Clinical implications of CT hyperdense artery sign in patients with acute middle cerebral artery occlusion in the era of modern mechanical thrombectomy

Kim, Seul-Kee; Baek, Byung Hyun; Lee, Yun Young; Yoon, Woong

doi:10.1007/s00415-017-8655-0

Cited by 49 publications

(46 citation statements)

References 30 publications

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“…Similarly, the proportion of proximal occlusions within our cohort of ischemic strokes (40.5%) parallels previous prospective reports [2], as does the average NIHSS score of our patients with LVO [14]. Finally, the stroke etiology distribution in our population was comparable to that in a recent study that analyzed the associations between HMCAS and stroke etiology [15]. So, the evidence provided by our study is likely to be transposable to most acute stroke settings.…”

Section: Discussion/conclusionsupporting

confidence: 88%

The Hyperdense Middle Cerebral Artery Sign in Drip-and-Ship Models of Acute Stroke Management

Jodaïtis

Ligot

Chapusette

et al. 2020

Cerebrovasc Dis Extra

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Background: Large vessel occlusion (LVO) leads to debilitating stroke and responds modestly to recombinant tissue plasminogen activator (rt-TPA). Early thrombectomy improves functional outcomes in selected patients with proximal occlusion but it is not available in all medical facilities. The best imaging modality for triage in an acute stroke setting in drip-andship models is still the subject of debate. Objectives: We aimed to assess the diagnostic value of millimeter-sliced noncontrast computed tomography (NCCT) hyperdense middle cerebral artery sign (HMCAS) in itself or associated with clinical data for early detection of LVO in drip-and-ship models of acute stroke management. Methods: NCCT of patients admitted to the Erasme Hospital, ULB, Brussels, Belgium, for suspicion of acute ischemic stroke between January 1 and July 31, 2017, were collected. Patients with brain hemorrhages were excluded, leading to 122 cases. The presence of HMCAS on NCCT was determined via visual assessment by 6 raters blinded to all other data. An independent rater assessed the presence of LVO on digital subtraction angiography imaging or contrast-enhanced CT angiography (CTA). The sensitivity, false-positive rate (FPR), and accuracy of HMCAS and the dot sign to detect LVO were calculated. The interobserver agreement of HMCAS was assessed using Gwet's AC1 coefficient. Then, on a separate occasion, the first 2 observers rereviewed all NCCT provided with clinical clues. The sensitivity, FPR, and accuracy of HMCAS were recalculated. Results: HMCAS was found in 21% of the cases and a dot sign was found in 9%. The mean HMCAS sensitivity was 62% (95% CI 45-79%) and its accuracy was 86% (95% CI 79-92%) for detecting LVO. The interobserver reliability coefficient was 80% for HMCAS. Combined with clinical information, HMCAS sensitivity increased to 81% (95% CI 68-94; p = 0.041) and accuracy increased to 91% (95% CI 86-96%). Conclusion: When clinical data are provided, detection of HMCAS on thinly sliced NCCT could be enough to decide on transfer for thrombectomy in drip-and-ship models of acute stroke management, especially in situations where CTA is less available and referral centers for thrombectomy fewer and further apart.either the HMCAS or the dot sign only marginally improved the sensitivity (68%, 95% CI 51-84) compared to the HMCAS but with a higher FPR (11%, 95% CI 5-17), resulting in a marginally lower accuracy (83%, 95% CI 77-90). See Table 2.

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Section: Discussion/conclusionsupporting

confidence: 88%

The Hyperdense Middle Cerebral Artery Sign in Drip-and-Ship Models of Acute Stroke Management

Jodaïtis

Ligot

Chapusette

et al. 2020

Cerebrovasc Dis Extra

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“…30 In this meta-analysis, patients with an initial HMCAS that were more resistant to intravenous thrombolysis might benefit from further endovascular therapy. The presence of HMCAS had a low prognostic value in mechanical thrombectomy, which indicates the potential value of implementing more aggressive treatments for HMCAS-positive patients.…”

Section: Discussionmentioning

confidence: 99%

“…The presence of HMCAS had a low prognostic value in mechanical thrombectomy, which indicates the potential value of implementing more aggressive treatments for HMCAS-positive patients. 30 In this meta-analysis, patients with an initial HMCAS that were more resistant to intravenous thrombolysis might benefit from further endovascular therapy.…”

