Expanding Stroke AI: How Net Water Uptake May Refine Thrombectomy and Transfer Decisions

Advanced imaging has transformed acute ischemic stroke care, yet non-contrast CT remains the universal first-line modality across virtually all stroke systems. While perfusion imaging and collateral assessment have refined patient selection for thrombectomy and thrombolysis, access to advanced imaging remains uneven, particularly in hub-and-spoke networks and community hospitals. As treatment windows expand and clinicians increasingly treat patients with large ischemic cores, the need for objective, reproducible biomarkers derived from routine CT has become more pressing.

At the 2026 International Stroke Conference (ISC), held February 4-6 in New Orleans, Louisiana, Brainomix introduced its next-generation Brainomix 360 Stroke platform, featuring a first-of-its-kind regulatory-cleared net water uptake (NWU) capability derived from standard non-contrast CT scans. NWU provides a quantitative assessment of edema severity within ischemic tissue, building upon established tools such as e-ASPECTS and automated core estimation. Emerging data suggest that NWU may serve as an important imaging biomarker for prognosis and for refining treatment decisions, particularly in patients with low ASPECTS or large core strokes.

In this conversation, George Harston, MD, Chief Medical and Innovation Officer at Brainomix and Consultant Stroke Physician at Oxford University Hospitals, and James Briggs, MD, Medical Director of Medical Affairs at Brainomix, discuss how neurologists should interpret NWU, how it complements existing imaging metrics, and how automated NCCT-based biomarkers may influence decision-making speed, transfer discussions, and treatment equity across diverse hospital systems.

For clinicians who are not yet familiar with net water uptake, how should neurologists interpret NWU on non-contrast CT in terms of infarct severity, tissue viability, and prognosis?

NWU provides a quantitative measure of the severity of ischemic injury from a head non-contrast CT. As stroke injury progresses, vasogenic edema causes changes in distribution of water within the brain, which appears darker on CT. Qualitative assessment of this darkness is often used to estimate the severity of the injury. NWU is defined as the relative difference in density of the affected area in relation to that of the contralateral side (i.e. a measure of how dark the lesion is) and is associated with a poorer prognosis after stroke. Brainomix NWU provides reproducible, quantitative assessment of this change.

How does NWU add to or differ from established imaging tools like ASPECTS, core volume estimation, and collateral assessment when making treatment or transfer decisions?

Non-contrast CT core volume measurement and ASPECTS both provide standardized measures of the extent of ischemic injury in anterior circulation stroke on non-contrast CT. NWU complements these by adding an indicator of severity within the ischemic territory.

Core volume evaluation using CTP or MRI can also give a measure of the extent and severity of ischemic change but requires advanced imaging techniques that are not routinely available. Collateral assessment using CTA or CTP is a proxy measure of compensatory blood supply to the threatened brain and severity of hypoperfusion and therefore can help estimate how quickly ischemia might progress.

In real-world practice, where do you see NWU having the greatest impact: borderline thrombectomy candidates, large core strokes, or centers without advanced perfusion imaging?

NWU is becoming increasingly important in evaluating those strokes with the largest ischemic core volumes prior to mechanical thrombectomy, so called low ASPECTS stroke patients. In addition to the association with a poorer prognosis, patients with a high NWU appear to benefit less from mechanical thrombectomy. Being able to evaluate this using only a non-contrast CT scan is particularly useful in the setting of a hub-and-spoke network. At a spoke hospital, a quantitative edema measure can add objectivity to the transfer discussion without the need for advanced imaging that might not be readily available.

The platform emphasizes workflow integration. How does this AI output practically change decision-making speed or confidence in emergency stroke settings?

Like all image analysis, NWU only adds value if trusted by clinicians and fully integrated into clinical workflows. Brainomix 360 Stroke is available to doctors in near real-time, not only on the hospital imaging systems but also on the physician’s cell phone app. This enables faster and more consistent decision-making in all settings. The Brainomix cloud infrastructure further augments the patient flow by connecting specialist and non-specialist doctors in different hospitals allowing doctors across the network of hospitals to receive alerts, view images and communicate with colleagues withing minutes of patients being scanned at their local hospital.

From a systems-of-care perspective, how might automated NCCT-based biomarkers like NWU influence treatment equity, especially in hospitals without access to advanced imaging?

At the system level, NCCT-based biomarkers, such as NWU, can help reduce variation across a whole network of hospitals and ensure that more patients are identified for life changing treatment. Because non-contrast CT scans are widely available in all hospitals, standardized quantitative outputs can support consistent triage and transfer decisions regardless of local imaging resources. In a hub-and-spoke model, that consistency can translate into more uniform access to advanced therapies and fewer decisions driven primarily by geography or local experience.

Transcript was edited for clarity.