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Original research
Influence of ASPECTS and endovascular thrombectomy in acute ischemic stroke: a meta-analysis
  1. Kevin Phan1,
  2. Serag Saleh1,
  3. Adam A Dmytriw2,3,
  4. Julian Maingard4,
  5. Christen Barras5,
  6. Joshua A Hirsch6,
  7. Hong Kuan Kok7,
  8. Mark Brooks4,
  9. Ronil V Chandra8,9,
  10. Hamed Asadi10
  1. 1 NeuroSpine Surgery Research Group (NSURG), Sydney, New South Wales, Australia
  2. 2 Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
  3. 3 Department of Medical Imaging, St Michael’s Hospital, Toronto, Ontario, Canada
  4. 4 Interventional Neuroradiology, Austin Health, Heidelberg, Victoria, Australia
  5. 5 University of Adelaide, Adelaide, South Australia, Australia
  6. 6 NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
  7. 7 Department of Radiology, Beaumont Hospital, Dublin, Ireland
  8. 8 Interventional Neuroradiology Unit, Monash Health, Clayton, Victoria, Australia
  9. 9 Department of Imaging, Monash University, Clayton, Victoria, Australia
  10. 10 Department of Radiology, Beaumont Hospital, Dublin, Ireland
  1. Correspondence to Dr Kevin Phan, NeuroSpine Surgery Research Group (NSURG), Sydney, New South Wales 2109, Australia;{at}


Background Prompt revascularization of the ischemic penumbra following an acute ischemic event (AIS) has established benefit within the literature. However, use of the semi-quantitative Alberta Stroke Program Early CT Score (ASPECTS) to evaluate patient suitability for revascularization has been inconsistent in patient risk stratification and selection.

Objective To conduct a meta-analysis to evaluate the available evidence for a clinically valid ASPECTS threshold in assessment of suitability for revascularization following AIS.

Methods Two independent reviewers searched Medline (Ovid) and Cochrane Central Register of Systematic Reviews databases for studies appraising outcomes of endovascular thrombectomy (EVT) in relation to a variably-defined preoperative ASPECTS.

Results A total of 13 articles were included. The pooled good outcome proportion after EVT was 41.4% (95% CI 36.4% to 46.6%; p<0.001), with subjective study-specific definitions of favorable and unfavorable subgroup outcomes of 49.7% (95% CI 44.2% to 55.3%; I2=76.5%; p<0.001) and 33.2% (95% CI 28.5% to 38.3%; I2=33.16%), respectively. Objective trichotomization into low (0–4), intermediate (5–7), and high (8–10) subgroups yielded pooled good outcome proportions of 17.1% (95% CI 6.8% to 36.8%; I2=64.24%; p=0.039), 35.7% (95% CI 30.5% to 41.3%; I2=23.11%; p=0.245), and 49.7% (95% CI 44.2% to 55.3%; I2=76.5%; p<0.001) for low, intermediate, and high ASPECTS, respectively.

Conclusions A subjectively favorable ASPECTS is associated with significantly better outcomes after EVT than an unfavorable ASPECTS, regardless of the cut-off used. EVT is unlikely to be useful in patients with an objectively low ASPECTS and is likely to be useful for those with high ASPECTS; findings in patients with intermediate ASPECTS were equivocal.

  • stroke
  • thrombectomy
  • thrombolysis

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  • Contributors Study inception: KP, HA. Data extraction: KP, SS, AAD, JM. Data analysis: KP, SS, AAD. Interpretation: all authors. Initial draft of manuscript: KP, SS, AAD, HA. Review and editing: all authors. Supervision: DMB, RC, HA.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data available in manuscript.