Objectives This study aimed to investigate whether venous outflow (VO) and net water uptake (NWU) mediate the relationship between the ghost infarct core (GIC) and clinical outcomes in patients with acute ischemic stroke (AIS) who underwent endovascular treatment (EVT). Materials and methods AIS patients who underwent Computed Tomography Perfusion (CTP) imaging and EVT at three tertiary hospitals between January 2019 and March 2024 were included. GIC was defined as a difference exceeding 10 mL between the initial CTP-derived core volume and the final infarct volume. Multiple mediation analyses were conducted to assess the mediating roles of VO and NWU in the relationship between GIC and a 90-day favorable functional outcome, defined as a modified Rankin Scale of 0–2. Results Among 313 included patients, 48 (15.3%) had GIC. Multivariable regression analysis revealed that GIC significantly increased the likelihood of a favorable outcome (p < 0.001). Multiple mediation analyses revealed that GIC was associated with both favorable VO (β = 0.34, 95% CI 0.21–0.48, p < 0.001) and lower baseline NWU (β = −1.71, 95% CI −2.43 to −1.08, p < 0.001). Favorable VO and lower NWU mediated 44.5% and 14.5% of the total effect of GIC on favorable outcome, respectively. Analyses based on an alternative causal ordering yielded consistent results. Conclusion GIC was significantly associated with favorable functional outcomes at 90 days in AIS patients following EVT. Favorable VO and reduced baseline NWU mediated a significant proportion (~ 60%) of the overall effect of GIC on a favorable functional outcome. Key Points <Emphasis Type="BoldItalic">Question</Emphasis> It remains unclear whether venous outflow (VO) and net water uptake (NWU) mediate the effect of ghost infarct core (GIC) on clinical outcomes in acute ischemic stroke (AIS) patients. <Emphasis Type="BoldItalic">Findings</Emphasis> The association between GIC and 90-day favorable functional outcomes in AIS patients undergoing endovascular treatment (EVT) was partially mediated by favorable VO and baseline NWU. <Emphasis Type="BoldItalic">Clinical relevance</Emphasis> GIC was significantly associated with a 90-day favorable functional outcome in AIS patients undergoing EVT. Joint evaluation of VO status and baseline NWU may help optimize selection for EVT in AIS patients and improve clinical outcomes. Graphical Abstract

Mediation of ghost infarct core on prognosis by venous outflow and net water uptake after stroke thrombectomy

期刊论文
发表日期：

2026年1月29日

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Yingzi Li,
Zhiyi Zong,
Chentao Wang,
Kechun Chen,
Da Liang,
Puzhi Wang,
Chongke Zhong,
Meili Zhou,
Chun-Feng Liu,
Weidong Hu,
Huihui Liu

摘要

Objectives

This study aimed to investigate whether venous outflow (VO) and net water uptake (NWU) mediate the relationship between the ghost infarct core (GIC) and clinical outcomes in patients with acute ischemic stroke (AIS) who underwent endovascular treatment (EVT).

Materials and methods

AIS patients who underwent Computed Tomography Perfusion (CTP) imaging and EVT at three tertiary hospitals between January 2019 and March 2024 were included. GIC was defined as a difference exceeding 10 mL between the initial CTP-derived core volume and the final infarct volume. Multiple mediation analyses were conducted to assess the mediating roles of VO and NWU in the relationship between GIC and a 90-day favorable functional outcome, defined as a modified Rankin Scale of 0–2.

Results

Among 313 included patients, 48 (15.3%) had GIC. Multivariable regression analysis revealed that GIC significantly increased the likelihood of a favorable outcome (p < 0.001). Multiple mediation analyses revealed that GIC was associated with both favorable VO (β = 0.34, 95% CI 0.21–0.48, p < 0.001) and lower baseline NWU (β = −1.71, 95% CI −2.43 to −1.08, p < 0.001). Favorable VO and lower NWU mediated 44.5% and 14.5% of the total effect of GIC on favorable outcome, respectively. Analyses based on an alternative causal ordering yielded consistent results.

Conclusion

GIC was significantly associated with favorable functional outcomes at 90 days in AIS patients following EVT. Favorable VO and reduced baseline NWU mediated a significant proportion (~ 60%) of the overall effect of GIC on a favorable functional outcome.

Key Points

Question It remains unclear whether venous outflow (VO) and net water uptake (NWU) mediate the effect of ghost infarct core (GIC) on clinical outcomes in acute ischemic stroke (AIS) patients.

Findings The association between GIC and 90-day favorable functional outcomes in AIS patients undergoing endovascular treatment (EVT) was partially mediated by favorable VO and baseline NWU.

Clinical relevance GIC was significantly associated with a 90-day favorable functional outcome in AIS patients undergoing EVT. Joint evaluation of VO status and baseline NWU may help optimize selection for EVT in AIS patients and improve clinical outcomes.

Graphical Abstract