Higher Baseline Subcortical Net Water Uptake in Computed Tomography Predicts Malignant Middle Cerebral Artery Infarction in Patients with Acute Ischemic Stroke

Purpose The objective of this study was to assess the predictive performance of Net water uptake (NWU) based on the Alberta stroke program early CT score (ASPECTS) from different ASPECT regions in relation to the development of malignant middle cerebral artery (MCA) infarction. Methods Patients with acute ischemic stroke (AIS) of the MCA territory were retrospectively enrolled between January 2019 and July 2022. Patients were divided into two groups according to the follow-up CT after 24 to 48 hours: malignant and non-malignant infarction. NWUs were measured on diverse ASPECT regions on admission non-contrast CT, namely affected ASPECTS-NWU (af-ASPECTS-NWU), subcortical ASPECTS-NWU (sc-ASPECTS-NWU) and cortical ASPECTS-NWU (c-ASPECTS-NWU). Baseline characteristics were collected for univariate analyses and multivariate regression analyses to explore the independent risk factors for malignant infarction. Receiver operating characteristic (ROC) curves were plotted and compared. Results 153 patients were included in the final analysis. Malignant MCA infarction was achieved in 42 (27.45%) patients and non-malignant was 111 (72.55%). Compared with the non-malignant infarction group, higher baseline NIHSS score, af-ASPECTS-NWU, c-ASPECTS-NWU, sc-ASPECTS-NWU, and lower ASPECTS were noted in malignant infarction group (all P<0.001). Multivariate logistic regression showed that only baseline sc-ASPECTS-NWU (>3.6%) was positive factor for malignant MCA infarction. The ROC analysis indicated the highest predictive value of sc-ASPECTS-NWU for indicating malignant infarction with the AUC 0.91. Conclusion Higher baseline sc-ASPECTS-NWU was a quantitative predictor for malignant MCA infarction in patients with AIS, which could be helpful for treatment decision.