Section: Discussionmentioning

confidence: 99%

Intravenous thrombolysis for ischemic stroke with hyperdense middle cerebral artery sign: A meta‐analysis

et al. 2019

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The first choice for acute ischemic stroke (AIS) within 3 and 4.5 hours from onset is intravenous thrombolysis by treating with recombinant tissue plasminogen activator (tPA). 1 However, the overall incidence of partial or complete early recanalization (ER) for large vessels was limited to 33%, and symptomatic intracerebral hemorrhage (sICH) related to thrombolysis was found to occur in 2.4%-10% of cases, and both are associated with increased disability or mortality. [2][3][4] The clinical efficacy of thrombolysis might be influenced by the size, site and composition of the occluding thrombus. With the development of additional reperfusion strategies like thrombectomy, 5 it is increasingly useful to identify specific markers that might indicate Hyperdense middle cerebral artery sign (HMCAS) on admitting to neuroimaging is reported to have prognostic value for poor outcomes after thrombolysis, while evidence from studies comprising a sufficiently large sample size is limited. To detect prognostic predictors after thrombolysis could help improve therapeutic clinical strategies for acute ischemic stroke. We included prospective and retrospective studies of stroke patients that were treated with intravenous thrombolysis, in which functional outcomes (ie, a modified Rankin scale [mRS]) and systematic intracranial hemorrhage (sICH) were assessed in relation to HMCAS during pretreatment head CT. Random-effects models were used to calculate pooled risk ratios (RR) of poor outcomes and sICH for HMCAS patients as compared to patients without HMCAS.Eleven studies permitted identification of 11 818 patients. The risk of poor outcome at 3 months in the HMCAS-positive group was 1.56-fold the negative group (RR, 1.56; 95% CI 1.50-1.62; P < .001). The sICH risk when comparing both groups was found to be non-significant. Sensitivity analysis regarding studies performing thrombolysis within 3 hours also exhibited significant differences in their functional outcomes (RR, 1.56, 95% CI 1.49-1.62; P < .001) in patients with HMCAS as compared to non-HMCAS patients, although this was true for sICH risk. The presence of HMCAS on pretreatment CT predicts a poor outcome at 3 months after intravenous thrombolysis, while its relationship with the incidence of sICH was found to have no statistic value. Our study implies that more aggressive treatment should be considered for HMCAS patients. K E Y W O R D Sfunctional outcome, hyperdense middle cerebral artery sign, intravenous thrombolysis, ischemic stroke, symptomatic intracranial hemorrhage

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“…Common cardioembolic sources such as atrial fibrillation or valvular heart diseases are typically considered as evidence of an embolic occlusion of an intracranial artery [ 7 ]. Specific imaging findings—for example, a hyperdense artery sign on CT or a blooming artifact on magnetic resonance imaging—have also been regarded as markers of embolic occlusion [ 14 , 20 ]. Uniquely, the occlusion type observed on preprocedural CTA was significantly associated with occlusion pathomechanism.…”

Section: Discussionmentioning

confidence: 99%

Utility of Leptomeningeal Collaterals in Predicting Intracranial Atherosclerosis-Related Large Vessel Occlusion in Endovascular Treatment

Baek

Kim

et al. 2020

JCM

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Earlier or preprocedural identification of occlusion pathomechanism is crucial for effective endovascular treatment. As leptomeningeal collaterals tend to develop well in chronic ischemic conditions such as intracranial atherosclerosis (ICAS), we investigated whether leptomeningeal collaterals can be a preprocedural marker of ICAS-related large vessel occlusion (ICAS-LVO) in endovascular treatment. A total of 226 patients who underwent endovascular treatment were retrospectively reviewed. We compared the pattern of leptomeningeal collaterals between patients with ICAS-LVO and without. Leptomeningeal collaterals were assessed by preprocedural computed tomography angiography (CTA) and basically categorized by three different collateral assessment methods. Better leptomeningeal collaterals were significantly associated with ICAS-LVO, although they were not independent for ICAS-LVO. When leptomeningeal collaterals were dichotomized to incomplete (<100%) and complete (100%), the latter was significantly more frequent in patients with ICAS-LVO (52.5% versus 20.4%) and remained an independent factor for ICAS-LVO (odds ratio, 3.32; 95% confidence interval, 1.52–7.26; p = 0.003). The area under the curve (AUC) value of complete leptomeningeal collateral supply was 0.660 for discrimination of ICAS-LVO. Incomplete leptomeningeal collateral supply was not likely ICAS-LVO, based on the high negative predictive value (88.6%). Considering its negative predictive value and the independent association between complete leptomeningeal collateral supply and ICAS-LVO, leptomeningeal collaterals could be helpful in the preprocedural determination of occlusion pathomechanism.

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Clinical implications of CT hyperdense artery sign in patients with acute middle cerebral artery occlusion in the era of modern mechanical thrombectomy

Cited by 49 publications

References 30 publications

The Hyperdense Middle Cerebral Artery Sign in Drip-and-Ship Models of Acute Stroke Management

The Hyperdense Middle Cerebral Artery Sign in Drip-and-Ship Models of Acute Stroke Management

Intravenous thrombolysis for ischemic stroke with hyperdense middle cerebral artery sign: A meta‐analysis

Utility of Leptomeningeal Collaterals in Predicting Intracranial Atherosclerosis-Related Large Vessel Occlusion in Endovascular Treatment

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