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Decoding the “Ghost Infarct Core” After Acute Stroke Thrombectomy

•Posted inRadiology

The concept of Ghost Infarct Core (GIC) is vital in acute ischemic stroke (AIS) management. GIC refers to the initial infarct core volume. It is derived from Computed Tomography Perfusion (CTP). However, this volume appears larger than the actual final infarct volume. Consequently, GIC represents brain tissue saved by successful reperfusion. Physicians routinely use endovascular treatment (EVT) to treat AIS patients. Therefore, accurately understanding prognostic markers after this procedure remains crucial. A new multicenter study investigates how venous outflow (VO) and net water uptake (NWU) mediate the positive prognostic role of GIC in EVT patients.

The researchers studied 313 AIS patients who received CTP imaging and EVT. These procedures took place across three tertiary hospitals between 2019 and 2024. The study defined GIC as a difference greater than 10 mL between the initial CTP core and the final infarct volume. GIC occurred in 15.3% of the patient cohort. Multiple mediation analyses determined the roles of VO and NWU on the clinical outcome. This outcome was a 90-day favorable functional outcome (mRS 0-2). Multivariable regression analysis showed that GIC significantly increased the likelihood of achieving a favorable outcome (p < 0.001). Interestingly, GIC is more likely to occur in younger patients, those with successful recanalization, and those presenting earlier after stroke onset.

The Predictive Power of Ghost Infarct Core and Imaging Markers

The analysis found that both VO and NWU partially mediate the positive association between GIC and a favorable 90-day outcome. Net water uptake accounted for a mediation effect of 24.3%, while venous outflow accounted for 15.0%. Therefore, the findings suggest two independent mechanisms are at play.

Net Water Uptake (NWU): NWU measures cerebral edema, calculable from non-contrast CT scans. Since cellular death causes water to accumulate in the brain tissue, higher NWU levels generally indicate more severe reperfusion injury and a larger infarct. Conversely, a lower NWU independently associates with both GIC presence and a better clinical prognosis. This marker quantifies the tissue salvage—or lack thereof—after the EVT procedure.

Venous Outflow (VO): VO reflects the brain’s collateral circulation status. A more robust, or favorable, VO profile predicts better tissue perfusion and a reduced rate of early edema progression. Furthermore, a lower VO score was independently linked to a higher GIC volume and a lower chance of a favorable outcome. In essence, GIC’s prognostic value is a composite measure. It reflects the combined protection offered by a favorable collateral status (VO) and less severe reperfusion injury (NWU) following thrombectomy. Therefore, physicians must interpret GIC in the context of these physiological factors.

Frequently Asked Questions

Q1: What is the clinical definition of a Ghost Infarct Core (GIC)?

GIC is defined as an initial infarct core volume from CTP that overestimates the final infarct volume by more than 10 mL, representing salvageable tissue.

Q2: How do Venous Outflow (VO) and Net Water Uptake (NWU) relate to GIC prognosis?

Favorable collateral status (VO) and less severe reperfusion injury (NWU) partially mediate the positive prognostic effect of GIC. A low NWU and a high VO profile are both associated with a better outcome.

References

  1. Li Y et al. Mediation of ghost infarct core on prognosis by venous outflow and net water uptake after stroke thrombectomy. Eur Radiol. 2026 Jan 29. doi: 10.1007/s00330-026-12321-0. PMID: 41609767.
  2. Broocks G et al. Degree of net water uptake on CT helps predict EVT treatment efficacy. AuntMinnie. 2025 Nov 4.
  3. Hacking C. Ghost infarct core. Radiopaedia.org. 2025 Oct 16.
  4. Kass-Hout T et al. Prevalence of “Ghost Infarct Core” after Endovascular Thrombectomy. OhioHealth Scholarly Works. 2024 Mar 7.
  5. Kass-Hout T et al. Prevalence of “Ghost Infarct Core” after Endovascular Thrombectomy. Am J Neuroradiol. 2024 Jan 25;45(1):16-21.
  6. Li W et al. Predictors of ghost infarct core on baseline computed tomography perfusion in stroke patients with successful recanalization after mechanical thrombectomy. Neuroradiology. 2023 Feb;65(2):297-307.
  7. Chen Z, Chen X, Yang J. Venous outflow profiles are associated with early edema progression in ischemic stroke. J Cereb Blood Flow Metab. 2022 Mar;42(3):524-531.
  8. Broocks G et al. CT Water Uptake May Predict EVT Benefit. Conexiant. 2025 Nov 13.