Stroke is a leading cause of mortality and long-term disability worldwide, imposing a substantial burden on healthcare systems. Acute ischemic stroke (AIS) accounts for approximately 80–85% of all stroke cases and results from the interruption of cerebral blood supply, leading to neuronal injury and cerebral infarction. Despite advances in diagnostic imaging and therapeutic interventions, AIS remains associated with considerable morbidity, mortality, and functional dependence. Early assessment of neurological severity and accurate prediction of clinical outcomes are therefore essential for optimizing patient management and rehabilitation strategies [1,2]. Non-contrast computed tomography (NCCT) is the preferred initial imaging modality in acute stroke evaluation because of its rapid availability and ability to exclude intracranial hemorrhage. The Alberta Stroke Program Early CT Score (ASPECTS) is a standardized, 10-point scoring system developed to quantify early ischemic changes within the middle cerebral artery (MCA) territory. Higher ASPECTS values indicate less extensive visible ischemic involvement, whereas lower scores suggest greater cerebral injury. ASPECTS has demonstrated clinical utility in assessing infarct extent, guiding reperfusion treatment decisions, and predicting neurological and functional outcomes [3–5]. The National Institutes of Health Stroke Scale (NIHSS) is widely used to quantify neurological deficits in patients with AIS. Higher NIHSS scores indicate greater neurological impairment and are generally associated with poorer prognosis. Similarly, the modified Rankin Scale (mRS) provides a standardized assessment of post-stroke disability and functional independence. Correlating baseline ASPECTS with NIHSS and subsequent mRS scores may help establish the relationship between radiological ischemic burden, initial neurological severity, and functional recovery [6-9]. Previous studies have demonstrated that lower ASPECTS values are associated with more severe neurological deficits, unfavorable functional outcomes, and an increased risk of hemorrhagic complications following thrombolytic therapy [10-12]. Although ASPECTS has been extensively investigated among patients undergoing reperfusion therapy, its prognostic significance in patients managed without intravenous thrombolysis or mechanical thrombectomy warrants further evaluation. This is particularly relevant in resource-limited settings, where delayed presentation and restricted access to specialized stroke interventions may influence treatment options and clinical outcomes [13,14]. The present study aims to evaluate the correlation of CT-based ASPECTS with neurological deficits and functional outcomes in patients with acute ischemic stroke involving the MCA territory who present within 48 hours of symptom onset and do not undergo reperfusion therapy. By examining the relationship between ASPECTS, NIHSS, and functional outcomes assessed using mRS, the study seeks to determine the prognostic utility of ASPECTS and explore its potential role in identifying patients at increased risk of neurological disability and unfavorable recovery.

Study Design and Setting This hospital-based observational study was conducted in the Department of General Medicine at a tertiary care teaching hospital. The study evaluated the correlation between computed tomography (CT)-based Alberta Stroke Program Early CT Score (ASPECTS), neurological deficits, and functional outcomes among patients diagnosed with acute ischemic stroke involving the middle cerebral artery (MCA) territory. Study Duration The study was conducted over a period of 18 months, during which eligible patients were enrolled, clinically evaluated, investigated, and followed up to assess neurological and functional outcomes. Study Population The study included adult patients diagnosed with acute ischemic stroke involving the MCA territory who presented to the hospital within 48 hours of symptom onset. Patients were recruited from the emergency department and inpatient services after confirmation of the diagnosis through clinical examination and neuroimaging. Sample Size A total of 90 patients fulfilling the eligibility criteria were included in the study. Patients were enrolled using consecutive sampling until the required sample size was achieved. Inclusion Criteria 1. Patients aged 18 years and above. 