Attenuation Changes in ASPECTS Regions: A Surrogate for CT Perfusion-based Ischemic Core in Acute Ischemic Stroke

Background Recent studies have proven the effectiveness of thrombectomy up to 24 hours after stroke onset for patients with specific criteria at advanced CT or MRI. Clinical implementation of treatment in this extended time window remains a challenge, as many stroke centers do not routinely use advanced imaging. Purpose To determine whether automated cerebral x-ray attenuation measurements at noncontrast CT provide information on the presence of CT perfusion-defined ischemic core as applied in late time windows for thrombectomy. Materials and Methods In this retrospective study, patients with middle cerebral artery stroke due to proximal occlusion from 2009 to 2017 were included. All patients underwent noncontrast CT and CT perfusion. Automated software was used to calculate relative Hounsfield unit (rHU) values for Alberta Stroke Program Early CT Score (ASPECTS) regions on noncontrast CT images as the ratio of x-ray attenuation between ischemic versus non-ischemic hemispheres. Sensitivity, specificity, and diagnostic performance of rHU and composite rHU-ASPECTS, a score incorporating rHU from all regions, were analyzed for the classification of regional ischemic core and late time window thrombectomy criteria at CT perfusion. Results Data in a total of 200 patients were evaluated (105 women [mean age, 74 years ± 14 {standard deviation}] and 95 men [mean age, 76 years ± 14]). There were 121 patients in the validation cohort and 79 patients in the independent test cohort. Compared among all examined regions, rHU values yielded the best classification of ischemic core for the caudate nucleus, the lentiform nucleus, and the insula (with areas under the receiver operating characteristic curve [AUCs] ranging from 0.70 to 0.77; P < .001 for each). The composite rHU-ASPECTS score allowed classification of CT perfusion imaging selection criteria of ischemic core sizes of less than 70 mL and target mismatch of greater than 1.8 with AUCs of 0.80 (P = .001; 75% sensitivity and 83% specificity) in the test cohort and 0.74 (P < .001; 58% sensitivity and 82% specificity) in the validation cohort. Conclusion Noncontrast CT x-ray attenuation measurements identify Alberta Stroke Program Early CT Score regions classified as ischemic core at CT perfusion. This approach may serve as a selection criteria surrogate for thrombectomy in late time windows. © RSNA, 2019 Online supplemental material is available for this article.