Malignant cerebral edema (MCE) is a life-threatening complication after endovascular therapy (EVT) for acute ischemic stroke (AIS). In this multicenter study, we observed a specific gyral hyperdensity sign (GHS) and sought to investigate its association with MCE, analyzing the underlying factors correlated with GHS. Consecutive anterior circulation AIS patients exhibiting post-EVT hyperdensities on 24-h follow-up computed tomography were included. GHS was defined as curvilinear hyperdensities distributed along ⩾2 adjacent cerebral gyri. A total of 542 patients were enrolled. GHS was identified in 142 patients with excellent interobserver agreement (κ = 0.804). We found that GHS (OR = 1.83, 95% CI = 1.13–2.95, P = 0.014) was independently associated with MCE. Furthermore, baseline NIHSS score (OR = 1.05, 95% CI = 1.02–1.09, P = 0.003), blood glucose (OR = 1.15, 95% CI = 1.05–1.25, P = 0.002), infarct ASPECTS (OR = 0.91, 95% CI = 0.83–0.99, P = 0.024), creatinine level (OR = 3.47, 95% CI = 1.71–7.02, P < 0.001), and intracranial internal carotid artery occlusion (OR = 1.66, 95% CI = 1.09–2.55, P = 0.020) were independently correlated with GHS. These results revealed that GHS can be reliably identified and can serve as an early warning indicator for MCE.
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