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    Alberta Stroke Program Early CT Score (ASPECTS)

    Determines MCA stroke severity using available CT data.
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    INSTRUCTIONS

    To compute the ASPECTS, 1 point is subtracted from 10 for any evidence of early ischemic change for each of the defined regions.
    When to Use
    Pearls/Pitfalls
    Why Use

    Patients presenting in the first minutes and hours of a stroke with clinical suspicion for middle cerebral artery occlusion.

    • Quantifies CT changes in early middle cerebral artery stroke. More early changes seen on CT suggest poorer outcome from stroke.
    • Patients with scores ≥8 have a better chance for an independent outcome.

    Points to keep in mind:

    • The score does not consistently predict treatment response or intracranial hemorrhage or offer nuanced prognostic information.
    • ASPECTS has mainly been studied in patients treated with or eligible for stroke reperfusion therapy (tPA), which many stroke patients do not qualify for.

    Identifying patients with a greater likelihood of poor functional outcome (scores <8) may be helpful in the early stages of care for supporting transfer or therapy decisions.

    Subcortical Structures
    No
    0
    Yes
    -1
    No
    0
    Yes
    -1
    No
    0
    Yes
    -1
    MCA Cortex
    No
    0
    Yes
    -1
    No
    0
    Yes
    -1
    No
    0
    Yes
    -1
    No
    0
    Yes
    -1
    No
    0
    Yes
    -1
    No
    0
    Yes
    -1
    No
    0
    Yes
    -1

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    Using the traditional cutoff (<8 vs ≥8) as a rough estimate for predicting independence may help inform decisions. ASPECTS suggests that early CT changes in stroke may be a harbinger of poor outcomes.

    More recent studies have evaluated ASPECTS on the basis of the entire scale, as well as dichotomous (<8 vs ≥8) or trichotomous (0-4, 5-7, and 8-10) divisions, but few robust prospective trials have been conducted (Prakkamakul 2017).

    Management

    In patients presenting with symptoms concerning for ischemic stroke, the following are generally considered standard practice:

    • Neurology consultation.

    • Determine onset of stroke symptoms, or time patient last felt or was observed normal.

    • Stat head CT to rule out hemorrhagic stroke.

    • In appropriate circumstances and in consultation with both neurology and the patient, consider IV thrombolysis for ischemic strokes in patients with no contraindications.

    • Always consider stroke mimics in the differential diagnosis, especially in cases with atypical features (age, risk factors, history, physical exam), including:

      • Recrudescence of old stroke from metabolic or infectious stress.

      • Todd’s paralysis after seizure.

      • Complex migraine.

      • Pseudoseizure or conversion disorder.

    Critical Actions

    The ASPECTS relies on subtle CT findings and thus requires an experienced radiologist. Its only validated use is as a binary variable (<8 vs ≥8) for general outcome prediction in those eligible for reperfusion therapy.

    For patients being considered for intra-arterial tPA administration, ASPECTS may be useful to exclude patients not likely to do well in terms of functional independence (i.e., intra-arterial treatment likely to be futile) (Yoo 2014).

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    Dr. Phillip A. Barber
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