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Original research
Prognostic importance of CT ASPECTS and CT perfusion measures of infarction in anterior emergent large vessel occlusions
  1. Syed Ali Raza,
  2. Clara M Barreira,
  3. Gabriel M Rodrigues,
  4. Michael R Frankel,
  5. Diogo C Haussen,
  6. Raul G Nogueira,
  7. Srikant Rangaraju
  1. Department of Neurology, Emory University, Atlanta, Georgia, USA
  1. Correspondence to Dr Srikant Rangaraju, Department of Neurology, Emory University, Atlanta, GA 30322, USA; srangar{at}


Background Age, neurologic deficits, core volume (CV), and clinical core or radiographic mismatch are considered in selection for endovascular therapy (ET) in anterior circulation emergent large vessel occlusion (aELVO). Semiquantitative CV estimation by Alberta Stroke Programme Early CT Score (CT ASPECTS) and quantitative CV estimation by CT perfusion (CTP) are both used in selection paradigms.

Objective To compare the prognostic value of CTP CV with CT ASPECTS in aELVO.

Methods Patients in an institutional endovascular registry who had aELVO, pre-ET National Institutes of Health Stroke Scale (NIHSS) score, non-contrast CT head and CTP imaging, and prospectively collected 3-month modified Rankin Scale (mRS) score were included. Age- and NIHSS-adjusted models, including either CT ASPECTS or CTP volumes (relative cerebral blood flow <30% of normal tissue, total hypoperfusion, and radiographic mismatch), were compared using receiver operator characteristic analyses.

Results We included 508 patients with aELVO (60.8% M1 middle cerebral artery, 34% internal carotid artery, mean age 64.1±15.3 years, median baseline NIHSS score 16 (12–20), median baseline CT ASPECTS 8 (7–9), mean CV 16.7±24.8 mL). Age, pre-ET NIHSS, CT ASPECTS, CV, hypoperfusion, and perfusion imaging mismatch volumes were predictors of good outcome (mRS score 0–2). There were no differences in prognostic accuracies between reference (age, baseline NIHSS, CT ASPECTS; area under the curve (AUC)=0.76) and additional models incorporating combinations of age, NIHSS, and CTP metrics including CV, total hypoperfusion or mismatch volume (AUCs 0.72–0.75). Predicted outcomes from CT ASPECTS or CTP CV-based models had excellent agreement (R2=0.84, p<0.001).

Conclusions Incorporating CTP measures of core or penumbral volume, instead of CT ASPECTS, did not improve prognostication of 3-month outcomes, suggesting prognostic equivalence of CT ASPECTS and CTP CV.

  • ct perfusion
  • thrombectomy
  • stroke

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  • Contributors SAR and SR conceptualized the study, performed the analyses, and wrote the manuscript. CMB, GMR, DCH, MRF, and RGN assisted in data collection, adjudication of imaging and clinical data, and critically revising the manuscript.

  • 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 RGN serves as follows: Stryker: DAWN trial principal investigator, TREVO Registry steering committee, Trevo-2 trial principal investigator, consultant; Medtronic: SWIFT Trial steering committee, SWIFT Prime Trial steering committee, STAR Trial sngiographic core laboratory; Cerenovus/Neuravi: ENDOLOW trial principal investigator, ARISE-2 trial steering Committee, Physician Advisory Board; Phenox:Physician Advisory Board; Anaconda: Physician Advisory Board; Genetech: Physician Advisory Board; Biogen: Physician Advisory Board; Viz-AI: Physician Advisory Board; Vesalio: Physician Advisory Board; Ceretrieve: Physician Advisory Board; and Intervention Neurology Journal: Editor-In-Chief.

  • Patient consent Not required.

  • Ethics approval Institutional review board approval was obtained for this study.

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