New Tools to Improve Prediction of Clinical Outcomes After Endovascular Therapy for Patients with Large Infarct Core
Demi Waworuntu1, Omair ul haq Lodhi1, Alex Phan1, Monica Mallavarapu1, Ritesh Bajaj1, Hyun Woo Kim2, Sergio Salazar-Marioni1, Luca Giancardo1, Shayan Shams1, Sunil Sheth1, Sushanth Aroor1, Jerome Jeevarajan1
1University of Texas Health Houston, 2Texas Stroke Institute
Objective:

To evaluate two novel non-contrast CT (NCCT) biomarkers—Net Water Uptake (NWU) and the Visual Hypodensity Score (VHS)—for predicting disability outcomes for patients with large infarct core (LIC) undergoing endovascular therapy (EVT).

Background:

Recent trials have shown that EVT can improve outcomes for patients with LIC. However, current imaging methods including the Alberta Stroke Program Early CT Score (ASPECTS) and CT Perfusion are limited by availability, inconsistency, and reliance on expert interpretation.

Design/Methods:

From a prospectively collected multicenter registry, we included patients with anterior circulation large vessel occlusion and LIC (ASPECTS 0-5) who underwent EVT. Blinded raters scored ASPECTS and VHS from NCCT, and NWU was computed with an automated algorithm. Primary outcome was prediction of 90-day disability outcome (mRS 0-3 versus 4-6). Multivariable logistic regression was used, adjusting for age, NIHSS, IV thrombolysis, time from last-known-well to groin puncture (LKW to GP), occlusion location, and TICI.

Results:
Among 114 patients, median age was 65 [IQR 53–75], median NIHSS 19 [IQR 16–22], and median LKW–GP 355 minutes [IQR 222–761]; 35.1% received IV thrombolysis, and 82.5% achieved TICI 2b–3. Interrater reliability was fair for ASPECTS (κ=0.31) and VHS (κ=0.24). In multivariable regression, ASPECTS (OR 0.84, p=0.16) and VHS (OR 1.11, p=0.17) were not significantly associated with outcome, whereas NWU in the M3 region was (OR 1.30, p=0.02). ROC curves were similar across methods (AUC 0.750 vs 0.739 vs 0.750). NWU also correlated with elapsed time from symptom onset (beta coefficient 36.6, p=0.01) and effectively replaced this variable in prediction models.

 

Conclusions:

In LIC patients undergoing EVT, NCCT-ASPECTS and VHS showed limited predictive value. NWU was independently associated with both 90-day outcome and time from onset. These findings support further validation of NWU as an improved, automated screening tool for EVT.

10.1212/WNL.0000000000216097
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