European Radiology

, Volume 29, Issue 11, pp 6285–6292 | Cite as

Automated versus manual imaging assessment of early ischemic changes in acute stroke: comparison of two software packages and expert consensus

  • Friederike AusteinEmail author
  • Fritz Wodarg
  • Nora Jürgensen
  • Monika Huhndorf
  • Johannes Meyne
  • Thomas Lindner
  • Olav Jansen
  • Naomi Larsen
  • Christian Riedel



The purpose of our study was to compare the agreement of both the total Alberta Stroke Program Early CT Score (ASPECTS) and region-based scores from two automated ASPECTS software packages and an expert consensus (EC) reading with final ASPECTS in a selected cohort of patients who had prompt reperfusion from endovascular thrombectomy (EVT).


ASPECTS were retrospectively and blindly assessed by two software packages and EC on baseline non-contrast-enhanced computed tomography (NCCT) images. All patients had multimodal CT imaging including NCCT, CT angiography, and CT perfusion which demonstrated an acute anterior circulation ischemic stroke with a large vessel occlusion. Final ASPECTS on follow-up scans in patients who had EVT and achieved complete reperfusion within 100 min from NCCT served as ground truth and were compared to total and region-based scores.


Fifty-two patients met our study criteria. Moderate agreement was obtained between both software packages and EC for total ASPECTS and there was no significant difference in overall performance. However, the software packages differed with respect to regional contribution. In this cohort, the majority of infarcted regions were deep structures. Package A was more sensitive in cortical areas than the other methods, but at a cost of specificity. EC and software package B had greater sensitivity, but lower specificity for deep brain structures.


In this cohort, using the final ASPECTS as ground truth, no clinically significant difference was observed for total ASPECT score between human or automated packages, but there were differences in the characteristics of the regions scored.

Key Points

• Some national stroke guidelines have incorporated ASPECTS in their recommendations for selecting patients for endovascular therapy.

• Computer-aided diagnosis is a promising tool to aid the evaluation of early ischemic changes identified on CT.

• Software packages for automated ASPECTS assessment differed significantly with respect to regional contribution without any significant difference in the overall ASPECT score.


Image interpretation Computer assisted Software validation Stroke Thrombectomy 



Alberta Stroke Program Early CT Score




CT perfusion


Expert consensus


Early ischemic changes


Endovascular therapy


Hounsfield units




Internal capsule


Interquartile range


Lentiform nucleus


Non-contrast computed tomography


Receiver operating characteristic


Thrombolysis in cerebral infarction with complete reperfusion



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Olav Jansen.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.


• Retrospective

• Diagnostic study or prognostic study

• Performed at one institution


  1. 1.
    Barber PA, Demchuk AM, Zhang J, Buchan AM, Group AS (2000) Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. Lancet 355:1670–1674CrossRefGoogle Scholar
  2. 2.
    Goyal M, Menon BK, Van Zwam WH et al (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387:1723–1731CrossRefGoogle Scholar
  3. 3.
    Powers WJ, Derdeyn CP, Biller J et al (2015) 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 46:3020–3035CrossRefGoogle Scholar
  4. 4.
    Farzin B, Fahed R, Guilbert F et al (2016) Early CT changes in patients admitted for thrombectomy intrarater and interrater agreement. Neurology 87:249–256CrossRefGoogle Scholar
  5. 5.
    Wilson AT, Dey S, Evans JW, Najm M, Qiu W, Menon BK (2018) Minds treating brains: understanding the interpretation of non-contrast CT ASPECTS in acute ischemic stroke. Expert Rev Cardiovasc Ther 16:143–153CrossRefGoogle Scholar
  6. 6.
    Kottner J, Audigé L, Brorson S et al (2011) Guidelines for reporting reliability and agreement studies (GRRAS) were proposed. Int J Nurs Stud 48:661–671CrossRefGoogle Scholar
  7. 7.
    Bossuyt PM, Reitsma JB, Bruns DE et al (2003) The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration. Ann Intern Med 138:W1–W12CrossRefGoogle Scholar
  8. 8.
    Shrout PE, Fleiss JL (1979) Intraclass correlations: uses in assessing rater reliability. Psychol Bull 86:420CrossRefGoogle Scholar
  9. 9.
    Herweh C, Ringleb PA, Rauch G et al (2016) Performance of e-ASPECTS software in comparison to that of stroke physicians on assessing CT scans of acute ischemic stroke patients. Int J Stroke 11:438–445CrossRefGoogle Scholar
  10. 10.
    Nagel S, Sinha D, Day D et al (2017) e-ASPECTS software is non-inferior to neuroradiologists in applying the ASPECT score to computed tomography scans of acute ischemic stroke patients. Int J Stroke 12:615–622CrossRefGoogle Scholar
  11. 11.
    Gupta AC, Schaefer PW, Chaudhry ZA et al (2012) Interobserver reliability of baseline noncontrast CT Alberta Stroke Program Early CT Score for intra-arterial stroke treatment selection. AJNR Am J Neuroradiol 33:1046–1049CrossRefGoogle Scholar
  12. 12.
    Pexman JH, Barber PA, Hill MD et al (2001) Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol 22:1534–1542PubMedGoogle Scholar
  13. 13.
    Khan M, Baird GL, Goddeau RP Jr, Silver B, Henninger N (2017) Alberta Stroke Program Early CT Score infarct location predicts outcome following M2 occlusion. Front Neurol 8:98CrossRefGoogle Scholar
  14. 14.
    Sheth SA, Malhotra K, Liebeskind DS et al (2018) Regional contributions to poststroke disability in endovascular therapy. Interv Neurol 7:533–543CrossRefGoogle Scholar
  15. 15.
    van der Zwan A, Hillen B, Tulleken CA, Dujovny M, Dragovic L (1992) Variability of the territories of the major cerebral arteries. J Neurosurg 77:927–940CrossRefGoogle Scholar
  16. 16.
    Seker F, Pfaff J, Nagel S et al (2018) CT reconstruction levels affect automated and reader-based ASPECTS ratings in acute ischemic stroke. J Neuroimaging.
  17. 17.
    Pfaff J, Herweh C, Schieber S et al (2017) e-ASPECTS correlates with and is predictive of outcome after mechanical thrombectomy. AJNR Am J Neuroradiol 38:1594–1599CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Department of Radiology and NeuroradiologyUniversity Hospital, Schleswig-Holstein, Campus KielKielGermany
  2. 2.Department of NeurologyUniversity Hospital, Schleswig-Holstein, Campus KielKielGermany

Personalised recommendations