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      Inter-rater reliability of modified Alberta Stroke program early computerized tomography score in patients with brain infarction

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          The Alberta Stroke Program Early Computerized Tomography Score (ASPECTS) was used to detect significant early ischemic changes on brain CT of acute stroke patients. We designed the modified ASPECTS and compared it to the above system based on the inter-rater reliability.


          A cross-sectional validation study was conducted based on the inter-rater reliability. The CT images were chosen from the stroke data bank of Ghaem hospital, Mashhad in 2010. The inclusion criteria were the presence of middle cerebral artery territory infarction and performance of CT within 6 hours after stroke onset. Axial CT scans were performed on a third-generation CT scanner (Siemens, ARTX, Germany). Section thickness above posterior fossa was 10 mm (130 kV, 150 mAs). Films were made at window level of 35 HU. The brain CTs were scored by four independent radiologists based on the ASPECTS and modified ASPECTS. The readers were blind to clinical information except symptom side. Cochrane Q and Kappa tests served for statistical analysis.


          24 CT scans were available and of sufficient quality. Difference in distribution of dichotomized ≤7 and >7 ASPECT scores between four raters was significant (Q=13.071, df=3, p=0.04). Distribution of dichotomized <6 and ≥6 scores based on modified ASPECT system between 4 raters was not significantly different (Q=6.349, df=3, p=0.096).


          Modified ASPECT method is more reliable than ASPECTS in detecting major early ischemic changes in stroke patients candidated to tPA thrombolysis.

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          Most cited references 17

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          Importance of early ischemic computed tomography changes using ASPECTS in NINDS rtPA Stroke Study.

          The importance of early ischemic change (EIC) on baseline computed tomography (CT) in the decision to thrombolyze the patient with acute ischemic stroke has been controversial. ASPECTS is a semiquantitative scale that scores the extent of EIC within the middle cerebral artery territory. We examined whether ASPECTS could be a treatment modifier by systematically reviewing the CT scans in the NINDS rtPA Stroke Study. Six hundred eight of the 624 CT scans were available and of sufficient quality. One of 2 teams (n=3 each) of expert ASPECTS readers evaluated each scan for an ASPECTS value using a consensus score approach. Each team was blind to all clinical information except symptom side and blind to follow-up imaging and outcome information. ASPECTS values were stratified before analysis. Multivariable logistic regression was used to determine if an ASPECTS by treatment interaction existed on treatment response, outcome, and intracerebral hemorrhage risk. A total of 57.2% (348 of 608) of scans showed EIC with an ASPECTS 7).
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            Symptomatic Intracerebral Hemorrhage following Thrombolytic Therapy for Acute Ischemic Stroke: A Review of the Risk Factors

            Background: Symptomatic intracerebral hemorrhage (SICH) following thrombolytic therapy for acute ischemic stroke is associated with a high rate of morbidity and mortality. Knowledge of the risk factors associated with SICH following thrombolyitc therapy may provide insight into the pathophysiological mechanisms underlying the development of SICH, lead to the development of treatments that reduce the risk of SICH and have implications for the design of future stroke trials. Methods: Relevant studies were identified through a search in Pubmed. Included studies used multivariate analyses to identify independent risk factors for SICH following thrombolytic therapy. For each variable that was found to have a significant association with SICH, a secondary literature search was conducted to identify additional reports on the specific relationship between that variable and SICH. Summary of Review: Twelve studies met inclusion criteria for the systematic review. Extent of hypoattenuated brain parenchyma on pretreatment CT and elevated serum glucose or history of diabetes were independent risk factors for thrombolysis-associated SICH in six of the twelve studies. Symptom severity was an independent risk factor in three of the studies and advanced age, increased time to treatment, high systolic blood pressure, low platelets, history of congestive heart failure and low plasminogen activator inhibitor levels were found to be independent risk factors for SICH in a single study. Although these data should not alter the current guidelines for the use of rt-PA in acute stroke, they may help develop future strategies aimed at reducing the rate of thrombolysis-associated SICH.
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              Alberta Stroke Program Early CT Scoring of CT perfusion in early stroke visualization and assessment.

              Qualitative CT perfusion (CTP) assessment by using the Alberta Stroke Program Early CT Score (ASPECTS) allows rapid calculation of infarct extent for middle cerebral artery infarcts. Published thresholds exist for noncontrast CT (NCCT) ASPECTS, which may distinguish outcome/complication risk, but early ischemic signs are difficult to detect. We hypothesized that different ASPECTS thresholds exist for CTP parameters versus NCCT and that these may be superior at predicting clinical and radiologic outcome in the acute setting. Thirty-six baseline acute stroke NCCT and CTP studies within 3 hours of symptoms were blindly reviewed by 3 neuroradiologists, and ASPECTS were assigned. Treatment response was defined as major neurologic improvement when a > or =8-point National Institutes of Health Stroke Scale improvement at 24 hours occurred. Follow-up NCCT ASPECTS and 90-day modified Rankin score (mRS) were radiologic and clinical reference standards. Receiver operating characteristic curves derived optimal thresholds for outcome. Cerebral blood volume and NCCT ASPECTS had similar radiologic correlations (0.6 and 0.5, respectively) and best predicted infarct size in the absence of major neurologic improvement. A NCCT ASPECT threshold of 7 and a cerebral blood volume threshold of 8 discriminated patients with poor follow-up scans (P < .0002 and P = .0001) and mRS < or =2 (P = .001 and P < .001). Only cerebral blood volume predicted major neurologic improvement (P = .02). Interobserver agreement was substantial (intraclass correlation coefficient, 0.69). Cerebral blood volume ASPECTS sensitivity, specificity, positive predictive value, and negative predictive value for clinical outcome were 60%, 100%, 100%, and 45%, respectively. No patients with cerebral blood volume ASPECTS <8 achieved good clinical outcome. Cerebral blood volume ASPECTS is equivalent to NCCT for predicting radiologic outcome but may have an additional benefit in predicting patients with major neurologic improvement.

                Author and article information

                J Res Med Sci
                J Res Med Sci
                Journal of Research in Medical Sciences : The Official Journal of Isfahan University of Medical Sciences
                Medknow Publications & Media Pvt Ltd (India )
                October 2011
                : 16
                : 10
                : 1326-1331
                [1- ]Professor of Cerebrovascular Disease, Neuroscience Research Center, Department of Neurology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
                [2- ]Assistant Professor of Internal Medicine, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran
                [3- ]Associate Professor of Biostatistics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
                [4- ]Assistant Professor, Department of Radiology, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran
                [5- ]Assistant Professor, Department of Neurology, Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Iran
                [6- ]Research Fellow, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
                [7- ]Research fellow, Department of Neuroscience, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
                Author notes
                Corresponding Author: Zahra Izadi Mood E-mail: Izadimz1@ 123456mums.ac.ir
                Copyright: © Journal of Research in Medical Sciences

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Original Article


                inter-rater reliability, computed tomography, cerebral infarction, thrombolysis


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