Abstract DP314: Ischemic Lesion Net Water Uptake Outperforms ASPECTS and CBF<30% in Predicting Futile Recanalization After Mechanical Thrombectomy

Background: Ischemic lesion net water uptake (NWU), a biomarker of cerebral edema, has been associated with poor outcomes in acute ischemic stroke due to large vessel occlusion (AIS-LVO). This study evaluates whether NWU more accurately predicts futile recanalization (FR)—defined as poor functional outcome despite successful endovascular thrombectomy (EVT)—compared to other biomarkers of ischemic injury, including the Alberta Stroke Program Early CT Score (ASPECTS) and CT perfusion (CTP)-derived ischemic core volume. Methods: We conducted a retrospective analysis of AIS-LVO patients who achieved successful recanalization via EVT at two comprehensive stroke centers. NWU and ASPECTS were measured on admission CT head; ischemic core volume was quantified as relative cerebral blood flow <30% (rCBF<30%) on CTP. Futile recanalization (FR) was defined as a 90-day modified Rankin Scale (mRS) score of 3–6. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed. Results: A total of 530 patients were included. NWU and rCBF<30% were significantly higher in patients with FR compared to those with good outcomes (median NWU: 7.77% vs. 2.75%; p<0.001; rCBF<30%: 17.0 mL vs. 3.0 mL; p<0.001). NWU (adjusted OR 1.72, 95% CI: 1.53–1.94, p<0.001), rCBF<30% (adjusted OR 1.01, 95% CI: 1.00–1.02, p<0.01), and ASPECTS (adjusted OR 0.79, 95% CI: 0.69–0.90, p<0.001) were independently associated with FR. NWU demonstrated significantly superior predictive performance (AUC=0.89) compared to rCBF<30% (AUC=0.66) and ASPECTS (AUC=0.65). Conclusion: NWU is a strong, non-invasive biomarker of futile recanalization, outperforming rCBF<30% and ASPECTS in AIS-LVO.