a significant nonlinear relationship was observed between NWU and an increased risk of 90-day poor functional outcome (p for nonlinear = 0.018). All participants were categorized into three grades based on 90-day mRS: complete independence (mRS 0–1 point), partial dependence (mRS 2–3 points), and complete dependence or mortality (mRS 4–6 points). In the multivariate ordinal logistic regression, both NLR (OR = 1.32, 95% CI = 1.12–1.56, p = 0.001) and NWU (OR = 1.29, 95% CI = 1.10–1.51, p = 0.002) were independently associated with the 90-day functional outcome grade. Receiver operating characteristic analysis demonstrated that the combination of NWU and NLR had the highest indicative value of poor outcome (area under the curve [AUC] = 0.800, 95% CI = 0.718–0.881, p < 0.001), followed by sole NWU (AUC = 0.764, 95% CI = 0.674–0.855, p < 0.001) and NLR (AUC = 0.662, 95% CI = 0.563–0.762, p = 0.003).

Conclusion: The combination of NWU and NLR provides stronger indicative value of poor outcome compared to either marker alone.

Predictive value of net water uptake for early neurological deterioration after mechanical thrombectomy in acute ischemic stroke with large vessel occlusion

 Useless. You described a problem, offered NO SOLUTION for preventing early neurological deterioration!

 Predictive value of net water uptake for early neurological deterioration after mechanical thrombectomy in acute ischemic stroke with large vessel occlusion

Min Kuang^1†Junying Li^2†Jian Wang^2*Guangwen Chen^1*Chao Luo¹

• ¹Department of Radiology, West China School of Medicine, Sichuan University, Sichuan University Affiliated Chengdu Second People’s Hospital, Chengdu, China
• ²Department of Neurology, West China School of Medicine, Sichuan University, Sichuan University Affiliated Chengdu Second People’s Hospital, Chengdu, China

Purpose: To investigate whether Net Water Uptake (NWU) can predict early neurological deterioration (END) after mechanical thrombectomy (MT) in acute ischemic stroke with large vessel occlusion (AIS-LVO).

Materials and methods: We retrospectively analyzed consecutive patients with AIS-LVO who underwent MT. Patients were categorized into the END group and the non-END group based on whether END occurred. NWU was an imaging parameter to quantify the water uptake capacity of brain tissue and measured on admission non-contrast computed tomography (NCCT). Early edema progression rate (EPR) was determined as the ratio of NWU and time from symptom onset to baseline imaging. Then, the baseline characteristics were subsequently collected. Variable and multiple regression analyses were performed to explore independent risk factors for END. Finally, receiver operating characteristic (ROC) curves were constructed to evaluate the predictive value of NWU for END.

Results: A total of 158 patients were included. The median NWU, admission National Institutes of Health Stroke Scale (NIHSS) and EPR in END group was 10.1% (IQR: 6.8–15.4), 16(IQR: 15–19) and 0.087% (IQR: 0.038–0.187). Respectively, the non-END group was 6.8% (IQR: 0–10.9), 13(IQR: 8–17) and 0.043% (IQR: 0–0.096). Compared with the non-END group, the END group had higher NWU (p = 0.004), higher admission NIHSS score (p = 0.001), and higher EPR (p = 0.006); multiple logistic regression showed that NWU (odds ratio [OR], 1.084; 95% confidence interval [CI], 1.004–1.171, p = 0.039) and admission NIHSS score (OR, 1.124; 95%CI, 1.032–1.224; p = 0.007) were independent risk factors for END. ROC curve showed that NWU had a moderate predictive ability for END. The area under the ROC curve (AUC) was 0.665 (95%CI, 0.561–0.770). The AUC of admission NIHSS score was 0.687 (95%CI, 0.698–0.776). NWU combined with admission NIHSS score had the highest predictive value for END, with an AUC of 0.739 (95%CI, 0.648–0.831).

Conclusion: The NWU was an independent predictor of END and increased NWU is associated with END in patients with AIS-LVO after MT. Similarly, the admission NIHSS score was also an independent predictor. The combination of NWU and the admission NIHSS score achieves the strongest predictive ability for END.

A novel automated CT biomarker to predict outcomes in acute ischemic stroke: net water uptake

Biomarkers are absolutely useless in getting survivors recovered! You're fired!

