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Net water uptake as a predictive neuroimaging marker for acute ischemic stroke outcomes: a meta-analysis

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Abstract

Objective

To assess the role of net water uptake (NWU) in predicting outcomes in acute ischemic stroke (AIS) patients.

Methods

A systematic review and meta-analysis were performed, adhering to established guidelines. The search covered PubMed, Scopus, Web of Science, and Embase databases until July 1, 2023. Eligible studies reporting quantitative ischemic lesion NWU in admission CT scans of AIS patients, stratified based on outcomes, were included. Data analysis was performed using R software version 4.2.1.

Results

Incorporating 17 original studies with 2217 AIS patients, NWU was significantly higher in patients with poor outcomes compared to those with good outcomes (difference of medians: 5.06, 95% CI: 3.00–7.13, p < 0.001). Despite excluding one outlier study, considerable heterogeneity persisted among the included studies (I2 = 90.8%). The meta-regression and subgroup meta-analyses demonstrated significantly higher NWU in patients with poor functional outcome, as assessed by modified Rankin Scale (difference of medians: 3.83, 95% CI: 1.98–5.68, p < 0.001, I2 = 72.9%), malignant edema/infarct (difference of medians: 8.30, 95% CI: 4.01–12.58, p < 0.001, I2 = 95.6%), and intracranial hemorrhage (difference of medians: 5.43, 95% CI: 0.44–10.43, p = 0.03, I2 = 91.1%).

Conclusion

NWU on admission CT scans shows promise as a predictive marker for outcomes in AIS patients. Prospective, multicenter trials with standardized, automated NWU measurement are crucial for robustly predicting diverse clinical outcomes.

Clinical relevance statement

The potential of net water uptake as a biomarker for predicting outcomes in acute ischemic stroke patients holds significant promise. Further validation through additional research could lead to its integration into clinical practice, potentially improving the accuracy of clinical decision-making and allowing for the development of more precise patient care strategies.

Key Points

• Net water uptake, a CT-based biomarker, quantifies early brain edema after acute ischemic stroke.

• Net water uptake is significantly higher in poor outcome acute ischemic stroke patients.

• Net water uptake on CT scans holds promise in predicting diverse acute ischemic stroke outcomes.

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Abbreviations

AIS:

Acute ischemic stroke

ASPECTS:

Alberta stroke program early computed tomography score

AUC:

Area under the curve

CI:

Confidence interval

CT:

Computed tomography

CTP:

Perfusion CT

ICH:

Intracranial hemorrhage

MCE:

Malignant cerebral edema

mRS:

Modified Rankin Scale

NWU:

Net water uptake

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

ROC:

Receiver operating characteristic

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Acknowledgements

We extend our appreciation to the Nested Knowledge developers, Karl Holub, Stephen Mead, Jeff Johnson, and Darian Lehmann-Plantenberg, for their contributions in enabling this study through the development of the AutoLit and Synthesis platforms for systematic review. We would also like to acknowledge the assistance provided by ChatGPT, an OpenAI language model based on the GPT-3.5 architecture, in language corrections during the manuscript editing process, which enhanced readability and language quality. However, the authors bear full responsibility for the content of this publication as they reviewed and edited the material after utilizing the tool.

Funding

The authors state that this work has not received any funding.

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Authors and Affiliations

  1. Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA

    Sherief Ghozy, Melika Amoukhteh, Alireza Hasanzadeh, Payam Jannatdoust, Mahan Shafie, Parya Valizadeh, Amir Hassankhani, Ramanathan Kadirvel & David F. Kallmes

  2. Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA

    Sherief Ghozy & Ramanathan Kadirvel

  3. Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA

    Melika Amoukhteh & Amir Hassankhani

  4. Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA

    Alzhraa Salah Abbas

  5. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA

    Alzhraa Salah Abbas

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  1. Sherief Ghozy
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Corresponding author

Correspondence to Amir Hassankhani.

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Guarantor

The scientific guarantor of this publication is David F. Kallmes.

Conflict of interest

David F. Kallmes holds equity in Nested Knowledge, Superior Medical Editors, Conway Medical, Marblehead Medical, and Piraeus Medical. He receives grant support from MicroVention, Medtronic, Balt, and Insera Therapeutics. Additionally, he has served on the Data Safety Monitoring Board for Vesalio and has received royalties from Medtronic.

Ramanathan Kadirvel is contracted or acts as a consultant for the following companies: Cerenovus Inc, Medtronic, Endovascular Engineering, Frontior Bio, Sensome Inc, Endomimetics, Ancure LLC, Neurogami Medical, MIVI Biosciences, Monarch Biosciences, Stryker Inc, Conway Medical, Pireus Medical, and Bionau Labs. He holds research grants from the National Institutes of Health (NIH) for projects with grant numbers R01NS076491, R44NS107111, R43NS110114, and R21NS128199. He also holds a research grant from the National Science Foundation (NSF) with grant number 081215707. The other authors affirm that they have no competing interests to declare.

The remaining authors of this manuscript have disclosed no affiliations with companies whose products or services pertain to the article’s subject matter.

Statistics and biometry

Payam Jannatdoust and Parya Valizadeh made substantial contributions to data analysis and interpretation, while Sherief Ghozy, with notable statistical expertise, offered guidance on statistical aspects.

Informed consent

Written informed consent was not required for this study because it is a systematic review and meta-analysis study.

Ethical approval

Institutional Review Board approval was unnecessary, given the nature of this systematic review and meta-analysis study.

Study subjects or cohorts overlap

No study subjects or cohorts overlap have been previously reported.

Methodology

• Multicenter study

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Sherief Ghozy, Melika Amoukhteh, and Alireza Hasanzadeh are co-first authors.

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Ghozy, S., Amoukhteh, M., Hasanzadeh, A. et al. Net water uptake as a predictive neuroimaging marker for acute ischemic stroke outcomes: a meta-analysis. Eur Radiol (2024). https://doi.org/10.1007/s00330-024-10599-6

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  • DOI: https://doi.org/10.1007/s00330-024-10599-6

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