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      Disappearing Hyperdense Middle Cerebral Artery Sign Is Associated with Striatocapsular Infarcts on Follow-Up CT in Ischemic Stroke Patients Treated with Intravenous Thrombolysis

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          Abstract

          Background: A striatocapsular infarct (SCI) is a subcortical infarct in the territory of the lenticulostriate arteries, most likely due to transient occlusion of the main stem of the middle cerebral artery (MCA). Presence of the hyperdense middle cerebral artery sign (HMCAS) is a reliable marker of occlusion of the MCA. We hypothesized that SCIs are related to HMCAS at baseline, which subsequently disappears (HMCAS-D) on follow-up CT in stroke patients treated with intravenous rtPA. Methods: Baseline and 24-hour follow-up CTs were evaluated for HMCAS in acute ischemic stroke patients treated with intravenous rtPA and follow-up scans were also reviewed for the presence of isolated cortical (CIn), SCI, cortical and striatocapsular (CI-SCI) or lacunar infarct. We determined the incidence of SCI and the association between SCI and HMCAS on baseline and follow-up CT. Results: Of the 247 patients, 43 had an SCI (17.4%; 95% CI: 13.1–22.5). The presence of HMCAS at baseline was related to the occurrence of infarction with involvement of the striatocapsular region (SCI or CI-SCI) on follow-up CT (OR: 11.6; 95% CI: 5.9–22.8). HMCAS-D on follow-up scans was significantly related to SCI on follow-up CT compared to CI-SCI (OR: 4.9; 95% CI: 3.7–6.1). Conclusions: Occurrence of SCI and CI-SCI is associated with the presence of HMCAS on CT before thrombolysis, whereas HMCAS-D on follow-up CT is strongly related to the occurrence of SCI. Our findings support the causative role of transient occlusion of the MCA main stem in the pathogenesis of SCI.

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          Early signs of brain infarction at CT: observer reliability and outcome after thrombolytic treatment--systematic review.

          Joanna M. Wardlaw, Orell Mielke (2005)
          To review systematically all reported early computed tomographic (CT) signs in acute ischemic stroke to determine interobserver agreement and the relationship between early CT signs and patient outcome with or without thrombolysis. A systematic review of the literature was conducted by using Cochrane Stroke Group methodology to identify studies published between 1990 and 2003 that were performed to assess interobserver agreement about early signs of infarction on CT scans obtained within 6 hours after onset of stroke symptoms and determine the relation of early signs of infarction to clinical outcome, including any interactive effect of thrombolysis. Interobserver agreement was measured with the kappa statistic, sensitivity, and specificity. The relation of early signs to clinical outcome with or without thrombolysis was assessed with calculated odds ratios and 95% confidence intervals. In 15 studies of interobserver agreement (median of 30 CT scans and six raters), the prevalence of all early infarction signs was 61% +/- 21 (standard deviation). Interobserver agreement (kappa statistics) ranged from 0.14 to 0.78 for any early infarction sign. The mean sensitivity and specificity for detection of early infarction signs with CT were 66% (range, 20%-87%) and 87% (range, 56%-100%), respectively. Experience improved detection, but knowledge of symptoms did not. In 15 studies of early infarction signs and outcome (including seven thrombolysis trials) in 3468 patients, any early infarction sign increased the risk of poor outcome (odds ratio, 3.11; 95% confidence interval: 2.77, 3.49). Two studies that sought interaction between early infarction signs and thrombolysis found no evidence that thrombolysis given in the presence of early infarction signs resulted in worse outcome than that due to early signs alone. Further work is required to determine which signs are most reliably detected, whether scoring systems help to improve detection, and whether any early infarction sign should influence decisions concerning thrombolysis. (c) RSNA, 2005.
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            The natural history of lacunar infarction: the Oxfordshire Community Stroke Project

            L. Jones, J. Bamford, P Sandercock … (1987)
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              Prevalence and significance of hyperdense middle cerebral artery in acute stroke.

              D Leys, J Pruvo, O Godefroy … (1992)
              Early noncontrast computed tomographic scans may visualize a hyperdense middle cerebral artery before the infarct becomes visible. This sign disappears within a few days, corresponds to the clot itself, and might be associated with a poor prognosis. The aim of the study was to determine its prevalence, diagnostic value, relationship to demographic data, ability to separate embolic from nonembolic causes, short-term prognostic value, evolution over time, and relationship to arterial occlusion on angiography. We performed this study using computed tomographic scans performed within 12 hours after onset in 272 consecutive unselected patients with a first acute cerebrovascular event. Seventy-three subjects had the hyperdense middle cerebral artery sign, leading to a prevalence of 26.8% in the whole group and 41.2% in patients with a middle cerebral artery infarct. Specificity was 100%, but sensitivity was only 30%. This sign was not dependent on cerebrovascular risk factors, but was more likely to occur in cortical and in large, deep, middle cerebral artery infarcts (p less than 0.01). It provided only a 3.5% gain in predicting death, and one fifth of patients with the sign recovered within 2 weeks; this sign was not an independent variable of poor outcome on multiple linear regression. It spontaneously disappeared within a few days and was always related to an occlusion of the middle cerebral artery in patients who underwent early angiography. The hyperdense middle cerebral artery sign is useful in the diagnosis of middle cerebral artery occlusion but does not always predict a poor prognosis.
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                Author and article information

                Journal
                Journal ID (publisher-id): CED
                Journal ID (nlm-ta): Cerebrovasc Dis
                Journal ID (doi): 10.1159/issn.1015-9770
                Title: Cerebrovascular Diseases
                Publisher: S. Karger AG
                ISSN (Print): 1015-9770
                ISSN (Electronic): 1421-9786
                Publication date Subscription-year: 2010
                Publication date (Print): August 2010
                Publication date (Electronic): 23 July 2010
                Volume: 30
                Issue: 3
                Pages: 285-289
                Affiliations
                aDepartment of Neurology and bCardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
                Article
                Publisher ID: 319071 Other ID: Cerebrovasc Dis 2010;30:285–289
                DOI: 10.1159/000319071
                PubMed ID: 20664262
                SO-VID: 3a4aa533-6f1a-4af2-98f7-0f009e2f2fb3
                Copyright © © 2010 S. Karger AG, Basel
                License:

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                Date received : 14 September 2009
                Date accepted : 23 April 2010
                Page count
                Tables: 1, References: 18, Pages: 5
                Categories
                Subject: Original Paper

                ScienceOpen disciplines: Geriatric medicine,Neurology,Cardiovascular Medicine,Neurosciences,Clinical Psychology & Psychiatry,Public health
                Keywords: Lenticulostriate arteries,Middle cerebral artery infarction,Tissue plasminogen activator,Striatocapsular infarction,Hyperdense middle cerebral artery sign
                Data availability:
                ScienceOpen disciplines: Geriatric medicine, Neurology, Cardiovascular Medicine, Neurosciences, Clinical Psychology & Psychiatry, Public health
                Keywords: Lenticulostriate arteries, Middle cerebral artery infarction, Tissue plasminogen activator, Striatocapsular infarction, Hyperdense middle cerebral artery sign

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