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Original research
Computed tomography-based triage of extensive baseline infarction: ASPECTS and collaterals versus perfusion imaging for outcome prediction
  1. Rosalie McDonough1,
  2. Sarah Elsayed1,
  3. Tobias Djamsched Faizy2,
  4. Friederike Austein1,
  5. Peter B Sporns3,
  6. Lukas Meyer1,
  7. Matthias Bechstein1,
  8. Noel van Horn1,
  9. Marie Teresa Nawka1,
  10. Gerhard Schön4,
  11. Helge Kniep1,
  12. Uta Hanning1,
  13. Jens Fiehler1,
  14. Jeremy J Heit5,
  15. Gabriel Broocks1
  1. 1Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  2. 2Radiology, Stanford University School of Medicine, Stanford, California, USA
  3. 3Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
  4. 4Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  5. 5Radiology, Neuroradiology and Neurointervention Division, Stanford University, Stanford, California, USA
  1. Correspondence to Dr Rosalie McDonough, Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; r.mcdonough{at}


Background Patients presenting with large baseline infarctions are often excluded from mechanical thrombectomy (MT) due to uncertainty surrounding its effect on outcome. We hypothesized that computed tomography perfusion (CTP)-based selection may be predictive of functional outcome in low Alberta Stroke Program Early CT Score (ASPECTS) patients.

Methods This was a double-center, retrospective analysis of patients presenting with ASPECTS≤5 who received multimodal admission CT imaging between May 2015 and June 2020. The predicted ischemic core (pCore) was defined as a reduction in cerebral blood flow (rCBF), while mismatch volume was defined using time to maximum (Tmax). The pCore perfusion mismatch ratio (CPMR) was also calculated. These parameters (pCore, mismatch volume, and CPMR), as well as a combined radiological score consisting of ASPECTS and collateral status (ASCO score), were tested in logistic regression and receiver operating characteristic (ROC) analyses. The primary outcome was favorable modified Rankin Scale (mRS) at discharge (≤3).

Results A total of 113 patients met the inclusion criteria. The median ischemic core volume was 74.1 mL (IQR 43.8–121.8). The ASCO score was associated with favorable outcome at discharge (aOR 3.7, 95% CI 1.8 to 10.7, P=0.002), while no association was observed for the CTP parameters. A model including the ASCO score also had significantly higher area under the curve (AUC) values compared with the CTP-based model (0.88 vs 0.64, P=0.018).

Conclusions The ASCO score was superior to the CTP-based model for the prediction of good functional outcome and could represent a quick, practical, and easily implemented method for the selection of low ASPECTS patients most likely benefit from MT.

  • CT
  • CT perfusion
  • stroke
  • thrombectomy
  • intervention

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  • Contributors Conception/design of work: GB. Data collection: RM, SE, TDF, JJH, PBS, Fabian Flottmann, NvH, MTN, MB, LM. Data analysis and interpretation: RM, GB, HK, GS, FA, UH, LM. Drafting the article: RM. Critical revision of the article: RM, SE, TDF, FA, PBS, LM, MB, NvH, MTN, GS, HK, UH, JF, JJH, GB. Final approval of the version to be published: GB, JF. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: RM, SE, TDF, FA, PBS, LM, MB, NvH, MTN, GS, HK, UH, JF, JJH, GB.

  • 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 JF reports personal fees as a consultant for Microvention, Stryker, Cerenovus, Acandis, Penumbra, and Medtronic outside the submitted work. He is a member of the executive boards of the German Society of Neuroradiology (DGNR) and the European Society of Minimally Invasive Neurological Therapy (ESMINT).

  • Patient consent for publication Not required.

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

  • Data availability statement Data are available upon reasonable request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.