Imaging biomarkers of cerebral edema automatically extracted from routine CT scans of large vessel occlusion strokes

Abstract

Background and Purpose Volumetric and densitometric biomarkers have been proposed to better quantify cerebral edema after stroke, but their relative performance has not been rigorously evaluated. Methods Patients with large vessel occlusion stroke from three institutions were analyzed. An automated pipeline extracted brain, cerebrospinal fluid (CSF), and infarct volumes from serial CTs. Several biomarkers were measured: change in global CSF volume from baseline (ΔCSF); ratio of CSF volumes between hemispheres (CSF ratio); and relative density of infarct region compared with mirrored contralateral region (net water uptake [NWU]). These were compared to radiographic standards, midline shift and relative hemispheric volume (RHV) and malignant edema, defined as deterioration resulting in need for osmotic therapy, decompressive surgery, or death. Results We analyzed 255 patients with 210 baseline CTs, 255 24‐hour CTs, and 81 72‐hour CTs. Of these, 35 (14%) developed malignant edema and 63 (27%) midline shift. CSF metrics could be calculated for 310 (92%), while NWU could only be obtained from 193 (57%). Peak midline shift was correlated with baseline CSF ratio (ρ = –.22) and with CSF ratio and ΔCSF at 24 hours (ρ = –.55/.63) and 72 hours (ρ = –.66/.69), but not with NWU (ρ = .15/.25). Similarly, CSF ratio was correlated with RHV (ρ = –.69/–.78), while NWU was not. Adjusting for age, National Institutes of Health Stroke Scale, tissue plasminogen activator treatment, and Alberta Stroke Program Early CT Score, CSF ratio (odds ratio [OR]: 1.95 per 0.1, 95% confidence interval [CI]: 1.52‐2.59) and ΔCSF at 24 hours (OR: 1.87 per 10%, 95% CI: 1.47‐2.49) were associated with malignant edema. Conclusion CSF volumetric biomarkers can be automatically measured from almost all routine CTs and correlate better with standard edema endpoints than net water uptake.

Updates in Management of Large Hemispheric Infarct

“…50 NWU can be inferred from changes in the attenuation coefficient or directly visualized on MRI DWI sequences and reflects the extent of water uptake in the brain. 51 In a post hoc analysis of 81 patients from the GAMES-RP Trial, it was shown that NWU on the admission CT scans was higher in patients who later developed malignant edema compared with those who did not and was an independent predictor for malignant edema after adjusting for baseline midline shift. 52 To determine whether different radiographic biomarkers predict edema endpoints, one study compared several radiographic biomarkers including change in global CSF volume, the ratio of CSF volumes between hemispheres, and NWU.…”

“…The authors concluded that CSF volumetric biomarkers could be automatically measured from almost all routine CTs and correlated better with standard edema endpoints than NWU. 51 While CSF and NWU are not yet standardly available or used in clinical practice, improved imaging processing and segmentation technology may make these measurements more widely available in the future.…”