Mallavarapu Monica, Kim Hyun Woo, Iyyangar Ananya, Salazar-Marioni Sergio, Yoo Albert J, Giancardo Luca, Sheth Sunil A, Jeevarajan Jerome A
McGovern Medical School, Department of Neurology, The University of Texas Health Houston, Houston, TX, United States.
Texas Stroke Institute, Plano, TX, United States.
Front Neurol. 2025 Aug 22;16:1629434. doi: 10.3389/fneur.2025.1629434. eCollection 2025.
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.
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.
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, ( = 0.513 with Delong test). Among the subgroups, performance was again similar, including patients with large infarct core (AUROC 0.795 vs. 0.863, = 0.312) and late time window (AUROC 0.638 vs. 0.677, = 0.267).
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.
近期大型取栓治疗试验表明，对于急性缺血性卒中（AIS）患者，我们对梗死特征和再灌注获益的传统认识可能并不完整。阿尔伯塔卒中项目早期CT评分（ASPECTS）在不同评估者之间存在较大差异，现代研究还表明，无论ASPECTS如何，再灌注治疗都能使部分患者获益。考虑到非增强计算机断层扫描（NCCT）上低密度程度的可重复性成像指标可能更适合指导治疗。在此，我们评估净水摄取量（NWU），这是一种可快速自动计算的新型NCCT指标，以确定其与ASPECTS相比在识别AIS患者临床结局方面的预测性能。
从我们前瞻性收集的涵盖11个认证卒中中心的登记数据中，我们识别出AIS患者。对CT图像进行预处理和分割，然后通过自动比较同侧和对侧脑区的密度来计算NWU。主要结局是接受者操作特征曲线下面积（AUROC），用于比较平均NWU与ASPECTS的多变量回归模型，以预测改良Rankin量表（mRS）测量的90天结局。回归模型对年龄、美国国立卫生研究院卒中量表（NIHSS）、tPA给药和血管内治疗进行了校正。次要分析包括对大面积梗死核心患者和晚期时间窗患者的亚组比较。
在402例前循环AIS患者中，中位年龄为69岁[四分位间距57 - 80岁]，49.3%为女性，中位NIHSS为11[四分位间距5 - 19]，中位ASPECTS为9[四分位间距7 - 10]，中位90天mRS为3[四分位间距1 - 5]。基于ASPECTS的模型在分类90天mRS结局方面的表现与基于NWU的模型无显著差异，AUROC分别为0.732和0.749，（德龙检验=0.513）。在亚组中，表现再次相似，包括大面积梗死核心患者（AUROC 0.795对0.863，=0.312）和晚期时间窗患者（AUROC 0.638对0.677，=0.267）。
NWU是一种定量指标，可从非增强CT快速自动获得，在预测广泛AIS表现患者的90天功能结局方面，其性能与ASPECTS相当。
