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

Abstract

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.

Predictors of Fatal Brain Edema in Massive Hemispheric Ischemic Stroke

“…Of these, 18 patients died, and the only predictor of outcome was major early CT hypodensity. Haring and colleagues 33 also demonstrated that major hypodensity in the MCA territory predicted herniation but found that attenuation of contrast between the gray and white matter was the single best predictor of this outcome in a study of 62 patients with hemispheric infarctions. In the analysis of radiographic factors by Krieger and colleagues, 12 only CT involvement of Ͼ50% of the MCA territory was found to predict fatal brain swelling.…”

Hemodynamic Factors and Perfusion Abnormalities in Early Neurological Deterioration

“…However, it is discussed here because it does often overlap with END; it has devastating consequences; and identifying reliable predictors of MMI has great implications on further management, especially in the context of performing early decompressive surgery. 20 Early CT predictors of MMI are large hypodensity of the middle cerebral artery territory, 21-27 the hyperdense middle cerebral artery sign, 25,26,28 perfusion deficit Ͼ66% of the middle cerebral artery territory, 24,27 and brain swelling 23,26 ; however, only the first 2 remained significant on multivariate analysis. 21,22,25 On DSA, carotid T occlusion was found to be a better predictor of MMI than CT in patients undergoing intra-arterial therapy.…”

Assessment of epidemiological factors and clinical profiles of cerebral infarction cases in tertiary health center in southern Maharashtra and hence evaluating computed tomography as its diagnostic modality: a prospective study

“…9 Haghighi et al also found 28% cases with severe headaches, 27% with agitation, 5% with seizures, 18% with eye gaze impairment. 10 It is also equally important to exclude hemorrhage in patients who are on anti-coagulants or the one who is considered for endarterectomy. If infarct is hemorrhagic, anti-coagulants are unsafe.…”