Abstract
The clinical implications of the CT hyperdense artery sign have yet to be established in the new era of modern mechanical thrombectomy. This study aimed to investigate prognostic implications of the CT hyperdense middle cerebral artery sign (HMCAS) on treatment outcomes after mechanical thrombectomy for acute MCA occlusions. A retrospective analysis of CT and clinical data from 212 patients with acute MCA occlusions who underwent mechanical thrombectomy was conducted. HMCAS was determined with visual assessment by consensus of two readers. Interobserver agreement was measured. HMCAS was classified into two groups: M1 and M2 HMCAS. Associations between HMCAS and vascular risk factors, stroke etiology, and treatment outcomes were analyzed. Of 212 patients, HMCAS was identified in 118 patients (55.7%). Overall, successful reperfusion was achieved in 82.5% (175/212) and a good outcome in 45.8% (97/212). There was no significant association between HMCAS and treatment outcomes after mechanical thrombectomy, regardless of HMCAS location. Cardioembolism was more frequent in patients with a positive HMCAS (67.8 vs 48.9%, P = 0.005). Large-artery atherosclerosis was more frequent in patients with a negative HMCAS (31.9 vs 12.7%, P = 0.001). Underlying severe MCA stenosis was more frequently observed in patients with a negative HMCAS (25.5 vs 3.4%, P < 0.001). Our study suggests that the prognostic implication of a HMCAS in predicting outcomes after endovascular therapy in patients with acute MCA occlusion may be low in the era of modern mechanical thrombectomy. Negative HMCAS is predictive of in situ thrombotic occlusion due to underlying severe atherosclerotic stenosis in such patients.
![](http://media.springernature.com/m312/springer-static/image/art%3A10.1007%2Fs00415-017-8655-0/MediaObjects/415_2017_8655_Fig1_HTML.gif)
Similar content being viewed by others
Abbreviations
- CT:
-
Computed tomography
- DWI:
-
Diffusion weighted imaging
- ELVO:
-
Emergent large vessel occlusion
- HMCAS:
-
Hyperdense middle cerebral artery sign
- MRI:
-
Magnetic resonance imaging
- mRS:
-
Modified Rankin scale
- TICI:
-
Treatment in cerebral infarction
References
Menon BK, Campbell BC, Levi C, Goyal M (2015) Role of imaging in current acute ischemic stroke workflow for endovascular therapy. Stroke 46:1453–1461
Gács G, Fox AJ, Barnett HJ, Vinuela F (1983) CT visualization of intracranial arterial thromboembolism. Stroke 14:756–762
Mair G, Boyd EV, Chappell FM, von Kummer R, Lindley RI, Sandercock P et al (2015) Sensitivity and specificity of the hyperdense artery sign for arterial obstruction in acute ischemic stroke. Stroke 46:102–107
Li Q, Davis S, Mitchell P, Dowling R, Yan B (2014) Proximal hyperdense middle cerebral artery sign predicts poor response to thrombolysis. PLoS One 9:e96123
Mair G, von Kummer R, Morris Z, von Heijne A, Bradey N, Cala L et al (2016) Effect of alteplase on the CT hyperdense artery sign and outcome after ischemic stroke. Neurology 86:118–125
Liebeskind DS, Sanossian N, Yong WH, Starkman S, Tsang MP, Moya AL et al (2011) CT and MRI early vessel signs reflect clot composition in acute stroke. Stroke 42:1237–1243
Leys D, Pruvo JP, Godefroy O, Rondepierre P, Leclerc X (1992) Prevalence and significance of hyperdense middle cerebral artery in acute stroke. Stroke 23:317–324
Manelfe C, Larrue V, von Kummer R, Bozzao L, Ringleb P, Bastianello S et al (1999) Association of hyperdense middle cerebral artery sign with clinical outcome in patients treated with tissue plasminogen activator. Stroke 30:769–772
Mattle HP, Arnold M, Georgiadis D, Baumann C, Nedeltchev K, Benninger D et al (2008) Comparison of intraarterial and intravenous thrombolysis for ischemic stroke with hyperdense middle cerebral artery sign. Stroke 39:379–383
Aries MJ, Uyttenboogaart M, Koopman K, Rödiger LA, Vroomen PC, De Keyser J et al (2009) Hyperdense middle cerebral artery sign and outcome after intravenous thrombolysis for acute ischemic stroke. J Neurol Sci 285:114–117
Kharitonova T, Ahmed N, Thorén M, Wardlaw JM, von Kummer R, Glahn J et al (2009) Hyperdense middle cerebral artery sign on admission CT scan–prognostic significance for ischaemic stroke patients treated with intravenous thrombolysis in the safe implementation of thrombolysis in Stroke International Stroke Thrombolysis Register. Cerebrovasc Dis 27:51–59
Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC et al (2015) 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke 46:3020–3035
Yoon W, Kim SK, Park MS, Baek BH, Lee YY (2017) Predictive factors for good outcome and mortality after stent-retriever thrombectomy in patients with acute anterior circulation stroke. J Stroke 19:97–103
Lapergue B, Blanc R, Gory B, Labreuche J, Duhamel A, Marnat G et al (2017) Effect of endovascular contact aspiration vs stent retriever on revascularization in patients with acute ischemic stroke and large vessel occlusion: the ASTER randomized clinical trial. JAMA 318:443–452
Yoon W, Jung MY, Jung SH, Park MS, Kim JT, Kang HK (2013) Subarachnoid hemorrhage in a multimodal approach heavily weighted toward mechanical thrombectomy with solitaire stent in acute stroke. Stroke 44:414–419
Kim SK, Yoon W, Moon SM, Park MS, Jeong GW, Kang HK (2015) Outcomes of manual aspiration thrombectomy for acute ischemic stroke refractory to stent-based thrombectomy. J Neurointerv Surg 7:473–477
Zaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL et al (2013) Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 44:2650–2663
Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL et al (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24:35–41
Brinjikji W, Duffy S, Burrows A, Hacke W, Liebeskind D, Majole CBLM et al (2017) Correlation of imaging and histopathology of thrombi in acute ischemic stroke with etiology and outcome: a systematic review. J Neurointerv Surg 9:529–534
Moftakhar P, English JD, Cooke DL, Kim WT, Stout C, Smith WS et al (2013) Density of thrombus on admission CT predicts revascularization efficacy in large vessel occlusion acute ischemic stroke. Stroke 44:243–245
Froehler MT, Tateshima S, Duckwiler G, Jahan R, Gonzalez N, Vinuela F et al (2013) The hyperdense vessel sign on CT predicts successful recanalization with the Merci device in acute ischemic stroke. J Neurointerv Surg 5:289–293
Mokin M, Morr S, Natarajan SK, Lin N, Snyder KV, Hopkins LN et al (2015) Thrombus density predicts successful recanalization with Solitaire stent retriever thrombectomy in acute ischemic stroke. J Neurointerv Surg 7:104–107
Spiotta AM, Vargas J, Hawk H, Turner R, Chaudry MI, Batten H et al (2014) Hounsfield unit value and clot length in the acutely occluded vessel and time required to achieve thrombectomy, complications and outcome. J Neurointerv Surg 6:423–427
Soize S, Batista AL, Rodriguez Regent C, Trystram D, Tisserand M, Turc G et al (2015) Susceptibility vessel sign on T2* magnetic resonance imaging and recanalization results of mechanical thrombectomy with stent retrievers: a multicentre cohort study. Eur J Neurol 22:967–972
Kim SK, Yoon W, Kim TS, Kim HS, Heo TW, Park MS (2015) Histologic Analysis of Retrieved clots in acute ischemic stroke: correlation with stroke etiology and gradient-echo MRI. AJNR Am J Neuroradiol 36:1756–1762
Kim SK, Yoon W, Heo TW, Park MS, Kang HK (2015) Negative susceptibility vessel sign and underlying intracranial atherosclerotic stenosis in acute middle cerebral artery occlusion. AJNR Am J Neuroradiol 36:1266–1271
Yoon W, Kim SK, Park MS, Kim BC, Kang HK (2015) Endovascular treatment and the outcomes of atherosclerotic intracranial stenosis in patients with hyperacute stroke. Neurosurgery 76:680–686
Heo JH, Kim K, Yoo J, Kim YD, Nam HS, Kim EY (2017) Computed tomography-based thrombus imaging for the prediction of recanalization after reperfusion therapy in stroke. J Stroke 19:40–49
Ernst M, Romero JM, Buhk JH, Kemmling A, Fiehler J, Groth M (2014) Sensitivity of visual and quantitative detection of middle cerebral artery occlusion on non-contrast-enhanced computed tomography. Neuroradiology 56:1063–1068
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Source of financial support
None.
Conflicts of interest
All authors declared that they have no potential conflict of interest.
Ethical standards
For this type of study formal consent is not required.
Rights and permissions
About this article
Cite this article
Kim, S.K., Baek, B.H., Lee, Y.Y. et al. Clinical implications of CT hyperdense artery sign in patients with acute middle cerebral artery occlusion in the era of modern mechanical thrombectomy. J Neurol 264, 2450–2456 (2017). https://doi.org/10.1007/s00415-017-8655-0
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00415-017-8655-0