The previous two research articles on this were useless; why continue more useless shit? Your mentors and senior researchers are that blitheringly stupid?

• Net Water Uptake(2 posts to March 2021)

 A novel automated CT biomarker to predict outcomes in acute ischemic stroke: net water uptake

Monica Mallavarapu¹Hyun Woo Kim^2†Ananya Iyyangar¹Sergio Salazar-Marioni¹Albert J. Yoo²Luca Giancardo¹Sunil A. Sheth¹Jerome A. Jeevarajan^1*

• ¹McGovern Medical School, Department of Neurology, The University of Texas Health Houston, Houston, TX, United States
• ²Texas Stroke Institute, Plano, TX, United States

Background: Recent trials of large core thrombectomy have shown that our traditional understanding of infarct characteristics and reperfusion benefit may be incomplete for patients with acute ischemic stroke (AIS). The Alberta Stroke Program Early CT Score (ASPECTS) has wide inter-rater variability, and modern studies have also shown that reperfusion therapies can benefit some patients regardless of the ASPECTS. Reproducible imaging metrics that account for the degree of hypo-attenuation on non-contrast computed tomography (NCCT) may be better suited to guide treatments. Here, we evaluate Net Water Uptake (NWU), a novel NCCT metric that can be calculated in a rapid and automated fashion, to determine its predictive performance for identifying clinical outcomes in patients with AIS compared to ASPECTS.

Methods: From our prospectively collected registry encompassing 11 certified stroke centers, we identified patients with AIS. CT images were pre-processed and segmented, then NWU was calculated by automated comparison of density on ipsilateral and contralateral brain regions. Primary outcome was the area under the receiver operating characteristic curve (AUROC) for competing multivariable regression models with Average NWU versus ASPECTS to predict 90-day outcome measured by modified Rankin Scale (mRS). Regression models were adjusted for age, National Institutes of Health Stroke Scale (NIHSS), tPA administration, and endovascular therapy. Secondary analyses included subgroup comparisons of patients with large infarct core and late time window.

Results: Among 402 subjects with anterior circulation AIS, median age was 69 [IQR 57–80], 49.3% were female, median NIHSS was 11 [IQR 5–19], median ASPECTS was 9 [IQR 7–10], and median 90-day mRS was 3 [IQR 1–5]. The ASPECTS-based model performance was not significantly different from the NWU-based model to classify 90-day mRS outcome, with AUROC 0.732 and 0.749, respectively, (p = 0.513 with Delong test). Among the subgroups, performance was again similar, including patients with large infarct core (AUROC 0.795 vs. 0.863, p = 0.312) and late time window (AUROC 0.638 vs. 0.677, p = 0.267).

Conclusion: NWU is a quantitative metric that can be rapidly and automatically obtained from non-contrast CT with comparable performance to ASPECTS when predicting 90-day functional outcome across a wide range of AIS presentations.

Automated Measurement of Net Water Uptake From Baseline and Follow-Up CTs in Patients With Large Vessel Occlusion Stroke

 Useless. You described a problem, offered NO SOLUTION.

 

Automated Measurement of Net Water Uptake From Baseline and Follow-Up CTs in Patients With Large Vessel Occlusion Stroke

Atul Kumar¹, Yasheng Chen¹, Aaron Corbin², Ali Hamzehloo¹, Amin Abedini³, Zeynep Vardar⁴, Grace Carey¹, Kunal Bhatia¹, Laura Heitsch⁵, Jamal J. Derakhshan³, Jin-Moo Lee¹ and Rajat Dhar^1*

• ¹Department of Neurology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
• ²Saint Louis University School of Medicine, Saint Louis, MO, United States
• ³Department of Radiology, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States
• ⁴Department of Radiology, University of Massachusetts Medical School, Worcester, MA, United States
• ⁵Department of Emergency Medicine, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States

