Temporal Net Water Uptake Evolution and Its Association with Functional Outcome in Acute Ischemic Stroke

American Journal of Neuroradiology, vol. 47, pp. 2526–2537

Abstract

BACKGROUND AND PURPOSE: Subacute lesion growth after acute ischemic stroke is associated with worse functional outcomes. The ischemic lesion severity can be assessed with Net Water Uptake (NWU), a CT-based marker of edema. Pre-treatment NWU has been associated with worse functional outcomes; however, it remains unclear how the temporal changes in NWU influence functional outcomes. In this study, we aimed to determine how associations between NWU and functional outcome vary across imaging times up to 1 week after stroke. MATERIALS AND METHODS: We included patients from the MRCLEAN NO-IV trial with anterior circulation large vessel occlusion who were treated with endovascular treatment and had baseline, 24-hour, and 1-week follow-up non-contrast CT scans. Functional outcome at 90 days was evaluated using the modified Rankin Scale (mRS), analyzed both as functional independence (mRS 0–2) and across the full ordinal distribution (mRS 0–6). In the primary analysis, associations between NWU measured at different imaging timepoints and functional independence were examined using univariable and multivariable logistic regression models. To evaluate temporal changes in NWU, ΔNWU was calculated at different time intervals (baseline-24 hours, 24 hours-1 week, and baseline-1 week), and its association with outcomes was analyzed using analogous regression models. RESULTS: Out of 539 MRCLEAN NO-IV patients, 115 were included in this study. The median time from stroke onset to randomization was 92(70-140) minutes. The median NWU evolved from 4.3%(IQR:2.1-6.8%) at baseline to 9.0%(IQR:3.0-13%) at 24 hours and 15%(IQR:11-19%) at 1 week. The median patient-level change (ΔNWU) from baseline to 1 week was 10%(IQR: 5.3-16%). NWU measured at 1 week, but not at baseline or 24 hours, was significantly associated with functional dependence, with an aOR of 0.66(95%CI=0.47-0.90) per 5-percantage-point increase in NWU. Furthermore, a higher increase in NWU from baseline to 1 week imaging was significantly associated with functional dependence, with an aOR of 0.66(95%CI=0.47-0.86) per 5-percentage-point increase in ΔNWU1wk-BL. CONCLUSIONS: In our population, NWU measured at 1 week is associated with 90-day clinical outcomes, suggesting that lesion evolution continues in the first week after stroke onset and may therefore represent a target for secondary treatments to improve clinical outcomes.

Authors 11

1. Wiktor Olszewski

   Amsterdam UMC Location University of Amsterdam

   Affiliation as printed

   Department of Radiology and Nuclear Medicine (W.O., F.C., L.v.P., L.B., B.J.E., H.M., C.M., P.K.), Amsterdam UMC-Location University of Amsterdam, Amsterdam, the Netherlands

   From the Department of Biomedical Engineering and Physics (W.O., L.v.P., H.M., P.K.), Amsterdam UMC-Location University of Amsterdam, Amsterdam, the Netherlands w.olszewski@amsterdamumc.nl

2. Fabiano Cavalcante

   Amsterdam UMC Location University of Amsterdam

   Affiliation as printed

   Department of Radiology and Nuclear Medicine (W.O., F.C., L.v.P., L.B., B.J.E., H.M., C.M., P.K.), Amsterdam UMC-Location University of Amsterdam, Amsterdam, the Netherlands

3. Laura M. van Poppel

   Amsterdam UMC Location University of Amsterdam

   Affiliation as printed

   Department of Radiology and Nuclear Medicine (W.O., F.C., L.v.P., L.B., B.J.E., H.M., C.M., P.K.), Amsterdam UMC-Location University of Amsterdam, Amsterdam, the Netherlands

   From the Department of Biomedical Engineering and Physics (W.O., L.v.P., H.M., P.K.), Amsterdam UMC-Location University of Amsterdam, Amsterdam, the Netherlands

4. Ludo Beenen

   Amsterdam UMC Location University of Amsterdam

   Affiliation as printed

   Department of Radiology and Nuclear Medicine (W.O., F.C., L.v.P., L.B., B.J.E., H.M., C.M., P.K.), Amsterdam UMC-Location University of Amsterdam, Amsterdam, the Netherlands

5. Bart J. Emmer

   Amsterdam UMC Location University of Amsterdam

   Affiliation as printed

   Department of Radiology and Nuclear Medicine (W.O., F.C., L.v.P., L.B., B.J.E., H.M., C.M., P.K.), Amsterdam UMC-Location University of Amsterdam, Amsterdam, the Netherlands

6. Ido R. van den Wijngaard Aachen Department of Neurology, Leiden University Medical Center (LUMC)

   Leiden University Medical Center · Medisch Centrum Haaglanden · Stichting Haaglanden Medisch Centrum

   Affiliation as printed

   Department of Neurology (I.v.d.W.), Leiden University Medical Center, Leiden, the Netherlands

   Department of Neurology and Radiology (I.v.d.W.), Haaglanden Medical Center, the Hague, the Netherlands

7. Robin Lemmens

   KU Leuven

   Affiliation as printed

   Department of Neurosciences (R.L.), Experimental Neurology, KU Leuven - University of Leuven, Leuven, Belgium; Department of Neurology (R.L.), University Hospitals Leuven, Leuven Belgium

8. Yvo B.W.E.M. Roos

   Amsterdam UMC Location University of Amsterdam

   Affiliation as printed

   Department of Neurology (Y.R.), Amsterdam UMC-Location University of Amsterdam, Amsterdam, the Netherlands

9. Henk A. Marquering

   Amsterdam UMC Location University of Amsterdam

   Affiliation as printed

   Department of Radiology and Nuclear Medicine (W.O., F.C., L.v.P., L.B., B.J.E., H.M., C.M., P.K.), Amsterdam UMC-Location University of Amsterdam, Amsterdam, the Netherlands

   From the Department of Biomedical Engineering and Physics (W.O., L.v.P., H.M., P.K.), Amsterdam UMC-Location University of Amsterdam, Amsterdam, the Netherlands

10. Charles B.L.M. Majoie

    Amsterdam UMC Location University of Amsterdam

    Affiliation as printed

    Department of Radiology and Nuclear Medicine (W.O., F.C., L.v.P., L.B., B.J.E., H.M., C.M., P.K.), Amsterdam UMC-Location University of Amsterdam, Amsterdam, the Netherlands

11. Praneeta R. Konduri

    Amsterdam UMC Location Vrije Universiteit Amsterdam · Stanford University

    Affiliation as printed

    From the Department of Biomedical Engineering and Physics (W.O., L.V.P., H.M., P. K.), Radiology and Nuclear Medicine (W.O., F.C., L.V.P., L.B., B.J.E., H.M., C.M., P.K.), Neurology (Y.R.), Amsterdam UMC - location University of Amsterdam, Amsterdam, Netherlands; Department of Neurology and Radiology (I.V.D.W.), Haaglanden Medical Center, the Hague, Netherlands; Department of Neurology (I. V.D.W.), Leiden University Medical Center, Leiden, Netherlands; KU Leuven, Department of Neurosciences (R.L.), Experimental Neurology; University Hospitals Leuven, Department of Neurology, Leuven, Belgium and Department of Neurology and Neurological Sciences (P.K.), Stanford University, Palo Alto, CA, United States