Prevalence, Comorbid Associations and Prognostic Value of the Hyperdense Middle Cerebral Artery Sign

Abstract

Background. The significance of the Hyperdense Middle Cerebral Artery Sign (HMCAS) is uncertain. Aims. This prospective study investigated the sensitivity, specificity, prevalence, prognosis, interobserver variability, and associated clinical features of HMCAS in acute ischemic stroke. Methods. Initial CT scans of 117 patients with acute ischemic stroke or transient ischemic attack (TIA) and 65 age-matched controls were reported independently by two neuroradiologists blinded to diagnosis. Details of initial stroke severity and comorbidities were collected, and outcome on the modified Rankin scale (mRS) was assessed at 3–6 months. Results. HMCAS was seen in 15% of all ischemic strokes and 25% of all middle cerebral artery (MCA) strokes; specificity was 100%. HMCAS was associated with more severe initial deficit and atrial fibrillation. Only 21% of patients with a first-ever MCA stroke and HMCAS had a good outcome (mRS≤2) compared to 55% of those without the sign (P<0.001). Interobserver agreement was only 0.747 (Kappa statistic). Conclusion. The prevalence, specificity, sensitivity, and clinical associations of HMCAS were similar to previous reports. This study confirmed prospectively that HMCAS was associated with a poorer outcome at 3 to 6 months and demonstrated interobserver variability in detection of the sign.

Graded fMRI Neurofeedback Training of Motor Imagery in Middle Cerebral Artery Stroke Patients: A Preregistered Proof-of-Concept Study

“…Ischemic stroke of the middle cerebral artery (MCA) is one of the most common forms of stroke (Leys et al, 1992 ; Aouad et al, 2013 ). The MCA is the main blood supply to the primary motor cortex, including the hand knob area, as well as the premotor cortex.…”

Direct Thrombus Imaging in Stroke

“…Since soft-tissue resolution in human CT is often insufficient to distinguish the thrombus from the surrounding blood pool, non-contrast CT does not usually allow a precise assessment of the extent and distribution of thromboemboli [ 7 , 10 ]. Clinicians often rely on the “dense artery” sign [ 51 - 53 ], which refers to the appearance of a cerebral artery on non-enhanced CT. However, this strategy has poor sensitivity.…”

“…However, this strategy has poor sensitivity. In a recent prospective study involving 117 patients with acute ischemic stroke or transient ischemic attack and 65 age-matched controls [ 53 ], the hyperdense MCA sign was observed in only 15% of all ischemic strokes and 25% of all MCA strokes. Moreover, agreement between expert neuroradiologists on the presence of a hyperdense MCA sign was not high (Kappa=0.747).…”

“…Moreover, agreement between expert neuroradiologists on the presence of a hyperdense MCA sign was not high (Kappa=0.747). The low sensitivity and higher possibility of disagreement between non-experts raise doubts about the practical utility of the dense artery sign in making time-sensitive decisions regarding optimal recanalization strategies [ 53 ]. In another study involving 35 patients with clinically suspected stroke [ 54 ], susceptibility-weighted MRI was found to be superior (sensitivity/specificity: 85%/100%) to fluid-attenuation inversion-recovery MRI (61%/98%) and CT (52%/93%) in detecting cerebral thromboemboli.…”

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

“…The hyperdense middle cerebral artery sign (HMCAS] was first described about 30 years ago as a high-density structure within the territory of the middle cerebral artery (MCA] on non-enhanced computed tomography (NECT) scans of patients with acute ischaemic stroke [ 1 ]. The HMCAS has been shown to be specific for acute ischaemic stroke affecting the MCA territory, and its presence is associated with a poorer outcome [ 2 ]. Its presence or absence has recently assumed increasing importance in the hyperacute management of patients presenting with ischaemic stroke, specifically in relation to whether or not consideration of intra-arterial thrombolysis or clot retrieval is appropriate [ 3 , 4 ].…”