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REVIEW ARTICLE
ASPECTS CT in Acute Ischemia: Review of Current Data
Supada Prakkamakul, MD,  and Albert J. Yoo, MD, PhD y
Abstract: The Alberta Stroke Program Early CT score (ASPECTS) is a 10-
point semiquantitative topographic scoring system developed for the assess-
ment of early ischemic changes (EICs) on noncontrast-enhanced computed
tomography (NCCT) in patients with acute ischemic stroke involving the
middle cerebral artery (MCA) territory. One point is subtracted from a total
score of 10, if an EIC is present in any part of each of the ASPECTS regions.
Higher ASPECTS has been associated with better outcomes and a lower risk
of symptomatic intracerebral hemorrhage. To date, there are still controversies
regarding the utility of ASPECTS for selecting patients for intravenous and
intra-arterial therapies. This article provides a comprehensive review regard-
ing methodology, limitations, and interobserver reproducibility of ASPECTS,
as well as application of ASPECTS in clinical care. The focus of this review is
ASPECTS evaluation on NCCT. The application of ASPECTS on multimodal
computed tomography and magnetic resonance imaging (MRI) is briefly
described.
Key Words: acute ischemic stroke, ASPECTS, computed tomography
(Top Magn Reson Imaging 2017;xx:xxx–xxx)
N oncontrast-enhanced computed tomography (NCCT) has long
been the mainstay of acute stroke evaluation. NCCT accurately
detects acute intracranial hemorrhage, enabling rapid differentiation
of acute ischemic from hemorrhagic strokes. In patients with acute
ischemic anterior circulation stroke, the extent of early ischemic
change (EIC) on pretreatment NCCT is a predictor of functional
outcomes and risk of intracranial hemorrhage after reperfusion
therapy. The Alberta Stroke Program Early CT score (ASPECTS)
is the standard approach for quantifying the amount of EIC.
DEFINING EARLY ISCHEMIC CHANGE
Historically, EICs encompassed both hypodensity in the brain
parenchyma and isolated cortical swelling. Parenchymal hypoden-
sity is defined as a region of abnormally low density compared with
the density of the remaining part of the same structure or of the
contralateral hemisphere. Hypodensity is best appreciated as loss of
gray-white matter differentiation (Fig. 1). Cortical swelling is
defined as any focal narrowing of the cerebrospinal fluid (CSF)
space resulting from compression by adjacent brain structures, and is
often associated with parenchymal hypodensity when there is devel-
opment of edema.
In the calculation of ASPECTS, only parenchymal hypodensity
is counted. As a sign of ionic and vasogenic edema, it is a highly
specific marker of irreversible injury.1 Isolated cortical swelling (i.e.,
without hypodensity), on the contrary, does not fulfill this important
criterion. Several studies have shown that this finding does not
always correspond to permanent ischemic damage.2,3 Thus, isolated
From the Department of Radiology, King Chulalongkorn Memorial Hospital the
Thai Red Cross Society, Bangkok, Thailand; and yDivision of Neurointerven-
tion, Texas Stroke Institute, Plano, TX.
Address correspondence to Albert J. Yoo, MD, PhD, Division of Neurointerven-
tion, Texas Stroke Institute, 1600 Coit Road, Suite 104, Plano, TX 75075.
(e-mail: ajyoo74@gmail.com).
The authors report no conflicts of interest.
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DOI: 10.1097/RMR.0000000000000122
Topics in Magnetic Resonance Imaging  Volume XX, Number X, Month 2017
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cortical swelling likely represents some combination of ischemic
penumbra and benign oligemia, and should not be used for
ASPECTS calculation.4
WHAT IS ASPECTS?
ASPECTS is a 10-point semiquantitative topographic scoring
system for the assessment of EICs on NCCT in patients with acute
ischemic stroke involving the middle cerebral artery (MCA) terri-
tory.5 The MCA territory is divided into 10 ASPECTS regions:
caudate (C), insular ribbon (I), posterior limb of internal capsule (IC),
lentiform nucleus (L), anterior inferior frontal cortex (M1), anterior
temporal cortex (lateral to the insular ribbon; M2), posterior temporal
cortex (M3), anterior superior MCA cortex (ACA-MCA borderzone;
M4), posterior frontal cortex (M5), parietal cortex (M6) (Fig. 2). The
M4, M5, M6 regions are the MCA territories immediately superior to
the M1, M2, and M3 regions, respectively. Unlike in the original
formulation where just 2 representative ganglionic and supragan-
glionic cuts were inspected,5 current recommendations are that all of
the NCCT slices should be inspected. Owing to the typical computed
tomography (CT) gantry angle, it is important to remember that on
axial images, the inferior portion of M5 will appear anterior to the
superior portion of M2, with the obliquely oriented Sylvian fissure
between them (Fig. 3). Care should also be taken to inspect the entire
caudate nucleus (head, body, and tail). For involvement in any part of
an ASPECTS region, 1 point is subtracted from a total score of 10,
such that lower scores indicate larger infarcts. Most often, ASPECTS
regions are only partially affected, including the ganglionic struc-
tures. For instance, the caudate nucleus has dual blood supplies6
(Fig. 4). The abnormality must be apparent on at least 2 consecutive
5-mm thick NCCT cuts, to ensure that it is a true lesion and not
related to partial volume averaging. If there are EICs in both of the
cerebral hemispheres, ASPECTS calculation is done on each
hemisphere separately.
PURPOSE OF ASPECTS
In the early time window after stroke onset (i.e., within 6 hours),
ischemic hypodensity on NCCT is typically subtle, and therefore, it is
difficult to discern lesion boundaries, particularly in the white matter
where the signal-to-noise ratio is poor. Therefore, infarct volume
cannot be determined on NCCT in the treatment window. For this
reason, a semiquantitative approach such as ASPECTS is necessary
to assess the extent of infarct-related changes in a rapid and repro-
ducible fashion in MCA ischemic stroke patients. Despite the fact
that an individual ASPECTS score can encompass a range of infarct
volumes, there is a strong correlation between these measures.7
Furthermore, higher baseline ASPECTS has been demonstrated to
be a predictor for favorable functional outcome and less symptomatic
hemorrhage after reperfusion therapy.5,8 Given these findings,
ASPECTS has been used as a criterion for patient enrollment in
clinical trials, and is now incorporated in patient selection criteria
after several recent randomized endovascular treatment trials.9
FACTORS AFFECTING ASPECTS
EICs become more pronounced with increasing time from
stroke symptoms onset to imaging10 (Fig. 5). Within the first
90 minutes, the degree of hypodensity is so subtle that it results in
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FIGURE 1. Findings of early ischemic changes (EIC) in a 59-year-old man who presented with acute left hemiparesis. A and B, NCCT 3.5 hours after
symptoms onset shows hypodensity and cortical swelling with sulcal effacement. There is loss of gray-white matter differentiation in the right frontal
operculum, right temporal operculum, right insular cortex, and right frontoparietal lobes (black arrowheads).

