Co-ASPECTS, a new scoring tool derived from immediate post-EVT noncontrast CT that integrates both hyperdensity and hypodensity signs, was significantly associated with unfavorable 90-day outcomes and outperformed conventional models including baseline ASPECTS and post-EVT ASPECTS based on single sign types alone.
Key Findings
Results
Co-ASPECTS was significantly associated with unfavorable functional outcomes at 90 days after endovascular therapy.
Unfavorable outcome was defined as modified Rankin Scale score of 3 to 6 at 90 days.
Adjusted odds ratio for unfavorable outcome was 0.45 (95% CI, 0.40–0.51).
Co-ASPECTS was formulated through equal-weight summation of hyperdensity and hypodensity signs consistent with the 0–10 score ASPECTS framework.
Total study population was 1015 patients across development and validation cohorts.
Results
Co-ASPECTS demonstrated strong discriminative performance for functional outcome in the development cohort, outperforming conventional models.
C-statistic of 0.889 in the development cohort (542 patients).
Co-ASPECTS outperformed baseline ASPECTS and immediate post-EVT ASPECTS calculated based on hyperdensity or hypodensity signs alone.
Development cohort was drawn from 2 academic hospitals retrospectively.
Results
Co-ASPECTS maintained robust predictive performance in an independent external validation cohort.
C-statistic of 0.847 in the validation cohort (473 patients).
Validation cohort was an independent national multicenter prospective cohort.
Performance was described as 'robust' relative to the development cohort results.
Results
Co-ASPECTS appeared to reflect both infarct burden and secondary injury following endovascular therapy.
Co-ASPECTS showed associations with final infarction volume.
Co-ASPECTS showed associations with intracranial hemorrhage.
The score integrates hyperdensity signs (reflecting hemorrhagic transformation or contrast staining) and hypodensity signs (reflecting ischemic injury) on immediate post-EVT noncontrast CT.
Methods
The study used a two-cohort design with a retrospective development cohort and a prospective multicenter external validation cohort.
Development cohort: 542 consecutive patients with acute ischemic stroke undergoing EVT from 2 academic hospitals, reviewed retrospectively.
Validation cohort: 473 patients from an independent national multicenter prospective cohort.
Total sample size: 1015 patients.
All patients had anterior circulation stroke treated with endovascular therapy.
What This Means
This research suggests that a new brain imaging scoring tool called Co-ASPECTS can reliably predict how well patients with a type of stroke (anterior circulation stroke) will recover 90 days after a procedure called endovascular therapy (EVT), which is used to remove blood clots from blocked arteries in the brain. Unlike existing scoring systems that look only at either areas of brightness (hyperdensity, which can indicate bleeding or contrast dye) or darkness (hypodensity, which indicates dead or damaged brain tissue) on CT scans taken immediately after the procedure, Co-ASPECTS combines both types of changes into a single 0–10 score. The study found that this combined approach was much better at predicting poor outcomes than the tools currently in use.
The new score was developed using data from 542 patients at two hospitals and then tested on a separate group of 473 patients from multiple hospitals across the country. In both groups, Co-ASPECTS performed well, with accuracy measures (C-statistics) of 0.889 and 0.847 respectively — values that indicate strong predictive ability. Patients with lower Co-ASPECTS scores were significantly more likely to have poor functional outcomes (defined as significant disability or death at 90 days). The score also correlated with the extent of final brain damage and the presence of bleeding in the brain after treatment.
This research suggests that Co-ASPECTS could be a practical, reliable tool for doctors to use right after a stroke procedure to quickly assess how much brain damage has occurred and to estimate a patient's likely recovery. Because it is based on standard CT scans already taken after EVT and follows a familiar scoring framework, it could be adopted into clinical practice without requiring additional imaging or complex calculations. This may help doctors better inform patients and families about expected recovery and guide decisions about further care.
Luo J, Zhao X, Xiao M, Yang G, Li P, Liu W, et al.. (2026). Assessing Brain Lesions and Predicting Functional Outcome in Patients With Anterior Circulation Stroke With Endovascular Therapy: Co-ASPECTS.. Journal of the American Heart Association. https://doi.org/10.1161/JAHA.126.051171