Large ischemic core defined by visually assessed ASPECTS predicts functional outcomes comparably accurate to automated CT perfusion in the 6-24 h window

Tolga D Dittrich; Anh Nguyen; Peter B Sporns; Anna M Toebak; Lilian F Kriemler; Salome Rudin; Annaelle Zietz; Benjamin Wagner; Filip Barinka; Martin Hänsel; Henrik Gensicke; Raoul Sutter; Christian H Nickel; Mira Katan; Nils Peters; Lars Michels; Zsolt Kulcsár; Grzegorz M Karwacki; Marco Pileggi; Carlo Cereda; Susanne Wegener; Leo H Bonati; Marios Psychogios; Gian Marco De Marchis

doi:10.1177/23969873241286691

Large ischemic core defined by visually assessed ASPECTS predicts functional outcomes comparably accurate to automated CT perfusion in the 6-24 h window

Eur Stroke J. 2024 Oct 7:23969873241286691. doi: 10.1177/23969873241286691. Online ahead of print.

Authors

Tolga D Dittrich^{1

2

3}, Anh Nguyen^{3

4}, Peter B Sporns^{3

4}, Anna M Toebak^{1

2}, Lilian F Kriemler^{1

5}, Salome Rudin¹, Annaelle Zietz^{1

3}, Benjamin Wagner^{1

3}, Filip Barinka⁶, Martin Hänsel⁷, Henrik Gensicke^{1

3

8

9}, Raoul Sutter^{3

10}, Christian H Nickel^{3

9

11}, Mira Katan^{1

3

7

9}, Nils Peters^{1

3

6}, Lars Michels^{12

13}, Zsolt Kulcsár¹², Grzegorz M Karwacki¹⁴, Marco Pileggi¹⁵, Carlo Cereda¹⁶, Susanne Wegener⁷, Leo H Bonati^{1

3

9

17}, Marios Psychogios^{3

4

9}, Gian Marco De Marchis^{1

2

3

9}

Affiliations

¹ Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.
² Department of Neurology and Stroke Center, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.
³ Department of Clinical Research, University of Basel, Basel, Switzerland.
⁴ Department of Neuroradiology, University Hospital Basel, Basel, Switzerland.
⁵ Department of Intensive Care Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
⁶ Department of Neurology and Stroke Center, Hirslanden Hospital Zurich, Zurich, Switzerland.
⁷ Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland.
⁸ Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, Basel, Switzerland.
⁹ Medical Faculty, University of Basel, Basel, Switzerland.
¹⁰ Department of Intensive Care Medicine, University Hospital Basel and University of Basel, Basel, Switzerland.
¹¹ Emergency Department, University Hospital Basel and University of Basel, Basel, Switzerland.
¹² Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland.
¹³ Neuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Zurich, Switzerland.
¹⁴ Department of Radiology and Nuclear Medicine, Cantonal Hospital of Lucerne, Lucerne, Switzerland.
¹⁵ Department of Neuroradiology, EOC Neurocenter of Southern Switzerland, Lugano, Switzerland.
¹⁶ Department of Neurology and Stroke Center, EOC Neurocenter of Southern Switzerland, Lugano, Switzerland.
¹⁷ Rheinfelden Rehabilitation Clinic, Rheinfelden, Switzerland.

Abstract

Introduction: Automated CT perfusion (aCTP) is commonly used to select patients with anterior circulation large vessel occlusion (aLVO) for endovascular treatment (EVT). The equivalence of visually assessed Non-contrast CT Alberta Stroke Program Early CT Scores (ASPECTS) and aCTP based selection in predicting favorable functional outcomes remains uncertain.

Patients and methods: Retrospective multicenter study of adult aLVO patients from the Swiss Stroke Registry (2014-2021) treated with EVT or best medical treatment 6-24 h after stroke onset. We assessed ASPECTS on non-contrast CT visually and ischemic core volumes on aCTP, defining ASPECTS 0-5 and aCTP CBF < 30% volumes ⩾50 mL as large ischemic cores. We used logistic regression to explore the association between CT modalities and favorable functional outcomes (modified Rankin Scale [mRS] score shift toward lower categories) at 3 months. Receiver operating characteristic (ROC) curve analysis compared the predictive accuracy of visually assessed ASPECTS and aCTP ischemic core for favorable outcomes (mRS 0-2) at 3 months.

Results: Of 210 patients, 11.4% had ASPECTS 0-5, and 12.9% aCTP core volumes ⩾50 mL. Within the same model, ASPECTS but not aCTP core volumes were associated with favorable outcomes (ASPECTS: acOR 1.85, 95%CI 1.27-2.70, p = 0.001). The ROC curve analyses showed comparable diagnostic accuracy in predicting favorable functional outcomes (mRS 0-2) at 3 months (ROC areas: ASPECTS 0.80 [95%CI 0.74-0.86] vs aCTP core 0.79 [95%CI 0.72-0.85]).

Discussion and conclusion: In patients with aLVO, visually assessed ASPECTS showed at least comparable accuracy to automatically generated CTP core volumes in predicting functional outcomes at 3 months.

Keywords: ASPECTS; CT perfusion; Ischemic stroke; endovascular treatment.