poor interobserver reliability.11 NCCT acquisition techniques, plane
of image acquisition/reconstruction, slice thickness, and window
settings also contribute to varying conspicuity of the EIC, as well
as artifacts.1,12,13 Although thicker slices result in greater volume
averaging, there is a beneficial reduction in image noise, such that 3
to 5-mm thick sections are considered standard. Using narrow
window width accentuates image contrast and improves sensitivity
for the detection of EIC without compromising the high specificity
that is important in clinical practice1 (Fig. 6). Disparity between the
initial ASPECTS on NCCT and on MRI after treatment is lower,
using optimized narrow-width window settings.14
INTEROBSERVER REPRODUCIBILITY OF ASPECTS
The reliability of an imaging finding is a critical parameter that
determines its clinical utility. Interobserver reproducibility of
ASPECTS varies depending on several factors, including reader
experience, amount of reader training, knowledge of stroke symp-
toms side, and stroke onset-to-imaging time. Furthermore, it will
depend on whether ASPECTS is evaluated on the basis of the entire
scale or grouped into dichotomous or trichotomous classes. Pexman
et al12 reported good overall agreement of ASPECTS dichotomiza-
tion at 7 among a stroke neurologist, neuroradiologist, and radiology
resident compared with the one-third MCA rule. On the contrary,
Mak et al,15 achieved only fair interobserver agreement of dicho-
tomized ASPECTS at 7 among a neurologist, general radiologist, and
neuroradiologist. In their discussion, the authors highlighted the
inexperience of the readers and the lack of rigorous ASPECTS
training as potential causes of their worse interobserver agreement.15
A prospective study in 214 NCCT scans within 12 hours of onset in
acute ischemic stroke or transient ischemic attack patients demon-
strated substantial interobserver agreement of NCCT ASPECTS
between real-time assessment by a stroke neurologist or stroke fellow
at the time of the CT scan and expert interpretation at a later time.16 A
study in consecutive acute ischemic stroke patients with proximal
arterial occlusion who underwent intra-arterial therapy (IAT)
demonstrated substantial agreement for total ASPECTS evaluated
by 2 experienced neuroradiologists.17 However, the same study
reported only moderate interobserver agreement for dichotomized
ASPECTS at 7, and fair to moderate agreement for each individual
ASPECTS region. A prospective study comparing interobserver agree-
ment for total and individual ASPECTS regions on NCCT [as well as
CT Angiography Source Image (CTA-SI) and CT Perfusion Cerebral
Blood Volume (CTP-CBV) map] demonstrated very good agreement
among 4 readers (2 neuroradiologists and 2 neurologists).18 Again, this
study showed lower interobserver concordance in individual
ASPECTS regions, than total ASPECTS. Among the individual
ASPECTS regions, highest agreement was observed in the caudate,
lentiform, and M1-M3 regions, whereas lower concordance was shown
in the internal capsule and M4-M6 regions.
Subacute ASPECTS on NCCT performed at least 2 days after
stroke onset has excellent interobserver reproducibility.19 This is
consistent with the greater conspicuity of infarction at later time points
in the acute/early subacute phase. As expected, there is higher inter-
observer reproducibility of DWI ASPECTS than NCCT ASPECTS.20
LIMITATIONS OF ASPECTS
ASPECTS is intended for acute thromboembolic stroke of the
anterior circulation. Certain patterns of infarction such as borderzone
infarction with multiple small hypodensities are difficult to evaluate
using ASPECTS.21 Additional limitations are related to NCCT
imaging. A parenchymal hypodensity related to acute infarction is
sometimes difficult to differentiate from an old infarct (Fig. 7),
although the latter are usually very dark and if large enough,
associated with clear volume loss. Acute infarcts isolated to the
white matter are also difficult to detect, unless they are well
established and if there are no chronic ischemic white matter changes
or age-related white matter hypodensities. This is particularly perti-
nent for the internal capsule, which is composed entirely of white
matter tracts. Some ASPECTS regions, especially those adjacent to
the skull base, are susceptible to beam-hardening artifacts with

