The ASPECTS template is weighted in favor of the striatocapsular region

The extent of cerebral infarction correlates with increased risk of intracerebral hemorrhage (ICH) following recombinant tissue plasminogen activator (rt-PA) administration. The Alberta Stroke Program Early CT Score (ASPECTS) is a widely used, validated method which assesses involvement of 10 selected regions of the MCA territory. An ASPECTS score >7 is associated with a higher risk of ICH following thrombolysis than lower scores. To understand the internal structure of the ASPECTS template better, we estimated the infarct volume corresponding to each region. We hypothesized that, in the ASPECTS scoring system, the striatocapsular region is weighted disproportionally. Four experienced radiologists rated individual ASPECTS regions on subacute CT images (day 5–day 10) of 19 patients with MCA territory stroke. Infarct volume was determined from manual segmentation of infarcts on CT images. Linear regression was used to estimate the regional volume associated with each ASPECTS region. The ASPECTS regions are weighted unequally with the striatocapsular region accounting for 21% of the MCA territory infarct volume. Together, the 10 ASPECTS regions account for approximately 51% of the maximum MCA infarct territory volume. These findings should provide impetus for research to develop a scoring system explicitly based on regional hemorrhage risk as an aid to selecting patients for thrombolysis.