ASPECTS (Alberta Stroke Program Early CT Score)

Measurement Using Hounsfield Unit Values When Selecting

Patients for Stroke Thrombectomy
Maxim Mokin, MD, PhD; Christopher T. Primiani, BS; Adnan H. Siddiqui, MD, PhD;
Aquilla S. Turk, DO

Background and Purpose—The ASPECTS (Alberta Stroke Program Early CT Score) is a quantitate score that measures the
extent of early ischemic changes. Our aim was to investigate how measurement of ASPECTS using Hounsfield unit (HU)
values on initial noncontrast head computerized tomography (CT) correlates with the extent of final infarct on follow-up
imaging.
Methods—Cases of acute stroke from the middle cerebral artery M1 occlusion in which complete recanalization (TICI
[Thrombolysis in Cerebral Infarction] 3) was achieved were included for analysis. Using HU ratio (HU affected/HU
control hemisphere) and HU difference (HU control−HU affected hemisphere) values, ASPECTS was measured on initial
CT imaging and correlated with final ASPECTS at 24 hours. The study cohort consisted of 41 patients with acute stroke
from the M1 occlusion. The mean time from stroke symptoms onset to baseline head CT imaging was 264 minutes and
from CT to TICI 3 recanalization was 142 minutes.
Results—HU ratio within the 0.94 to 0.96 ranges showed the highest correlation coefficient and lowest mean and median
errors with the final ASPECTS. The difference of 2.0 HU between the 2 hemispheres demonstrated the higher correlation
coefficient (r=0.71; P<0.0001) and the lowest mean and median absolute errors (1.4 and 1, respectively).
Conclusions—We established a simple algorithm for rapid and accurate assessment of ASPECTS on baseline CT
imaging to predict the extent of final stroke in patients with emergent large vessel occlusion who undergo endovascular
revascularization.   (Stroke. 2017;48:1574-1579. DOI: 10.1161/STROKEAHA.117.016745.)
Key Words: algorithms ◼ follow-up studies ◼ middle cerebral artery ◼ stroke ◼ thrombectomy
Downloaded from http://ahajournals.org by on September 10, 2019

T he ASPECTS (Alberta Stroke Program Early CT Score)

is a quantitate score that measures the extent of early
ischemic changes in anterior circulation hyperacute ischemic
stroke.1 The territory of the middle cerebral artery is divided
into 10 regions, and points are subtracted for areas with early
ischemic signs, such as focal swelling or parenchymal hypoat-
tenuation. The score was originally designed to help identify
patients who were likely to demonstrate the most clinical ben-
efit from intravenous thrombolysis.1 Subsequently, this score
was applied in imaging selection for endovascular therapies
to isolate patients with greatest extent of ischemic damage,
in whom recanalization would be futile or harmful.2,3 More
recently, ASPECTS has been recognized as a key selection
criteria in the updated American Heart Association guidelines
on the management of acute stroke, where endovascular ther-
apy in patients with baseline ASPECTS≥6 is recommended.4
Rapid screening of patients for thrombectomy without the
need for more advanced imaging modalities, such as com-
puterized tomography (CT)– or magnetic resonance imag-
ing (MRI)–based perfusion, is the main advantage of using
ASPECTS in clinical practice. However, studies have shown
variations in agreement for detection of early ischemic changes
depending on the reader’s experience and clinical background,
imaging settings (such as the use of the standard versus stroke
window settings), and type of diagnostic work station (smart-
phone versus standard desktop viewing station), which can all
affect the interpretation of ASPECTS and influence clinical-
decision making.5–7 Noncontrast head CT is the most common
initial strategy for evaluation of patients with acute stroke,
and misinterpretation of ASPECTS can have significant effect
on clinical-decision making.8,9 Computer-assisted automated
ASPECTS measurement can help in the assessment of early
ischemic changes, but reliable clinical validation of such algo-
rithms in clinical practice is currently lacking.10,11
Here, we investigate how identification of early ischemic
changes using Hounsfield unit (HU) values on initial non-
contrast head CT in patients who achieved complete recana-
lization with endovascular therapy correlates with the extent
of final infarct on follow-up imaging. Such method may be
used by clinicians to help with interpretation of ASPECTS,