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FIGURE 2. The MCA territory is divided into 10 ASPECTS regions, including Caudate (C), Insular ribbon (I), Internal Capsule (IC), Lentiform
nucleus (L), Anterior inferior frontal cortex (M1), Anterior temporal cortex lateral to the insular ribbon (M2), Posterior temporal cortex (M3),
Anterior superior frontal cortex (M4), Posterior frontal cortex (M5), Parietal cortex (M6). The M4, M5, M6 are the MCA territories superior to the
M1, M2, and M3 regions, respectively. Notice that on the upper right image, M5 and M2 are on the same slice, owing to the CT gantry angulation
(see Fig. 3).

certain image acquisition techniques13 (Fig. 8). An ASPECTS region
should be counted as being involved only if the findings are certain.
APPLICATION OF ASPECTS IN CLINICAL CARE
Multiple factors may affect the ability of baseline NCCT
ASPECTS to predict functional outcomes, including level and
location of arterial occlusion, time from symptoms onset, collateral
status, type of reperfusion treatment, and timing and degree of
recanalization/reperfusion.
Baseline NCCT ASPECTS is a strong prognostic marker, and
has been correlated with baseline NIHSS score.5,8,22,23 This is related
in strong measure to the level of arterial occlusion, as very low
ASPECTS are only possible when there is blockage of the internal
carotid artery (ICA) or the MCA stem (M1 segment). In addition, it
reflects the degree of collateral circulation.8,22 In the placebo arm of
the National Institute of Neurological Disorders and Stroke rtPA
stroke study (NINDS rtPA stroke study), patients with ASPECTS less
than 3 had lower chance of good functional outcome than those with
higher ASPECTS.24
Intravenous Thrombolysis
Patients with lower ASPECTS on pretreatment NCCT have
worse functional outcomes5,24,25 and increased symptomatic hem-
orrhage5,25 after treatment with intravenous alteplase. However, post
hoc analyses of the NINDS rtPA Stroke Study and ECASS II failed to
demonstrate treatment-modifying effect of dichotomized ASPECTS
on good outcome after intravenous rtPA.24,26 Both studies evaluated
ASPECTS dichotomized as 0 to 7 versus 8 to 10. In the NINDS rtPA
study, good outcome was defined as 90-day mRS 0 to 1. Moreover,
the time from onset to treatment in the NINDS rtPA was within
3 hours, and the extent of EICs did not preclude trial eligibility.24 The
definition of good outcome was 90-day mRS 0 to 2 in the ECASS II
trial, which treated patients within 6 hours of symptoms onset, and
excluded patients with hypoattenuation more than one-third MCA
territory.26 Notably, the number of patients with extensive EICs was
low in both trials, which may have limited the power to detect a
significant interaction between ASPECTS and IV rtPA treatment.
There were only 16 (2.6%) patients with ASPECTS 0 to 2 in the
NINDS IV rtPA study. Furthermore, the high number (>40%) of