Quantifying the extent and evolution of cerebral edema developing after stroke is an important but challenging goal. Lesional net water uptake (NWU) is a promising CT-based biomarker of edema, but its measurement requires manually delineating infarcted tissue and mirrored regions in the contralateral hemisphere. We implement an imaging pipeline capable of automatically segmenting the infarct region and calculating NWU from both baseline and follow-up CTs of large-vessel occlusion (LVO) patients. Infarct core is extracted from CT perfusion images using a deconvolution algorithm while infarcts on follow-up CTs were segmented from non-contrast CT (NCCT) using a deep-learning algorithm. These infarct masks were flipped along the brain midline to generate mirrored regions in the contralateral hemisphere of NCCT; NWU was calculated as one minus the ratio of densities between regions, removing voxels segmented as CSF and with HU outside thresholds of 20–80 (normal hemisphere and baseline CT) and 0–40 (infarct region on follow-up). Automated results were compared with those obtained using manually-drawn infarcts and an ASPECTS region-of-interest based method that samples densities within the infarct and normal hemisphere, using intraclass correlation coefficient (ρ). This was tested on serial CTs from 55 patients with anterior circulation LVO (including 66 follow-up CTs). Baseline NWU using automated core was 4.3% (IQR 2.6–7.3) and correlated with manual measurement (ρ = 0.80, p < 0.0001) and ASPECTS (r = −0.60, p = 0.0001). Automatically segmented infarct volumes (median 110-ml) correlated to manually-drawn volumes (ρ = 0.96, p < 0.0001) with median Dice similarity coefficient of 0.83 (IQR 0.72–0.90). Automated NWU was 24.6% (IQR 20–27) and highly correlated to NWU from manually-drawn infarcts (ρ = 0.98) and the sampling-based method (ρ = 0.68, both p < 0.0001). We conclude that this automated imaging pipeline is able to accurately quantify region of infarction and NWU from serial CTs and could be leveraged to study the evolution and impact of edema in large cohorts of stroke patients.

Introduction

A major consequence of brain ischemia is the development of cerebral edema. This water accumulation within and around the injured tissue leads to brain swelling, raising compartmental pressure and eventually leading to midline shift and herniation. The development of malignant cerebral edema represents the greatest source of mortality in the acute period after ischemic stroke, especially for strokes due to large vessel occlusion (LVO) (1). As key mediators remain incompletely understood, few interventions currently exist to mitigate cerebral edema (2). One of the major limitations in studying edema is the need for an accurate means of quantifying its formation in the early stages after stroke (3, 4). Midline shift is a crude measure that does not adequately capture edema as it develops over the first 24–48 h after stroke, but only captures its delayed and decompensated phenotype. Furthermore, labeling edema only when it leads to deterioration (i.e., malignant edema) obscures a continuum of injury severity that is seen across almost all LVO stroke patients (5).

One of the hallmarks of evolving brain edema is tissue hypoattenuation (6). This can be captured by the progressively decreasing density (measured in Hounsfield Units, HU) of infarcted tissue on non-contrast computed tomography (NCCT) imaging. NCCT is readily available and routinely performed in almost all stroke patients, both acutely on presentation and frequently at follow-up. It affords an accessible means of serially assessing edema as it develops in the days after stroke. However, measurement of the total lesional hypodensity volume encompasses both infarcted tissue and associated edema, with relative proportions varying across patients (5, 7). A recent imaging method has been proposed to disentangle the contribution of edema to subacute lesion volume and quantify the progression edema after stroke (8). Net water uptake (NWU) evaluates the relative density of the ischemic tissue compared to a contralateral homologous region; increasing NWU on admission NCCT has been associated with longer time from stroke onset to imaging and poor collateral status (9, 10). NWU has also exhibited promise in quantifying edema progression, rising more in those with malignant outcomes and in those without successful recanalization (11, 12). Therefore, it has emerged as one of the most promising biomarkers of edema after stroke, with a wide array of potential applications across LVO cohorts (13).

However, implementation of NWU measurement from serial CTs in large stroke cohorts faces several challenges. The principal challenge is that its assessment is dependent on identification and delineation of the area of early infarction on acute and subacute CTs. As this region is not usually clearly visible on baseline NCCT within a few hours of stroke onset, most studies measuring early NWU have relied on CT perfusion (CTP) images to visually guide manual delineation of core infarct. In some studies where CTP was not available, NWU was estimated by measuring density within regions-of-interest (ROIs) placed within ASPECTS regions exhibiting early hypoattenuation and matched regions in the contralateral hemisphere (14). Measurement of NWU on follow-up NCCT requires manually outlining the visible region of infarction and flipping this manual ROI to create a homologous normal region for density assessment. This approach is time-consuming, subject to variability, and makes studying edema in large cohorts with NWU, although attractive in theory, challenging to perform in practice. Our objective was to develop an accurate means of automatically extracting infarct regions and measuring NWU from both baseline and follow-up CTs of LVO stroke patients. This imaging algorithm could then be leveraged to accelerate research into edema using larger cohorts of stroke patients (15).