2. Patients diagnosed with acute ischemic stroke involving the MCA territory. 3. Patients presenting within 48 hours of symptom onset. 4. Patients who underwent non-contrast CT of the brain during initial evaluation. 5. Patients who did not receive intravenous thrombolysis or mechanical thrombectomy. 6. Patients or their legally authorized representatives who provided informed consent. Exclusion Criteria 1. Patients with hemorrhagic stroke or subarachnoid hemorrhage. 2. Patients with posterior circulation infarction or isolated infarction outside the MCA territory. 3. Patients with a history of previous stroke resulting in significant residual neurological disability. 4. Patients with intracranial tumors, traumatic brain injury, or other structural intracranial abnormalities affecting neurological assessment. 5. Patients who underwent intravenous thrombolysis or mechanical thrombectomy. 6. Patients with incomplete clinical or radiological data required for analysis. Data Collection and Clinical Assessment Following enrollment, demographic characteristics, including age and sex, were recorded. Relevant clinical information, including time from symptom onset to hospital presentation, presenting symptoms, vascular risk factors, and associated comorbidities such as hypertension, diabetes mellitus, dyslipidemia, smoking, and cardiovascular disease, was documented using a structured data collection form. All patients underwent detailed clinical and neurological examinations at admission. Neurological impairment was assessed using the National Institutes of Health Stroke Scale (NIHSS), which evaluated consciousness, gaze, visual fields, facial movements, motor function, sensory deficits, language, dysarthria, and neglect. The total NIHSS score ranged from 0 to 42, with higher scores indicating greater neurological impairment. Radiological Assessment and ASPECTS Calculation All patients underwent non-contrast CT of the brain as part of the initial diagnostic evaluation. CT images were assessed for early ischemic changes, including loss of gray-white matter differentiation, obscuration of the lentiform nucleus, loss of the insular ribbon, and focal sulcal effacement. The Alberta Stroke Program Early CT Score (ASPECTS) was calculated by evaluating ten predefined regions within the MCA territory. These included the caudate nucleus, lentiform nucleus, internal capsule, insular cortex, and six cortical regions designated M1 to M6. Each patient was initially assigned a score of 10, and one point was deducted for every region demonstrating early ischemic changes. The final score ranged from 0 to 10, with higher scores indicating less extensive ischemic involvement and lower scores indicating more extensive ischemic injury. Assessment of Functional Outcomes Functional outcomes were assessed using the modified Rankin Scale (mRS), which measured the degree of disability and dependence following stroke. The scale ranged from 0, indicating no symptoms, to 6, indicating death. Patients were categorized according to their functional status, with mRS scores of 0–2 representing favorable functional outcomes and scores of 3–6 representing unfavorable outcomes. The relationship between baseline ASPECTS and subsequent functional disability was evaluated. Study Variables The primary variables included baseline CT-based ASPECTS, NIHSS score at admission, and functional outcome assessed using the mRS. Additional variables included demographic characteristics, vascular risk factors, clinical presentation, and time from symptom onset to hospital admission. Statistical Analysis Data were entered into Microsoft Excel and analyzed using appropriate statistical software. Continuous variables were expressed as mean ± standard deviation or median with interquartile range, depending on data distribution. Categorical variables were presented as frequencies and percentages. The Shapiro–Wilk test was used to assess normality. Correlations between ASPECTS and NIHSS scores and between