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FIGURE 3. Sagittal image (A) demonstrates the typical gantry angle for CT acquisition, where the dotted straight lines show the axial slice
orientation. The axial image (B) corresponds to the middle dotted straight line on the sagittal image. Notice that M5 is anterior to M2 on this image,
with the Sylvian fissure separating them.

patients with ASPECTS 10 (no EIC) may have resulted in a
significant proportion of patients without arterial occlusion, for
whom reperfusion therapy would not be expected to yield a clinical
benefit. Finally, in both analyses, the ASPECTS criteria included
isolated cortical swelling, which as previously mentioned is not a
marker of irreversible injury. Nevertheless, because treatment modi-
fication could not be demonstrated, low baseline NCCT ASPECTS is
not a criterion to withhold fibrinolytic treatment in the current
American Heart Association/American Stroke Association (AHA/
ASA) guidelines for the early management of patients with acute
ischemic stroke.27,28
The ECASS II analysis demonstrated treatment-by-ASPECTS 7
or less effect modification in predicting parenchymal hemorrhage
and symptomatic intracerebral hemorrhage.26 However, no such
interaction was found in the NINDS IV rtPA analysis.24 Currently,
the only imaging contraindication to IV rtPA based on the extent of
ischemic injury in the AHA/ASA guidelines is frank hypodensity
involving more than one-third of the MCA territory due to a
presumed increased risk of symptomatic intracerebral hemorrhage.27
Unfortunately, there is no reliable systematic way to assess the extent
of parenchymal hypodensity involving more than one-third of the
MCA territory.29

FIGURE 4. EIC involving only some part of an ASPECTS region in a patient with right MCA occlusion. A and B, NCCT shows hypodensity in the
superior part (B, white arrowhead) but not the inferior part (A, black arrowhead) of the right caudate nucleus, due to different blood supplies. The
superior portion of the caudate head is commonly supplied with perforator branches from the MCA, while the inferior portion is supplied with
perforator branches from the ACA. As long as the finding is on at least 2 cuts, partial involvement is sufficient for subtracting 1 point for that region.

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FIGURE 5. Evolution of early ischemic changes over time in a 35-year-old woman who presented with acute aphasia. A, NCCT at 1 hour after
symptoms onset shows loss of gray white matter differentiation in the left frontal and temporal operculum and insular cortex and hypodensity in the
lentiform nucleus (ASPECTS was 4 points for involvement of insula, lentiform, M1-3, M5). B and C, NCCT and CTA SI at 2 hours after symptoms onset
and IV rtPA administration show more conspicuous hypodensity and mild effacement of cortical sulci compared with NCCT at 1 hour after symptoms
onset. D, NCCT at 8 hours after symptoms onset shows frank hypodensity in the infarcted areas. The extent of the hypodense areas remains the same
but is more conspicuous than prior NCCT studies.