More at link.

Net Water Uptake Calculated in Standardized and Blindly Outlined Regions of the Middle Cerebral Artery Territory Predicts the Development of Malignant Edema in Patients With Acute Large Hemispheric Infarction

 Useless. You described a problem, offered NO SOLUTION.

Net Water Uptake Calculated in Standardized and Blindly Outlined Regions of the Middle Cerebral Artery Territory Predicts the Development of Malignant Edema in Patients With Acute Large Hemispheric Infarction

Hai-Bin Xu¹, Yu-Fei Sun¹, Na Luo¹, Jia-Qi Wang¹, Guo-Can Chang¹, Lin Tao¹, Ben-Qiang Yang² and Hui-Sheng Chen^1*

• ¹Department of Neurology, General Hospital of Northern Theater Command, ShenYang, China
• ²Department of Radiology, General Hospital of Northern Theater Command, ShenYang, China

Background and purpose: Previous studies have demonstrated that Net Water Uptake (NWU) is associated with the development of malignant edema (ME). The current study aimed to investigate whether NWU calculated in standardized and blindly outlined regions of the middle cerebral artery can predict the development of ME.

Methods: We retrospectively included 119 patients suffering from large hemispheric infarction within onset of 24 h. The region of the middle cerebral artery territory was blindly outlined in a standard manner to calculate NWU. Patients were divided into two groups according to the occurrence of ME, which is defined as space-occupying infarct requiring decompressive craniotomy or death due to cerebral hernia in 7 days from onset. The clinical characteristics were analyzed, and the receiver operating characteristic curve (ROC curve) was used to assess the predictive ability of NWU and other factors for ME.

Results: Multivariable analysis showed that NWU was an independent predictor of ME (OR 1.168, 95% CI 1.041–1.310). According to the ROC curve, NWU≥8.127% identified ME with good predictive power (AUC 0.734, sensitivity 0.656, specificity 0.862).

Conclusions: NWU calculated in standardized and blindly outlined regions of the middle cerebral artery territory is also a good predictor for the development of ME in patients with large hemispheric infarction.

Introduction

Stroke has become a leading cause of mortality and disability worldwide, and it brings huge economic costs and family burdens (1). Acute ischemic stroke accounts for about 80% of all types of stroke (2). Large hemispheric infarction (LHI) is defined as affecting the majority of or complete middle cerebral artery (MCA) territory with or without anterior cerebral artery and posterior cerebral artery involvement (3). It is a disastrous subtype of acute ischemic stroke, which may lead to life-threatening swelling (4). Furthermore, LHI patients with malignant edema (ME) develop a mortality rate of nearly 40 ~ 80% under standard treatment, while mortality of those without ME is nearly 5 ~ 25% (3, 5, 6). It has been demonstrated by previous studies that timely decompressive craniotomy may reduce the mortality of LHI patients with ME (7, 8). Thus, early identification of LHI patients at risk for ME should be anticipated (3, 9).

There have been several studies exploring valid predictors of ME in LHI patients, such as the National Institutes of Health Stroke Scale (NIHSS), presence of hyperdense artery sign, a higher level of blood glucose, decreased level of consciousness, early infarct signs, intracranial cerebrospinal fluid volume, fluid balance variations, collateral circulation (10–17).

Interestingly, in 2018, Broocks' team found that Net Water Uptake (NWU) on baseline Computed Tomography (CT) was an important predictor of ME in LHI patients (9). Since then, accumulating evidence demonstrates that NWU can be used as an important qualified biomarker of edema in ischemic stroke. For example, NWU was used to estimate final infarction volumes (18), which serves as an indicator of “tissue clock” instead of the real “time clock” (19), and predicted the effect of recanalization (20) and early bleeding risk after endovascular treatment, especially with low ASPECTS (21). However, the measurement of NWU in previous studies mainly depends on CT perfusion (CTP) (9, 18–21). However, not all stroke centers have access to CTP in clinical practice. In this study, we aimed to investigate, whether NWU calculated in standardized and blindly outlined regions of the MCA territory is a reliable predictor of ME in patients with LHI.