Received January 16, 2017; final revision received March 21, 2017; accepted April 3, 2017.
From the Department of Neurosurgery, University of South Florida, Tampa (M.M., C.T.P.); Department of Neurosurgery, University at Buffalo, NY
(A.H.S.); and Department of Neurosurgery, Medical University of South Carolina, Charleston (A.S.T.).
Correspondence to Maxim Mokin, MD, PhD, Department of Neurosurgery, University of South Florida, 2 Tampa General Cir, 7th Floor, Tampa, FL
33606. E-mail maximmokin@gmail.com
© 2017 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.117.016745

1574
 Mokin et al   ASPECTS and Hounsfield Units    1575
as well as serve as a platform for development of automated
ASPECTS software.
Methods
The study was approved by the local institutional review board. We
retrospectively reviewed cases of patients with acute ischemic stroke
who were treated with endovascular therapy between July 2014 and
June 2016. Figure 1 shows the selection process used in our study.
Cases that met the following criteria were included: (1) occlusion
of the middle cerebral artery M1 segment; (2) complete recanali-
zation corresponding to TICI (thrombolysis in cerebral infarction)
3 score at the end of thrombectomy; and (3) availability of base-
line noncontrast CT head and a follow-up noncontrast CT or MRI
brain at 24 hours. Cases with hemorrhagic transformation preclud-
ing accurate interpretation of the extent of final infarct or scans
with significant motion artifacts were excluded from analysis. All
patients had CT angiography performed for confirmation of large
vessel occlusion. We excluded cases with a tandem separate occlu-
sion at a more proximal location (such as cervical or internal carotid
artery terminus occlusion) or occlusion of other territories, such as
the anterior cerebral artery. Intravenous thrombolysis was not an
exclusion criterion. We typically selected patients for thrombectomy
based on the ASPECTS cutoff value of 6. Cases with ASPECTS<6
were also treated with endovascular therapy on an individual case
by case basis. Patients eligible for systemic thrombolysis received
intravenous tPA (tissue-type plasminogen activator) first and then
were treated intra-arterial thrombectomy. There were no patients
in our cohort in whom intravenous thrombolysis alone resulted in
successful recanalization, which was confirmed angiographically
at the beginning of thrombectomy. Patients ineligible for systemic
thrombolysis were taken for intra-arterial thrombectomy directly. All
thrombectomy procedures were performed by 2 operators using the
same approach to thrombectomy: direct aspiration first, with a sub-
sequent use of a stent retriever, if aspiration alone was unsuccessful
Downloaded from http://ahajournals.org by on September 10, 2019
in achieving TICI 3 results.
Image Analysis
All patients underwent 5-mm noncontrast head CT imaging per-
formed using Brilliance 64 PHILIPS scanner with the following stan-
dard parameters: tube voltage, 140 kV; tube current, 320 mA; and
rotation speed, 0.75 seconds. Using baseline noncontrast CT images,
Figure 1. Flow diagram showing selection of patients for the
study. IA indicates intra-arterial; ICA, internal carotid artery; M1,
middle cerebral artery M1 segment; and TICI, thrombolysis in
cerebral infarction.
10 separate regions corresponding to the standard middle cerebral
artery territory ASPECTS areas were manually outlined. HU values
were recorded from the affected (stroke) and the contralateral (con-
trol) hemispheres within the 10 regions, as shown in Figure 2. The
regions were outlined blinded to the knowledge of the extent of final
stroke on follow-up imaging. The HU ratio (rHU) was calculated by
dividing the HU value of the affected side by the HU value of the
contralateral side.
MRI fluid-attenuated inversion recovery was performed at ≈24
hours to measure the extent of final infarct. If MRI was not avail-
able, noncontrast CT study repeated at 24 hours was used. ASPECTS
values on follow-up imaging was calculated by counting the presence
or absence of final infarct within the standard 10 ASPECTS regions.
Statistical Analysis
The rHU ASPECTS (HU affected/HU control hemisphere) ranging
from 0.90 to 0.99 and HU difference (HU control−HU affected hemi-
sphere) were compared with final MRI ASPECTS. Pearson r correla-
tion coefficient, mean absolute error, and median absolute error were
calculated for the total ASPECTS scores for each individual case.
Sensitivity and specificity were analyzed for each ratio and difference
interval, as well as corresponding receiver operating characteristic
curves. Statistical analyzes were performed using GraphPad Prism
version 7 for Windows, GraphPad Software, La Jolla, CA. P<0.05
was considered statistically significant.
Results
Forty-one patients with acute stroke from the middle cere-
bral artery M1 occlusion who achieved complete recanaliza-
tion were included in this study. The baseline characteristics
of these patients are summarized in Table 1. Mean time from
stroke onset to baseline head CT imaging was 264 minutes
and from CT to TICI 3 recanalization was 142 minutes. For
the 24-hour follow-up imaging, brain MRI was performed in
95% (39 of 41) of patients, and the remaining 2 patients had a
repeat head CT. Mean and median ASPECTS at 24 hours were
6.7 and 8, respectively. Figure 2C shows the distribution of
24-hour ASPECTS within the cohort. The majority of patients
(83%) had ASPECTS ≥5.
Table 2 shows the correlation of ASPECTS calculated
based on the ratio of HU (HU affected/HU control hemi-
sphere) on baseline CT imaging with final ASPECTS values
on the 24-hour follow-up imaging. rHU within the 0.94 to
0.96 ranges showed the highest correlation coefficient and
lowest mean and median errors with the final ASPECTS. In
a multivariate analysis, no significant effect of intravenous
tPA use, age, National Institutes of Health Stroke Scale,
or demographic factors on 24-hour ASPECTS was found
(P=0.195).
The correlations of ASPECTS calculated by subtracting
HU of the affected hemisphere from the contralateral (control)
side with final ASPECTS are shown in Table 2. HU differ-
ence within the range of 1.5 to 2.0 showed the highest cor-
relation while minimizing mean and median absolute value.
Specifically, absolute difference of 2.0 HU between the 2
hemispheres demonstrated the higher correlation coefficient
(r=0.71; P<0.0001) and the lowest mean and median absolute
errors (1.4 and 1, respectively).
The diagnostic sensitivity and specificity of ASPECTS
based on rHU or HU difference on initial CT with final
ASPECTS at 24 hours according to different threshold values
are represented in Table 3. Receiver operating characteristic
 1576  Stroke  June 2017