Intra-Arterial Therapy
Just as with IV rtPA, baseline ASPECTS is a strong predictor of
outcomes after IAT.8,30 Several studies have sought to further
determine whether baseline ASPECTS might be useful to select
patients who are likely to benefit from IAT. A retrospective analysis
of the PROACT-II trial demonstrated a clinical benefit (in terms of
independent functional outcomes) of intra-arterial thrombolysis
using pro-urokinase in acute ischemic stroke patients with proximal
MCA occlusion who had baseline ASPECTS more than 7, whereas
no benefit was seen in those who had ASPECTS at or lower than 7.31
Analysis of combined data from the IMS-I and NINDS tPA trials also
showed a significant interaction between baseline NCCT ASPECTS
dichotomized at 7 and treatment using IV-IA rtPA, where the benefit
of bridging therapy was seen in the higher ASPECTS patients.32 On
the contrary, data from IMS-III, a randomized controlled trial (RCT)
that failed to demonstrate benefit of intra-arterial treatment over IV
rtPA alone,33 did not demonstrate significant interaction between
baseline NCCT ASPECTS dichotomized at 7 and endovascular
treatment using mechanical thrombectomy and/or endovascular
delivery of tPA.30 As the authors noted, the lack of significant
treatment effect modification might have been due to a host of
factors, including the overall neutral trial results, the early timing
of the scans that might have limited the conspicuity of EICs, and the
relatively low rate of substantial reperfusion (mTICI 2B-3) in the
endovascular arm.
Despite these conflicting results, baseline ASPECTS evaluation
is now mandated before IAT by the AHA/ASA guidelines.9 This is
based on the recent RCTs (MR CLEAN,34 EXTEND IA,35

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FIGURE 6. Effect of window width and window-level adjustments for the detection of EIC on NCCT. Single image from NCCT (3 hours after onset) of
a 75-year-old female patient with right M1 occlusion except displayed in different window settings. A, Standard NCCT window (window level 40,
window width 80). B, Narrow NCCT window adjustment (window level 35, window width 25) improves conspicuity of hypodense lesions in the
right frontal operculum, right insular cortex, right caudate head, and right lentiform nucleus.

ESCAPE,36 SWIFT-PRIME,37 REVASCAT38) that established the
clinical benefit of IAT in selected acute ischemic stroke patients. In
order to enrich the trial populations for those most likely to benefit, 3
of these trials excluded patients with lower ASPECTS. The ESCAPE
and SWIFT-PRIME trials excluded patients with baseline NCCT
ASPECTS less than 6,36,37 whereas REVASCAT excluded patients
with baseline NCCT ASPECTS less than 7.38 As a consequence, the
recent focused update of the guidelines regarding IAT recommended
that patients who were candidates for endovascular treatment with a
stent retriever should have ASPECTS at least 6, among other
criteria.9
However, it remains uncertain whether the benefit of throm-
bectomy extends to patients with baseline NCCT ASPECTS less than
6. Data from the MR CLEAN trial, which was the only randomized
trial that did not formally exclude patients with low ASPECTS,
demonstrated no significant modification of treatment effect by

FIGURE 7. Example of an old infarction that might confuse ASPECTS evaluation. A, NCCT at 1 hour after onset of acute left facial palsy in a 79-year-
old man. There is a small hypodense lesion in the left corona radiata (A, white arrowhead), which does not correspond with clinical symptoms. This
represents an old lacunar infarction (A, white arrowhead). B, NCCT 24 hours later shows apparent hypodensities in the cortex and subcortical white
matter of the right frontal and parietal lobes (black arrowheads), which were not seen on the earlier NCCT study. This represents acute infarction that
has caused acute left facial palsy (black arrowheads). The old lacunar infarction appears unchanged (white arrowhead).

