Accuracy of Reporting the Hyperdense Middle Cerebral Artery Sign as a Function of Clinical Experience

Abstract

Background/Aim: The hyperdense middle cerebral artery sign (HMCAS) is a useful clinical sign in the management of acute stroke and may alter time-critical decisions within an emergency setting. Though gold standards have been published, these are rarely used in clinical practice and scans tend to be reported subjectively. It is therefore possible that the level of experience of the doctor reporting the scan may impact on the accuracy of the reporting and hence patient management. This study was designed to evaluate the accuracy in detecting HMCAS across doctors with varying levels of experience. Methods: Forty doctors were recruited into four categories of experience. Each subject received a brief computer-based tutorial on how to identify an HMCAS and was then asked to report on the presence or absence of an HMCAS in 19 pre-prepared CT scans using a standardised viewing template. Results: The mean (±SE) percentage correct scores increased with experience from 76.8 ± 3.69 among interns and residents to 90.1 ± 2.23 (neurologists and radiologists; p < 0.01). Sensitivity and specificity as well as positive and negative predictive values all increased with experience. In addition, more experienced clinicians were better able to distinguish scans which met the radiological criteria for HMCAS from those which only just failed to do so. Conclusions: Experienced neurologists and radiologists consistently and accurately reported the presence or absence of HMCAS, whereas less experienced clinicians tended to over-report the presence of HMCAS. This may have implications for the acute management of thromboembolic stroke.

Thin Slices and Maximum Intensity Projection Reconstructions Increase Sensitivity to Hyperdense Middle Cerebral Artery Sign in Acute Ischemic Stroke

“…However, no significant differences on the correct assessment of HAS were to be expected between neurologists and radiologists at the beginning of their educational training. Fourth, a cross check with experienced observers at a specialist level should be addressed in future studies considering previous reports that less experienced clinicians possibly tend to overreport the presence of HAS [6]. Finally, results of ranking of detectability of HAS were biased due to restriction of ranking to that cases if HAS was presumed.…”

“…In acute ischemic stroke, the correct assessment of the presence of hyperdense artery sign (HAS) on cranial nonenhanced CT (NECT) has grown in importance due to its impact on the decision-making process of thrombolysis with or without mechanical thrombectomy [1-5]. As known from previous studies, the sensitivity for the detection of HAS might depend on individual observer’s experience level [6] as well as on image reconstruction parameters, for example, slice thickness [1], and rendering techniques like maximum intensity projection (MIP) [2, 7, 8], respectively.…”

CT assessment of the increased density of cerebral vessels in plateau region

“…Since the large blood vessels are under sulcus and cranial plate, it may be an encumbrance to clearly distinguish the high density of blood vessels from subarachnoid hemorrhage when the sulcus are not wide enough, and the density of sulcus is high. Further, the hyperdense artery sign is always attributed to the arterial thrombus and leads to cerebral infarction 2 – 4 . Apart from the arterial thrombus, the morbidity age of cerebral venous sinus thrombosis, a hemostatic abnormality, was found to be relatively young and appears to be more common in women.…”