ASPECTS and mRS scores were evaluated using Pearson's or Spearman's correlation coefficients, as appropriate. Comparisons between patients with favorable and unfavorable functional outcomes were performed using the independent-samples t-test or Mann–Whitney U test for continuous variables and the chi-square test or Fisher's exact test for categorical variables. Receiver operating characteristic (ROC) curve analysis was used to evaluate the ability of baseline ASPECTS to predict unfavorable functional outcomes. The area under the curve (AUC) was calculated, and an optimal cutoff value was identified using the Youden index. A p-value of less than 0.05 was considered statistically significant

The present study included 90 patients diagnosed with acute ischemic stroke, with a mean age of 57.8 ± 12.6 years. The highest proportion of patients belonged to the 51–60 years age group (30.0%), followed by 61–70 years (23.3%) and 41–50 years (20.0%). Patients aged 18–40 years and those older than 70 years each accounted for 13.3% of the study population. Male predominance was observed, with 58 (64.4%) males and 32 (35.6%) females. Regarding the time from symptom onset to presentation, the majority of patients presented between 12 and 24 hours (34.4%), followed by 24–48 hours (25.6%) and 6–12 hours (24.4%). Only 14 (15.6%) patients presented within the first 6 hours of symptom onset. The baseline demographic and clinical characteristics of the study population are presented in Table 1. Hypertension was the most prevalent vascular risk factor, affecting 56 (62.2%) patients, followed by diabetes mellitus in 38 (42.2%), dyslipidemia in 35 (38.9%), and smoking in 29 (32.2%). Atrial fibrillation was documented in 14 (15.6%) patients, while 9 (10.0%) had a previous history of transient ischemic attack. Regarding clinical presentation, hemiparesis or hemiplegia was the most common neurological manifestation, observed in 76 (84.4%) patients, followed by facial weakness in 61 (67.8%) and speech disturbance in 49 (54.4%). Sensory deficits were present in 33 (36.7%) patients, altered sensorium in 21 (23.3%), and visual disturbances in 16 (17.8%). Multiple vascular risk factors and neurological manifestations were observed in individual patients. The distribution of vascular risk factors and clinical presentations is summarized in Table 2. The distribution of CT-based Alberta Stroke Program Early CT Scores (ASPECTS) demonstrated that 41 (45.6%) patients had scores between 8 and 10, representing the largest proportion of the study population. Scores between 5 and 7 were observed in 35 (38.9%) patients, while 14 (15.6%) had scores between 0 and 4. Assessment of neurological severity using the National Institutes of Health Stroke Scale (NIHSS) revealed that moderate neurological deficits (NIHSS 5–15) were most common, affecting 44 (48.9%) patients. Moderate-to-severe neurological deficits (NIHSS 16–20) were observed in 20 (22.2%) patients, while 15 (16.7%) had mild deficits (NIHSS 0–4). Severe neurological impairment (NIHSS 21–42) was documented in 11 (12.2%) patients. The distribution of ASPECTS scores and NIHSS severity categories is presented in Table 3 and Figure 1. An inverse relationship was observed between CT-based ASPECTS scores and neurological deficit severity at admission. Patients with lower ASPECTS scores (0–4) demonstrated the highest mean NIHSS score of 21.4 ± 5.2, indicating greater neurological impairment. Patients with intermediate ASPECTS scores (5–7) had a mean NIHSS score of 14.6 ± 4.8, whereas those with higher ASPECTS scores (8–10) exhibited the lowest mean NIHSS score of 8.3 ± 3.9. These findings demonstrated a progressive reduction in neurological deficit severity with increasing ASPECTS scores. The observed pattern suggests that patients with more extensive early ischemic changes on CT, reflected by lower ASPECTS scores, tended to present with greater neurological impairment. The association between CT-based ASPECTS categories and mean NIHSS scores is illustrated in Table 4 and Figure 2. Functional outcomes were assessed using the modified Rankin Scale (mRS), with scores of 0–2 categorized as favorable outcomes and scores of 3–6 as