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FIGURE 8. Artifact limiting ASPECTS evaluation. A, Beam-hardening
artifact on a NCCT causes obscuration of right inferior temporal lobe
near the skull base (black arrowheads).
ASPECTS, whether trichotomized (0 to 4 vs 5 to 7 vs 8 to 10) or
using the full scale.22 There was no substantial difference in IAT
effect between ASPECTS 5 to 7 and 8 to 10 subgroups. Although it
was anticipated that the ASPECTS 0 to 4 subgroup would have
minimal to no treatment effect, a treatment benefit could not be
excluded. This may have been related to the very small number of
such patients (6%) in the trial population. Nevertheless, this group
had significantly worse outcomes (3% rate of mRS 0 to 2 and 40%
mortality at 90 days). This was consistent with another study of
patients with acute anterior circulation proximal arterial occlusion
who were treated with catheter-based thromboaspiration (i.e.,
Penumbra system).8 In this study, patients with NCCT ASPECTS
>4 had significantly lower death rate and better functional outcome
(mRS 0 to 2) at 90 days than those with ASPECTS 0 to 4, whereas
patients with ASPECTS more than 7 had significantly lower occur-
rence of symptomatic intracranial hemorrhage. The NCCT
ASPECTS 0 to 4 patients had 5% rate of functional independence
and 55% mortality at 90 days, with a 17.5% rate of symptomatic
intracerebral hemorrhage. The very poor outcomes among these
patients might limit the cost-effectiveness of IAT by constraining
the absolute treatment benefit, even if a relative benefit were
demonstrated to exist. Further data are needed to more precisely
characterize the treatment effect in this population.
Additional factors will influence what the appropriate
ASPECTS cutpoint is for IAT candidacy. Confirming clinical
experience, numerous studies have shown that older patients
are less tolerant of infarct burden, suffering clinical disability at
lower infarct volumes.39 – 42 Furthermore, a minimum number-
needed-to-treat should be established on the basis of cost-
effectiveness analysis.
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ASPECTS CT in Acute Ischemia
LIMITATIONS OF CT ANGIOGRAPHY SOURCE
IMAGING AND CT PERFUSION
A proliferation of studies have investigated the utility of con-
trast-based methods to characterize tissue viability, primarily CTA-SI
and CTP imaging.43 Unfortunately, there are significant challenges to
these approaches (Fig. 9). The main theoretical challenge relates to
the role of collaterals in the pathophysiology of ischemic stroke. A
foundational principle from tissue studies is that both the degree of
perfusion impairment and the duration of ischemia determine
whether the ischemic tissue undergoes irreversible injury.44 Using
a perfusion parameter [i.e., cerebral blood flow (CBF)] alone to
define acute infarction neglects a critical variable, namely time. Also,
imaging at a single time point may be insufficient, as collateral
strength may fluctuate over time. Even if an accurate assessment of
CBF could be achieved, stroke duration is impossible to determine
with a sufficiently high degree of precision. Finally, a practical
challenge is that both CTA-SI and CTP are technique dependent,
and have been shown to suffer from significant measurement
error.45–47 For these reasons, studies have shown that a substantial
portion of tissue that is deemed to be irreversibly injured on CTP and
CTA-SI is, in fact, still viable.45,48,49
Because the abnormality that is scored on each CT imaging
modality may depict different pathophysiologic tissue states,
ASPECTS can differ across different modalities for the same patient.
Typically, ASPECTS scores derived from CTP and CTA-SI are lower
than NCCT ASPECTS.50,51 In these circumstances, the score on
NCCT should be used for treatment decision making. An important
clinical principle of acute infarct imaging is that it should be highly
specific for determining tissue that is irreversibly injured. This will
prevent false-positive cases where patients are incorrectly deemed to
have a large infarction, and consequently would be inappropriately
excluded from reperfusion treatments. The only imaging techniques
that satisfy this criterion are NCCT and MRI diffusion-weighted
imaging (DWI).
ASPECTS APPLIED TO DIFFUSION-WEIGHTED
IMAGING
DWI is the most sensitive and specific (both >90%) modality to
detect early infarction in the clinical setting.52 Cytotoxic edema
from neuronal death is the putative mechanism of restricted fluid
diffusion within infarcted tissue.53 Tissue with diffusion restriction
is characterized by high signal intensity (SI) on trace images and low
SI on the corresponding apparent diffusion coefficient map. Com-
pared with EICs on NCCT, infarcts and their borders are highly
conspicuous on DWI, which permits assessment of infarct volume in
the early time window. However, accurate volumetric assessments
are difficult and time-consuming to perform in real time. The most
common approach in the clinical setting is the ellipsoid approxi-
mation (i.e., ABC/2 method), but this has been shown to mildly
overestimate volumes compared with reference standard planimet-
ric measurement.54
For this reason, ASPECTS also may be useful for clinical
decision making when MRI is used for infarct imaging. A recent
analysis of patients from the DEFUSE 2 study who underwent both
pre-treatment NCCT and DWI demonstrated that DWI ASPECTS
had substantially better inter-rater agreement, and was significantly
better at predicting 90-day functional independence after IAT.20
Moreover, earlier work identified DWI ASPECTS as an independent
prognostic factor for symptomatic intracerebral hemorrhage in acute
ischemic stroke patients who received intravenous or intra-arterial
thrombolytic therapy within 6 hours after onset.55 The rate of symp-
tomatic hemorrhage was significantly higher in DWI ASPECTS 0 to
7 than 8 to 10 points, with a 20.3% rate in ASPECTS 0 to 5.
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FIGURE 9. Post ischemic hyperperfusion as a pitfall of CBV-CTP ASPECTS calculation. Multimodality CT using a 64-slice CT scanner at 2 hours after
symptoms onset in a 63-year-old man who presented with acute left hemiparesis (A–D). A, NCCT scan shows partial loss of right insular ribbon,
obscuration of the right caudate head, and right lentiform nucleus, representing ASPECTS score of 7 (black arrowheads). B, CTA SI shows
parenchymal hypodensity in the right lentiform nucleus, right caudate head, right insular cortex, right temporal lobe (M2, M3 regions), representing
CTA SI ASPECTS score of 5 (black arrowheads). C, MTT color map of CTP shows delayed mean transit time in areas similar to the hypodensity seen on
CTA-SI (white arrowheads). D, CBV color map of CTP shows increased perfusion in the right caudate head, right lentiform nucleus, right insular
cortex, and right M2 region (white arrowheads), representing CBV-CTP ASPECTS score of 10. E, NCCT scan at day 4 shows frank hypodensity, which
represents final infarct tissue in the same areas that show increased CBV (E, black arrow heads).