Figure 2. An example of initial computerized tomography head with Hounsfield unit (HU) values calculated between the 2 hemispheres.
A, Ten ASPECTS (Alberta Stroke Program Early CT Score) regions are outlined manually. HU values representing each individual region
are shown at the bottom. Solid lines label the affected hemisphere and dotted lines label contralateral (control) hemisphere. B, Follow-up
magnetic resonance imaging fluid-attenuated inversion recovery repeated at 24 hours shows the extent of final stroke, ASPECTS=5. C,
Distribution of ASPECTS at 24 hours. C indicates caudate; I, insular ribbon; IC, internal capsule; L, lentiform; and M1–6, middle cerebral
artery cortical regions 1 to 6.
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analysis demonstrated an area under the curve of 0.7799 (95% Discussion

confidence interval, 0.73–0.83; P<0.0001) between ASPECTS
based on rHU with final ASPECTS at 24 hours (Figure 3A).
ASPECTS-based HU difference had area under the curve
of 0.7813 (95% confidence interval, 0.73–0.83; P<0.0001;
Figure 3B).
Table 1.  Baseline Characteristics of Patients With MCA M1
Occlusion Who Achieved TICI 3 Recanalization
Age, mean±SD
Baseline NIHSS, median
Sex, female, n (%)
Atrial fibrillation, n (%)
CAD, n (%)
Diabetes mellitus, n (%)
Dyslipidemia, n (%)
Hypertension, n (%)
Intravenous thrombolysis, n (%)
Symptom onset to initial head CT, mean, min
Groin puncture to recanalization, mean, min
Initial head CT to recanalization, mean, min
CAD indicates coronary artery disease; CT, computed tomography; MCA,
middle cerebral artery; NIHSS, National Institutes of Health Stroke Scale; and
TICI, Thrombolysis in Cerebral Infarction.
In our study, we established and validated a simple algorithm
for rapid and accurate assessment of ASPECTS on baseline
CT imaging to predict the extent of final stroke in patients
with emergent large vessel occlusion who undergo endovas-
cular revascularization. We think that such algorithm can be
used in clinical practice to assist clinicians in the evaluation
and interpretation of CT imaging in patients who are consid-
ered potential candidates for endovascular therapy, as well as
serve as a foundation to develop automated software analysis
All, n=41
for ASPECTS measurement.
71±15.2 Studies have shown that ASPECTS interpretation is sub-
17.5 ject to interobserver reliability and can substantially affect the
decision-making process, resulting in erroneous inclusion or
24/41 (59)
exclusion of patients for thrombectomy.8,9 Although no stud-
13/41 (32) ies have specifically addressed this issue, we suspect that the
11/41 (27) interpretation of ASPECTS is even more challenging when
8/41 (20)
performed on portable work stations, tablets, or smartphone
devices. For example, 1 study showed excellent performance
13/41 (32) of smartphone teleradiology applications in evaluation and
23/41 (56) recognition of intracranial hemorrhages or neoplasms but
20/41 (49) much lower interobserver agreement in assessing early isch-
emic changes.7
264
Previous research to establish automated ASPECTS mea-
40 surement algorithms was based on the use of early diffusion
142 weighted MRI as the gold standard in detecting the extent of
early ischemia.10 The limitation of this approach is an increas-
ing body of evidence showing, in some cases, that diffusion
weighted imaging lesions can be reversed in patients who
 Mokin et al   ASPECTS and Hounsfield Units    1577

