Dense middle cerebral artery sign: an indicator of poor outcome in middle cerebral artery area infarction.

Background and Purpose-No neuroradiological markers have been characterized that support a timely decision for decompressive surgery in malignant middle cerebral artery (MCA) infarction (mMCAI). This case-control study was designed to analyze whether early cerebral CT (CCT) scanning provides reliable information for the prospective selection of stroke patients at risk of developing mMCAI. Methods-Thirty-one pairs (nϭ62) were formed with cases (mMCAI) and controls (acute but not malignant MCA infarction) closely matched in terms of age, sex, and stroke etiology. CCT was performed within 18 hours of stroke onset and analyzed by a blinded neuroradiologist according to a defined panel of 12 CCT criteria. Results-In terms of predicting mMCAI, the criteria of extended MCA territory hypodensities Ͼ67% and Ͼ50%, hemispheric brain swelling, midline shift, and hyperdense MCA sign exhibited high specificity (100%, 93.5%, 100%, 96.7%, and 83.9%, respectively) but low sensitivity (45.2%, 58.1%, 12.9%, 19.4%, and 70.9%, respectively). Two criteria yielded high sensitivity (subarachnoid space compressed, 100%; cella media compressed, 80.6%) but low specificity (29% and 74.2%, respectively). The criterion of attenuated corticomedullary contrast yielded both high specificity (96.8%) and sensitivity (87.1%). The latter remained as the crucial criterion [Exp(B)ϭ90.8; 95% CI, 5.8 to 1427.5] in a 2-tailed logistic regression analysis with the strongest correlating parameters (Spearman correlation factor Ն0.6 or ՅϪ0.6). Conclusions-The analysis of CCT scans within 18 hours of stroke onset revealed an attenuated corticomedullary contrast as the crucial CCT criterion, which, with both sufficient sensitivity and specificity, predicted mMCAI with 95% certainty.

Section: Discussionsupporting

confidence: 81%

Attenuated Corticomedullary Contrast: An Early Cerebral Computed Tomography Sign Indicating Malignant Middle Cerebral Artery Infarction

Haring

Dilitz

Pallua

et al. 1999

“…Recanalization after IAT was assessed systematically by DSA at the end of thrombolysis, but DSA was not performed in the IVT group. Neumann-Haefelin and coworkers, using MR angiography, assessed recanalization on day 1 in 52 stroke patients pres- Large artery disease, n (%) 11 (19) 5 (9) Other determined, n (%) 5 (9) 5 (9) Undetermined, n (%) 14 (25) enting with MCA main stem occlusion. 7 They found TIMI-2 or -3 recanalization grades in 20 of 52 patients (38%) after IVT and a positive correlation between recanalization and functional outcome.…”

Section: Discussionmentioning

confidence: 99%

Comparison of Intraarterial and Intravenous Thrombolysis for Ischemic Stroke With Hyperdense Middle Cerebral Artery Sign

Mattle

Arnold

Georgiadis

et al. 2008

189

112

Background and Purpose-It is unclear whether intraarterial (IAT) or intravenous (IVT) thrombolysis is more effective for ischemic stroke with hyperdense middle cerebral artery sign (HMCAS) on computed tomography (CT). The aim of this study was to compare IAT and IVT in stroke patients with HMCAS. Methods-Comparison of data from 2 stroke units with similar management of stroke associated with HMCAS, except that 1 unit performed IAT with urokinase and the other IVT with plasminogen activator. Time to treatment was up to 6 hours for IAT and up to 3 hours for IVT. Outcome was measured by mortality and the modified Rankin Scale (mRS), dichotomized at 3 months into favorable (mRS 0 to 2) and unfavorable (mRS 3 to 6). Results-One hundred twelve patients exhibited a HMCAS, 55 of 268 patients treated with IAT and 57 of 249 patients who underwent IVT. Stroke severity at baseline and patient age were similar in both groups. Mean time to treatment was longer in the IAT group (244Ϯ63 minutes) than in the IVT group (156Ϯ21 minutes; Pϭ0.0001). However, favorable outcome was more frequent after IAT (nϭ29, 53%) than after IVT (nϭ13, 23%; Pϭ0.001), and mortality was lower after IAT (nϭ4, 7%) than after IVT (nϭ13, 23%; Pϭ0.022). After multiple regression analysis IAT was associated with a more favorable outcome than IVT (Pϭ0.003) but similar mortality (Pϭ0.192). Conclusion-In this observational study intraarterial thrombolysis was more beneficial than IVT in the specific group of stroke patients presenting with HMCAS on CT, even though IAT was started later. Our results indicate that a randomized trial comparing both thrombolytic treatments in patients with middle cerebral artery occlusion is warranted.

“…9,10 The HMCAS has been associated with severe neurological deficits and poor clinical outcome. 11,12 More recently, the MCA "dot" sign was described, representing a hyperdensity of the MCA branches (M2 or M3 segment) within the Sylvian fissure. 13 The MCA dot sign is a marker of thromboembolic occlusion of distal MCA branches and is associated with better outcome than the HMCA sign.…”

mentioning

confidence: 99%

Hyperdense Internal Carotid Artery Sign

Özdemir¹,

Leung²,

Bussiére³

et al. 2008

Background and Purpose-The hyperdense middle cerebral artery sign (HMCAS) is a well-established marker of early ischemia on noncontrast computed tomography of the brain (NCCT). Recently the MCA dot sign has been described and proposed to indicate thrombosis of the M2 or M3 middle cerebral artery branches. The purpose of this study was to define the hyperdense ICA sign (HICAS) and determine its prevalence, diagnostic and prognostic value, and its reliability as a marker for ischemia. Methods-Noncontrast computed tomography scans of 71 patients with acute ischemic stroke were analyzed for the presence of a HICAS, HMCAS, or MCA dot sign. For the validation of HICA and HMCA signs on NCCT, 32 of 71 patients who underwent gold standard CT angiography (CTA) before thrombolytic therapy were included in the analysis. The presence of a HICAS was correlated with initial neurological severity and the short and long-term outcomes. Results-A HICAS was found in 24% of patients on NCCT. In patients with a HICAS, mean age was 63Ϯ17.4 and mean time from symptom onset to CT was 103 minutes. Interobserver agreement was excellent for the HICAS. The HICAS has high specificity (100%) and positive predictive value (100%) in predicting the presence of distal internal carotid artery thrombus on CTA. Patients with a HICAS had a more severe initial neurological deficit and worse prognosis than patients without a HICAS. Conclusion-The HICAS is a reliable and a highly specific marker of thromboembolic occlusion of the distal ICA and is associated with severe initial neurological deficit and worse outcome despite thrombolytic therapy.