Studies that have compared infarct volumes with ASPECTS on
DWI have yielded valuable insights regarding clinically useful
ASPECTS thresholds. Despite a strong negative correlation between
DWI ASPECTS and DWI infarct volume, each ASPECTS score
corresponds to a wide range of volumes.7,56,57 Nevertheless, studies
have identified DWI ASPECTS cutpoints that might serve as a
reliable marker for the presence of a large infarct volume. Two
publications have suggested that DWI ASPECTS less than 4 may
indicate an infarct volume more than 100 mL with a high speci-
ficity.7,56 In 1 study of 150 MCA stroke patients, the optimal DWI
ASPECTS threshold for an infarct volume at least 100 mL was a
score less than 4, with a sensitivity of 77% and a specificity of 98%.56
Another study with 330 MCA stroke patients treated within 6 hours
found that the highest infarct volume among patients with a DWI
ASPECTS at least 7 was 67 mL, whereas the lowest volume in
patients with DWI ASPECTS less than 4 was 93 mL.7 Taken
together, DWI ASPECTS at least 7 may be a surrogate for infarct
volume less than 70 mL, and DWI ASPECTS less than 4 may be used
as a surrogate for infarct volume more than 90 mL. These findings
were subsequently confirmed in a large multicenter observational
study, which reported 99% specificity of DWI ASPECTS less than
4 for DWI lesion volume at least 100 mL.57 As previously mentioned,
this high specificity is critical for using the cutpoint for treatment
exclusion. Support for the clinical importance of the 100-mL
infarct volume threshold was provided by a study of final infarct
volumes in patients with anterior circulation proximal artery occlu-
sions who underwent IAT, which found that infarcts larger than
100 mL had more than 90% specificity for poor outcomes (90-day
mRS 3 to 6).39
These data also provide indirect support for NCCT ASPECTS 0
to 4 as a marker of very poor outcomes. Owing to the greater
sensitivity of DWI over NCCT for acute infarct detection, DWI
ASPECTS is generally lower than the corresponding NCCT
ASPECTS for the same patient.58 For this reason, a patient with
ASPECTS 0 to 4 on NCCT is also very likely to have an acute infarct
volume greater than 100 mL.

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A study in acute MCA stroke patients with DWI ASPECTS
more than 3 who were treated with stent-retriever embolectomy
within 6 hours of symptoms onset demonstrated that age and suc-
cessful revascularization were independent predictors of good out-
come (90-day mRS 0 to 2), not pretreatment DWI ASPECTS.59
Although outcomes were worse and mortality higher in the inter-
mediate DWI ASPECTS (4 to 6 points) patients, these differences
were not substantial and did not reach statistical significance.
Furthermore, the benefit of revascularization was seen in both
groups. This corresponds with studies of patients with intermediate
NCCT ASPECTS (i.e., 5 to 7).8,22
AUTOMATED ASPECTS EVALUATION
In an effort to standardize imaging evaluation and patient
selection, there has been increasing attention paid toward automated
software analysis. Electronic Alberta Stroke Program Early CT score
(e-ASPECTS) is a software designed for automated calculation of
ASPECTS on NCCT. A study in 34 acute ischemic stroke patients
demonstrated similar performance between e-ASPECTS and NCCT
ASPECTS evaluation by stroke experts.60 Recently, e-ASPECTS has
been implemented for use in a mobile stroke unit to enhance
prehospital stroke treatment and triage.61 Although further validation
in large prospective studies will be necessary, these findings offer
promise for the future of imaging-based treatment selection.
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