Clinical, Imaging, and Serum Biomarker Predictors of Malignant Cerebral Infarction

Abstract

Malignant cerebral infarction (MCI) is rare but often fatal. Early identification helps guide monitoring and decompressive surgery. This study evaluated whether serum biomarkers add predictive value beyond clinical and imaging data in severe stroke patients with anterior circulation large vessel occlusion (LVO). In this prospective study, 73 acute severe LVO stroke patients underwent whole-brain CT perfusion (CTP) with rCBV-based core measurement at admission and follow-up MRI at 24 ± 12 h for infarct and edema volume assessment. Serum biomarkers (s100b, NSE, VEGF, ICAM1) were sampled a median of 20.5 h after baseline imaging. Logistic regression models predicted MCI using baseline variables (NIHSS, ASPECTS, rCBV < 30%), adding treatment data (rtPA, mTICI, NIHSS posttreatment), and adding serum biomarkers. Performance was assessed by AUC, accuracy, F1, and cross-validated R². MCI occurred in 18/73 (24%) patients. Baseline models showed an AUC of 0.72; adding treatment improved the AUC to 0.88. Biomarkers slightly increased the AUC (0.90) but did not improve F1. Higher s100b was associated with more severe injury but did not enhance the prediction of MCI. Models with baseline imaging and treatment best explained infarct (R² ≈ 0.27) and edema (R² ≈ 0.58). In conclusion, admission severity, CTP, and early treatment response are the main predictors of MCI and aid early risk stratification of patients. Despite their pathophysiologic relevance, serum biomarkers do not add substantial predictive value.

Keywords: CT perfusion; biomarkers; cerebral edema; large vessel occlusion; malignant cerebral infarction; predictive modelling.

Figure 1

Flow chart describing screening, exclusions, and the final cohort.

Figure 2

A previously healthy 55-year-old male transferred to the emergency department with severe right hemispheric syndrome (NIHSS: 20). NCCT (A) showed an extensive right ischemic lesion (ASPECTS 4) due to an occlusion of the M1 segment of the middle cerebral artery visualized on CTA ((B), arrow) and an extensive and severe volume drop on rCBV-based CTP, where the darker blue color indicates greater volume drops (C). Due to the extent of the injury, acute reperfusion treatment was not performed. The follow-up MRI performed 16 h after admission showed an extensive ischemic area on DWI (D), as well as abundant cerebral edema on FLAIR (E), causing a midline shift greater than 6 mm. A decompressive hemicraniectomy was performed 24 h after admission. The follow-up NCCT revealed an extensive ischemic lesion with cerebral edema and postsurgical changes (F). After the procedure, the patient survived but with serious sequelae that led to severe disability at 3 months.

Figure 3

Performance metrics for malignant cerebral infarction by model set.