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Original research
ASPECTS discrepancies between CT and MR imaging: analysis and implications for triage protocols in acute ischemic stroke
  1. Ferdinand K Hui1,
  2. Nancy A Obuchowski2,
  3. Seby John1,
  4. Gabor Toth1,
  5. Irene Katzan1,
  6. Dolora Wisco1,
  7. Esteban Cheng-Ching1,
  8. Ken Uchino1,
  9. Shu-Mei Man1,
  10. Shazam Hussain1
  1. 1Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
  2. 2Quantitative Health Services, Cleveland Clinic, Cleveland, Ohio, USA
  1. Correspondence to Dr Ferdinand K Hui, Cerebrovascular Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave S80, Cleveland, OH 44120, USA; ferdinandhui{at}


Background Optimal imaging triage for intervention for large vessel occlusions remains unclear. MR-based imaging provides ischemic core volumes at the cost of increased imaging time. CT Alberta Stroke Program Early CT Score (ASPECTS) estimates are faster, but may be less sensitive.

Objective To assesses the rate at which MRI changed management in comparison with CT imaging alone.

Methods Retrospective analysis of patients with acute ischemic stroke undergoing imaging triage for endovascular therapy was performed between 2008 and 2013. Univariate and multivariate analyses were performed. Multivariate logistic regression was used to evaluate the effect of time on disagreement in MRI and CT ASPECTS scores.

Results A total of 241 patients underwent both diffusion-weighted imaging (DWI) and CT. Six patients with DWI ASPECTS ≥6 and CT ASPECTS <6 were omitted, leaving 235 patients. For 47 patients, disagreement between the two modalities resulted in different treatment recommendations. The estimated probability of disagreement was 20.0% (95% CI 15.4% to 25.6%). In a multivariate logistic regression, CT ASPECTS >7 (p=0.004) and admission National Institutes of Health Stroke Scale (NIHSS) score <16 (p=0.008) were simultaneously significant predictors of agreement in ASPECTS. The time between modalities was a marginally significant predictor (p=0.080).

Conclusions The study suggests that patients with NIHSS scores at admission of <16 and patients with CT ASPECTS >7 have a higher likelihood of agreement between CT and DWI based on an ASPECTS cut-off value of 6. Additional MRI for triage in patients with NIHSS at admission of >16, and ASPECTS of 6 or 7 may be more likely to change management. Unsurprisingly, patients with low CT ASPECTS had good correlation with MRI ASPECTS.

  • Stroke
  • CT
  • MRI

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  • Contributors FKH: conceived and designed the research. DW, S-MM, SJ, and EC-C: acquired the data. FKH and DW: analyzed and interpreted the data. NAO: performed the statistical analysis. FKH: drafted the manuscript. FKH, SH, GT, KU, and IK: made critical revisions of the manuscript. FKH, SH, GT, KU, and DW: approved the final manuscript.

  • Competing interests None declared.

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