unfavorable outcomes. Overall, 49 (54.4%) patients achieved favorable functional outcomes, whereas 41 (45.6%) experienced unfavorable outcomes. Among patients with ASPECTS scores of 0–4, only 2 (14.3%) achieved favorable outcomes, while 12 (85.7%) had unfavorable outcomes. In the intermediate ASPECTS category (5–7), favorable outcomes were observed in 15 (42.9%) patients, whereas 20 (57.1%) had unfavorable outcomes. In contrast, among patients with higher ASPECTS scores (8–10), 32 (78.0%) achieved favorable functional outcomes, while only 9 (22.0%) experienced unfavorable outcomes. These findings demonstrated a progressive increase in the proportion of favorable functional outcomes with increasing baseline ASPECTS scores. Patients with higher ASPECTS scores were more likely to achieve functional independence, whereas those with lower scores exhibited a greater proportion of unfavorable outcomes. The association between baseline ASPECTS categories and functional outcomes is presented in Table 5 and Figure 3. Table 1. Baseline Demographic and Clinical Characteristics of the Study Population (N = 90) Characteristics Frequency (n) Percentage (%) Age group (years) 18–40 12 13.3 41–50 18 20.0 51–60 27 30.0 61–70 21 23.3 >70 12 13.3 Sex Male 58 64.4 Female 32 35.6 Time from symptom onset Within 6 hours 14 15.6 >6–12 hours 22 24.4 >12–24 hours 31 34.4 >24–48 hours 23 25.6 mean age: 57.8 ± 12.6 years. Table 2. Distribution of Vascular Risk Factors and Clinical Presentation (N = 90) Characteristics Frequency (n) Percentage (%) Vascular risk factors Hypertension 56 62.2 Diabetes mellitus 38 42.2 Dyslipidemia 35 38.9 Smoking 29 32.2 Atrial fibrillation 14 15.6 Previous transient ischemic attack 9 10.0 Clinical presentation Hemiparesis/hemiplegia 76 84.4 Facial weakness 61 67.8 Speech disturbance 49 54.4 Sensory deficit 33 36.7 Altered sensorium 21 23.3 Visual disturbance 16 17.8 Multiple risk factors and clinical manifestations could occur in the same patient; percentages therefore do not total 100%. Table 3. Distribution of CT-Based ASPECTS Scores and Neurological Severity at Admission (N = 90) Parameter Frequency (n) Percentage (%) ASPECTS score 0–4 14 15.6 5–7 35 38.9 8–10 41 45.6 NIHSS severity category Mild (0–4) 15 16.7 Moderate (5–15) 44 48.9 Moderate to severe (16–20) 20 22.2 Severe (21–42) 11 12.2 Table 4. Association Between CT-Based ASPECTS Score and Neurological Deficit at Admission (N = 90) ASPECTS category n NIHSS score (mean ± SD) 0–4 14 21.4 ± 5.2 5–7 35 14.6 ± 4.8 8–10 41 8.3 ± 3.9 Table 5. Association Between Baseline ASPECTS Score and Functional Outcome (N = 90) ASPECTS category Favorable mRS 0–2 n (%) Unfavorable mRS 3–6 n (%) Total 0–4 2 (14.3) 12 (85.7) 14 5–7 15 (42.9) 20 (57.1) 35 8–10 32 (78.0) 9 (22.0) 41 Total 49 (54.4) 41 (45.6) 90 (100)

The present study evaluated the relationship between CT-based Alberta Stroke Program Early CT Score (ASPECTS), neurological deficit, and functional outcomes in 90 patients with acute ischemic stroke. The findings demonstrated that patients with lower ASPECTS scores had greater neurological impairment and a higher proportion of unfavorable functional outcomes, highlighting the potential prognostic value of early CT-based assessment. In the present study, the mean age was 57.8 ± 12.6 years, with the highest proportion of patients belonging to the 51–60 years age group (30.0%), followed by 61–70 years (23.3%). Male predominance was observed, with 58 patients (64.4%) being male and 32 (35.6%) female. Regarding symptom onset, 34.4% presented within 12–24 hours, while 25.6% presented after 24–48 hours. Only 15.6% presented within six hours. These findings indicated a substantial proportion of delayed hospital presentations, emphasizing the importance of accessible neuroimaging-based prognostic assessment. These observations can be compared with the study by Barber et al. (2000) [15], which evaluated 156 patients with anterior-circulation ischemic stroke and demonstrated the clinical relevance of early CT changes. However, differences in study populations and treatment exposure should be considered when comparing outcomes. Hypertension was the most prevalent vascular risk factor in the