Table 2.  Correlation Between ASPECTS Based on HU Ratio Table 3.  Sensitivity (%) and Specificity (%) Between
and HU Difference With Final ASPECTS at 24 Hours ASPECTS Based on HU Ratio or HU Difference With Final
ASPECTS at 24 Hours According to Different Threshold Values
Mean Mean Median
Pearson r (Median) Absolute Absolute Cutoff Sensitivity, % Specificity, %
(95% CI) P Value ASPECTS Error Error
HU ratio (HU affected/HU control hemisphere)
HU ratio (HU affected/HU control hemisphere)
 <0.85 1.46 100
 0.90 0.46 (0.18–0.68) 0.0011 4.2 (4) 2.7 2
 <0.86 2.19 100
 0.91 0.48 (0.20–0.69) 0.0007 5.2 (5) 2.4 2
 <0.87 3.65 99.63
 0.92 0.51 (0.24–0.71) 0.0003 6.0 (6) 2.2 1
 <0.88 6.569 99.27
 0.93 0.50 (0.22–0.70) 0.0005 6.9 (7) 1.8 1
 <0.89 8.029 98.17
 0.94 0.65 (0.43–0.80) <0.0001 7.5 (8) 1.6 1
 <0.90 16.06 97.8
 0.95 0.65 (0.42–0.80) <0.0001 8.1 (8) 1.4 1
 <0.91 21.9 96.34
 0.96 0.69 (0.49–0.82) <0.0001 8.5 (9) 1.3 2
 <0.92 24.82 94.87
 0.97 0.55 (0.29–0.73) 0.0001 8.8 (9) 1.7 2
 <0.93 34.31 94.14
 0.98 0.53 (0.26–0.72) 0.0002 9.0 (10) 2.0 3
 <0.94 44.53 93.04
 0.99 0.51 (0.24–0.71) 0.0003 9.3 (10) 2.7 4
 <0.95 53.28 89.01
HU difference (HU control−HU affected)
 <0.96 61.31 83.88
 ≥1 0.59 (0.35–0.76) <0.0001 5.9 (6) 1.5 2
 <0.97 69.34 74.36
 ≥1.5 0.64 (0.42–0.79) <0.0001 7.0 (7) 1.3 2
 <0.98 75.18 65.2
 ≥2 0.71 (0.52–0.84) <0.0001 7.9 (8) 1.4 1
 <0.99 81.75 54.21
 ≥2.5 0.50 (0.23–0.70) 0.0008 8.6 (9) 1.9 1
HU difference (HU control−HU affected hemisphere)
 ≥3 0.49 (0.21–0.69) 0.0012 9.0 (9) 2.3 1
 >1.0 69.85 73.26
 ≥3.5 0.42 (0.13–0.65) 0.0057 9.4 (10) 2.7 2
 >1.5 58.82 84.98
ASPECTS indicates Alberta Stroke Program Early CT Score; CI, confidence
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interval; and HU, Hounsfield unit.  >2.0 47.79 93.04

