To compare the ischemic core volume estimated by CT Perfusion 4D and Vue PACS with that estimated by RAPID software in acute ischemic stroke (AIS).

CT perfusion data from AIS patients were retrospectively post-processed with RAPID, CT Perfusion 4D and Vue PACS software. The Vue PACS application included three different settings: method A (Circular Singular Value Decomposition), method B (Oscillating index Singular Value Decomposition) and method C (Standard Singular Value Decomposition). Bland–Altman analysis, intraclass correlation coefficients (ICCs) and Kappa analysis were used to evaluate concordance between estimated ischemic core values. Final infarct volume (FIV) was measured by follow-up non-contrast CT or MRI 5-7 days after mechanical thrombectomy (MT) in patients with successful recanalization.

A total of 82 patients were included in the study. Concordance with RAPID ranged from good (method B: ICC 0.780; method C: ICC 0.852) to excellent (CT perfusion 4D: ICC 0.950; method A: ICC 0.954). The limits of agreement (-32.3, 41.8 mL) were the narrowest with method A. For detecting core volumes ≤ 70 ml, method A and CT perfusion 4D showed almost perfect concordance with RAPID (CT perfusion 4D, kappa=0.87; method A, kappa=0.87), whereas methods B and C showed substantial concordance with RAPID (method B, kappa=0.77; method C, kappa =0.73). Thirty-two patients had good reperfusion after MT. RAPID showed the highest accuracy for predicting FIV, followed by method A.

CT perfusion 4D and Vue PACS method A showed excellent concordance with RAPID for quantifying ischemic core volume, which can be considered as alternatives in selecting patients for MT in clinical practice.