present study (62.2%), followed by diabetes mellitus (42.2%), dyslipidemia (38.9%), and smoking (32.2%). Hemiparesis or hemiplegia was the commonest presentation (84.4%), followed by facial weakness (67.8%) and speech disturbances (54.4%). These findings reflected the predominance of motor deficits among patients with MCA-territory infarction. Pexman et al. (2001) [16] described the anatomical basis of ASPECTS assessment and emphasized the importance of systematically evaluating ischemic involvement within the MCA territory. Their findings support the relevance of correlating CT abnormalities with neurological manifestations, although their study did not report directly comparable risk-factor frequencies. In the present study, 45.6% of patients had ASPECTS scores of 8–10, followed by 38.9% with scores of 5–7 and 15.6% with scores of 0–4. Moderate neurological impairment (NIHSS 5–15) was observed in 48.9%, while 22.2% had moderately severe deficits. Similarly, a published cohort of 343 thrombectomy-treated patients reported that 293 patients had ASPECTS 6–10 and 50 had ASPECTS 0–5 . The predominance of higher ASPECTS scores in both studies suggests that less extensive early ischemic changes are frequently encountered, although the different populations limit direct comparison. The present study demonstrated progressively lower NIHSS scores with increasing ASPECTS categories. Patients with ASPECTS 0–4 had a mean NIHSS of 21.4 ± 5.2, compared with 14.6 ± 4.8 for ASPECTS 5–7 and 8.3 ± 3.9 for ASPECTS 8–10. Barber et al. (2000) [15] similarly reported a significant inverse correlation between ASPECTS and NIHSS (r = −0.56, p < 0.001). Another study involving 343 patients reported higher baseline NIHSS scores among patients with ASPECTS 0–5 than among those with ASPECTS 6–10 (18.1 ± 5.1 versus 14.6 ± 4.3; p < 0.001). These findings support an inverse association between radiological ischemic burden and neurological function. Favorable functional outcomes (mRS 0–2) were observed in 54.4% of patients in the present study. The proportion increased from 14.3% among patients with ASPECTS 0–4 to 42.9% with ASPECTS 5–7 and 78.0% with ASPECTS 8–10. Similarly, the 343-patient cohort reported favorable 90-day outcomes in 28.0% of patients with ASPECTS 0–5 compared with 50.5% with ASPECTS 6–10 (p = 0.038). Another multicenter study involving 2,345 thrombectomy-treated patients reported favorable outcomes in 22.1% of patients with ASPECTS 2–5. These findings consistently indicate poorer functional prognosis with lower ASPECTS values, although differences in reperfusion treatment and outcome assessment timing must be considered. Overall, the findings suggest that baseline ASPECTS may be useful for identifying patients at increased risk of severe neurological impairment and unfavorable functional recovery.

The present study demonstrated that CT-based ASPECTS was associated with neurological severity and functional outcomes in patients with acute ischemic stroke. Lower ASPECTS scores were associated with higher NIHSS scores and a greater proportion of unfavorable functional outcomes, whereas higher ASPECTS scores indicated better neurological and functional prognosis. These findings suggest that ASPECTS may serve as a simple, rapid, and accessible tool for early risk stratification and prognostic assessment. Incorporating ASPECTS alongside clinical evaluation may facilitate timely management decisions, prognostic counseling, and individualized rehabilitation planning in patients with acute ischemic stroke. LIMITATIONS The present study was limited by its single-center design and relatively small sample size of 90 patients, which may restrict the generalizability of the findings. The study included only patients with middle cerebral artery territory infarction, limiting its applicability to other stroke subtypes. ASPECTS assessment using non-contrast CT may be influenced by interobserver variability and the timing of imaging. Additionally, the observational design and potential influence of confounding factors limited the ability to establish causal relationships between ASPECTS and functional outcomes.

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