CHIH-HUNG WANGCHU-LIN TSAILi, HuaHuaLiSu, Chin-HuaChin-HuaSuTsai, Tou-YuanTou-YuanTsaiSchmieschek, Maximilian H TMaximilian H TSchmieschekJOYCE TAYMENG-CHE WUOnur, Oezguer AOezguer AOnurCHENG-YI WUCHIEN-CHANG LEECHIEN-HUA HUANG2025-08-192025-08-192025-08-0110538119https://scholars.lib.ntu.edu.tw/handle/123456789/731517Aim: To compare the prognostic accuracy of manually (mGWR) and automatically (aGWR) computed gray-white matter ratios on brain computed tomography for predicting neurological outcomes in adult post-cardiac arrest patients. Methods: We systematically searched the PubMed and Embase databases from their inception to August 2024. Studies providing sufficient data on mGWR or aGWR to predict neurological outcomes in adult post-cardiac arrest patients were selected. A Bayesian bivariate random-effects meta-analysis model was used to synthesize data. Between-study heterogeneity was quantified using the I² statistic, and publication bias was assessed with Deek's test. Results: A total of 42 studies, involving 8104 patients, were included in the meta-analysis (mGWR: 41 studies, 6843 patients; aGWR: 5 studies, 1261 patients; 4 studies reported both mGWR and aGWR). The pooled area under the curve (AUC) for mGWR was 0.77 (95 % credible interval [CrI], 0.73–0.81; I², 100 %), with a pooled sensitivity of 0.55 (95 % CrI, 0.50–0.61) and specificity of 0.96 (95 % CrI, 0.93–0.99). For aGWR, the pooled AUC was 0.84 (95 % CrI, 0.81–0.87; I², 98 %), with a pooled sensitivity of 0.53 (95 % CrI, 0.34–0.71) and specificity of 0.95 (95 % CrI, 0.88–0.99). Subgroup analyses did not identify the source causing the heterogeneity, including brain regions for GWR calculations, GWR calculation formulas, and threshold values. No significant publication bias was found (mGWR, p = 0.28; aGWR, p = 0.79). Conclusions: The neuroprognostic performance of mGWR and aGWR was comparable, with a slightly higher AUC for aGWR. aGWR shows potential as a standardized imaging biomarker for guiding treatment decisions.enfalseCardiac arrestCardiopulmonary resuscitationComputed tomographyGray-white matter ratioNeurological outcome[SDGs]SDG3journal article10.1016/j.neuroimage.2025.121298404804042-s2.0-105007651983