achieve successful recanalization, thus questioning the cred-
ibility of MRI as the gold standard.12,13
In other studies of automated detection of ASPECTS, early
signs of ischemia were compared with the extent of final
stroke on repeat imaging at 24 hours.11 However, because of
ASPECTS decay, which will result in worsening of the over-
all score over time unless the patient is successfully reper-
fused, the findings in such studies should be interrupted with
caution.14 Therefore, in our study, we only included patients
who achieved complete recanalization characterized by TICI
3 score to minimize the extent of ASPECTS decay over time.
Such inclusion criterion to selectively include patients with
emergent large vessel occlusion who have achieved full
recanalization have successfully been used previously to esti-
mate perfusion-based parameters to define ischemic core and
penumbra.15 Our study has several limitations. First, these
findings are only applicable to patients with acute stroke
from M1 occlusion. Also, patients with ASPECTS<6 were
under-represented in our study. Additional studies would be
required to test whether the same algorithm applies to patients
with more distal strokes, such as M2 segment of the middle
cerebral artery or strokes in other territories, including pos-
terior circulation, as well as in patients with less favorable
baseline imaging profile. Second, although TICI 3 recanaliza-
tion is highly associated with complete reperfusion, research
suggests that reperfusion is more influential on clinical and
radiographic outcomes. Therefore, it would be important to
 >2.5 32.35 94.51
 >3.0 23.53 96.34
 >3.5 13.97 97.44
ASPECTS indicates Alberta Stroke Program Early CT Score; and HU,
Hounsfield unit.
test our results using a cohort with CT- or MR-defined reper-
fusion rather than using TICI grading scale alone.15,16 Third,
because of a rather significant delay from baseline CT to
angiographic recanalization of 142 minutes, there is some
possibility of ASPECTS decay in our cohort. Our findings
need to be validated in patients with shorter time from initial
imaging to recanalization (ideally, in a cohort that is based on
patients with <60 minutes from picture to puncture). Forth, a
small sample size could have introduced type II error to our
results. Finally, the retrospective nature of the study could
have resulted in selection bias.
Conclusions
Using measurement of HU values between the affected and
contralateral hemispheres, we introduced a simple algorithm
for rapid and accurate assessment of ASPECTS on baseline
CT imaging to predict the extent of final stroke in patients
with emergent large vessel occlusion who undergo endo-
vascular revascularization. Such algorithm may be used in
clinical practice to assist clinicians in the evaluation and
interpretation of CT imaging in patients who are considered
 1578  Stroke  June 2017
Figure 3. Receiver operating characteristic analysis for prediction of final infarct on repeat imaging at 24 hours. A, Predicted ASPECTS
(Alberta Stroke Program Early CT Score) based on Hounsfield unit (HU) ratio thresholds. B, Predicted ASPECTS based on HU difference
thresholds. Both curves seem similarly, indicating comparable sensitivity, specificity, and accuracy of both algorithms. The 45° diagonal
line represents the line of no discrimination corresponding to the area under the curve (AUC) of 0.5.
for endovascular therapy, as well as serve as a foundation to
develop automated software analysis for ASPECTS measure-
ment. The optimal rHU between the affected and contralat-
eral hemispheres to predict final infarct on follow-up imaging
was 0.94 to 0.96. Our findings need to be validated prospec-
tively by comparing such automated algorithm with human
interpretation of ASPECTS.
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Disclosures
Dr Siddiqui received grants from National Institutes of Health/National
Institute of Neurological Disorders and Stroke/National Institute of
Biomedical Imaging and Bioengineering and University at Buffalo
(none related to this study); he received financial interests from
Hotspur, Intratech Medical, StimSox, Valor Medical, Blockade
Medical, and Lazarus Effect; he reports serving as a consultant
for Codman & Shurtleff, Inc, Concentric Medical, ev3/Covidien
Vascular Therapies, GuidePoint Global Consulting, Penumbra,
Stryker, Pulsar Vascular, MicroVention, Lazarus Effect, and
Blockade Medical; he reports serving on the speakers’ bureau for
Codman & Shurtleff, Inc, National Steering Committee–Penumbra
Inc’s 3D Separator Trial, Covidien’s SWIFT PRIME trial (Solitaire
With the Intention for Thrombectomy as Primary Endovascular
Treatment), and MicroVention’s FRED trial (Pivotal Study of
the MicroVention Flow Re-Direction Endoluminal Device Stent
System in the Treatment of Intracranial Aneurysms); he is a mem-
ber of advisory boards for Codman & Shurtleff and Covidien
Neurovascular; he received honoraria from Abbott Vascular,
Codman & Shurtleff, and Penumbra Inc. Dr Turk is a consultant
for Stryker, Codman, Penumbra, and Microvention and he received
research grants (not related to this study) from Stryker, Codman,
Micorvention, Penumbra, and Covidien; he also received financial
interests from Medina Medical, Lazarus Effect, Pulsar Vascular, and
Blockade Medical. The other authors report no conflicts.
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