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Early automated cerebral edema assessment following endovascular therapy: impact on stroke outcome
  1. Marina Guasch-Jiménez1,2,
  2. Rajat Dhar3,
  3. Atul Kumar3,
  4. Julien Cifarelli3,
  5. Garbiñe Ezcurra-Díaz1,4,
  6. Álvaro Lambea-Gil1,4,
  7. Anna Ramos-Pachón1,4,
  8. Alejandro Martínez-Domeño1,4,
  9. Luis Prats-Sánchez1,4,
  10. Daniel Guisado-Alonso1,4,
  11. Israel Fernández-Cadenas1,4,
  12. Ana Aguilera-Simón1,4,
  13. Rebeca Marín1,4,
  14. José Pablo Martínez-González5,
  15. Joaquin Ortega-Quintanilla6,
  16. Isabel Fernández-Pérez7,
  17. Carla Avellaneda-Gómez7,
  18. Jorge Rodríguez-Pardo8,
  19. Elena de Celis8,
  20. Francisco Moniche9,
  21. María del Mar Freijo10,
  22. Elisa Cortijo11,
  23. Santiago Trillo12,
  24. Pol Camps-Renom1,4,
  25. Joan Martí-Fábregas1,4
    1. 1Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
    2. 2Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
    3. 3Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
    4. 4Stroke Unit, Institut de Recerca Sant Pau (IIB-SANT PAU), Barcelona, Spain
    5. 5Neurointerventional Radiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
    6. 6Neurointerventional Radiology, Virgen del Rocio University Hospital, Seville, Spain
    7. 7Neurology, Hospital del Mar, Barcelona, Spain
    8. 8Neurology, La Paz University Hospital, Madrid, Spain
    9. 9Neurology, Hospital Universitario Virgen del Rocio, Seville, Spain
    10. 10Neurology, Cruces University Hospital, Barakaldo, Spain
    11. 11Neurology, Valladolid University Hospital, Valladolid, Spain
    12. 12Neurology, Hospital Universitario de la Princesa, Madrid, Spain
    1. Correspondence to Dr Pol Camps-Renom, Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona 08025, Spain; pcamps{at}


    Background Cerebral edema (CED) is associated with poorer outcome in patients with acute ischemic stroke (AIS). The aim of the study was to investigate the factors contributing to greater early CED formation in patients with AIS who underwent endovascular therapy (EVT) and its association with functional outcome.

    Methods We conducted a multicenter cohort study of patients with an anterior circulation AIS undergoing EVT. The volume of cerebrospinal fluid (CSF) was extracted from baseline and 24-hour follow-up CT using an automated algorithm. The severity of CED was quantified by the percentage reduction in CSF volume between CT scans (∆CSF). The primary endpoint was a shift towards an unfavorable outcome, assessed by modified Rankin Scale (mRS) score at 3 months. Multivariable ordinal logistic regression analyses were performed. The ∆CSF threshold that predicted unfavorable outcome was selected using receiver operating characteristic curve analysis.

    Results We analyzed 201 patients (mean age 72.7 years, 47.8% women) in whom CED was assessable for 85.6%. Higher systolic blood pressure during EVT and failure to achieve modified Thrombolysis In Cerebral Infarction (mTICI) 3 were found to be independent predictors of greater CED. ∆CSF was independently associated with the probability of a one-point worsening in the mRS score (common odds ratio (cOR) 1.05, 95% CI 1.03 to 1.08) after adjusting for age, baseline mRS, National Institutes of Health Stroke Scale (NIHSS), and number of passes. Displacement of more than 25% of CSF was associated with an unfavorable outcome (OR 6.09, 95% CI 3.01 to 12.33) and mortality (OR 6.72, 95% CI 2.94 to 15.32).

    Conclusions Early CED formation in patients undergoing EVT was affected by higher blood pressure and incomplete reperfusion. The extent of early CED, measured by automated ∆CSF, was associated with worse outcomes.

    • Stroke
    • Thrombectomy

    Data availability statement

    Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request.

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    Data availability statement

    Data are available upon reasonable request. The data that support the findings of this study are available from the corresponding author upon reasonable request.

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    • PC-R and JM-F contributed equally.

    • Contributors The study was conceived by MGJ, RD, PCR, and JMF. MGJ prepared the initial draft of the manuscript. MGJ, PCR, and JMF carried out the statistical analysis. RD, PCR, JMF, ARP, LP, AMD, GED, and ALG revised the manuscript. All authors participated in the data collection, analysis, and interpretation. MGJ, RD, AK, JC, and JPMG did the image analysis. The final version of the manuscript was approved by all the authors. MGJ, PCR, and JMF are guarantors of the scientific integrity.

    • Funding Redes de Investigación Con Objetivos de Resultados en Salud (RICORS) RD21/0006/0006, FEDER (Fondo Europeo de Desarrollo Regional) and PI19/00859 grant, Instituto de Salud Carlos III, Ministry of Science and Innovation (Government of Spain).

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.