ObjectivesWe used two automated software commonly employed in clinical practice—Olea Sphere (Olea) and Shukun-PerfusionGo (PerfusionGo)—to compare the diagnostic utility and volumetric agreement of computed tomography perfusion (CTP)-predicted final infarct volume (FIV) with true FIV in patients with anterior-circulation acute ischemic stroke (AIS).MethodsIn all, 122 patients with anterior-circulation AIS who met the inclusion and exclusion criteria were retrospectively enrolled and divided into two groups: intervention group (n= 52) and conservative group (n= 70), according to recanalization of blood vessels and clinical outcome (NIHSS) after different treatments. Patients in both groups underwent one-stop 4D-CT angiography (CTA)/CTP, and the raw CTP data were processed on a workstation using Olea and PerfusionGo post-processing software, to calculate and obtain the ischemic core (IC) and hypoperfusion (IC plus penumbra) volumes, hypoperfusion in the conservative group and IC in the intervention group were used to define the predicted FIV. The ITK-SNAP software was used to manually outline and measure true FIV on the follow-up non-enhanced CT or MRI-DWI images. Intraclass correlation coefficients (ICC), Bland–Altman, and Kappa analysis were used to compare the differences in IC and penumbra volumes calculated by the Olea and PerfusionGo software to investigate the relationship between their predicted FIV and true FIV.ResultsThe IC and penumbra difference between Olea and PerfusionGo within the same group (p< 0.001) was statistically significant. Olea obtained larger IC and smaller penumbra than PerfusionGo. Both software partially overestimated the infarct volume, but Olea significantly overestimated it by a larger percentage. ICC analysis showed that Olea performed better than PerfusionGo (intervention-Olea: ICC 0.633, 95%CI 0.439–0.771; intervention-PerfusionGo: ICC 0.526, 95%CI 0.299–0.696; conservative-Olea: ICC 0.623, 95%CI 0.457–0.747; conservative-PerfusionGo: ICC 0.507, 95%CI 0.312–0.662). Olea and PerfusionGo had the same capacity in accurately diagnosing and classifying patients with infarct volume <70 ml.ConclusionBoth software had differences in the evaluation of the IC and penumbra. Olea’s predicted FIV was more closely correlated with the true FIV than PerfusionGo’s prediction. Accurate assessment of infarction on CTP post-processing software remains challenging. Our results may have important practice implications for the clinical use of perfusion post-processing software.