Dense Middle Cerebral Artery Sign Research Articles

Headache, TIA and subarachnoid haemorrhage: dissecting an unusual cause for stroke-like symptoms

We present a case of supraclinoid internal carotid artery dissection. Eleven months prior, the patient developed isolated periorbital pain and was diagnosed with giant-cell arteritis with iritis. The patient experienced...

External Validation of the ASTRAL and DRAGON Scores for Prediction of Functional Outcome in Stroke.

ASTRAL (Acute Stroke Registry and Analysis of Lausanne) and DRAGON (includes dense middle cerebral artery sign, prestroke modified Rankin Scale score, age, glucose, onset to treatment, National Institutes of Health Stroke Scale score) are 2 recently developed scores for predicting functional outcome after acute stroke in unselected acute ischemic stroke patients and in patients treated with intravenous thrombolysis, respectively. We aimed to perform external validation of these scores to assess their predictive performance in the large multicentre Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register. We calculated the ASTRAL and DRAGON scores in 36 131 and 33 716 patients, respectively, registered in Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register between 2003 and 2013. The proportion of patients with 3-month modified Rankin Scale scores of 3 to 6 was observed for each score point and compared with the predicted proportion according to the risk scores. Calibration was assessed using calibration plots, and predictive performance was assessed using area under the curve of the receiver operating characteristic. Multivariate logistic regression coefficients for the variables in the 2 scores were compared with the original derivation cohorts. The ASTRAL showed an area under the curve of 0.790 (95% confidence interval, 0.786-0.795) and the DRAGON an area under the curve of 0.774 (95% confidence interval, 0.769-0.779). All ASTRAL parameters except range of visual fields and all DRAGON parameters were significantly associated with functional outcome in multivariate analysis. The ASTRAL and DRAGON scores show an acceptable predictive performance. ASTRAL does not require imaging-data and therefore may have an advantage for the use in prehospital patient assessment. Prospective studies of both scores evaluating the impact of their use on patient outcomes after intravenous thrombolysis and endovascular therapy are needed.

Hidden Dense Middle Cerebral Artery Sign in a 4-Year-Old Boy With Traumatic Subarachnoid Hemorrhage

A 4-year-old boy was admitted with acute onset of hemiplegia of the right side that was secondary to a traffic accident. Initial computed tomography revealed a traumatic subarachnoid hemorrhage, and follow-up computed tomography showed a more localized hematoma of the left sylvian cistern. After a few days of conservative treatment, magnetic resonance imaging (MRI) revealed a cerebral infarction of the left lenticulostriate territory, even though magnetic resonance angiography showed preserved middle cerebral artery flow. Thus, we realized that the hematoma of the sylvian cistern was the so-called dense middle cerebral artery sign. This case of posttraumatic infarction suggested the importance of meticulous investigations and clinical correlations of imaging studies in pediatric patients with head injuries.

Defining Intravenous Recombinant Tissue Plasminogen Activator Failure

Although the 2 National Institute of Neurological Disorders and Stroke (NINDS) trials1 and subsequent studies from Europe (ECASS-3, IST-3)2,3 established intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rtPA) within 4.5 hours of symptom onset as an effective treatment for acute ischemic stroke, the ability of IV rtPA to predictably result in an excellent outcome is still limited; in most cases, IV rtPA treatment is not enough to produce complete recanalization.4,5 Intraarterial (endovascular) treatment (IAT) is superior to IV rtPA in opening arteries, particularly when coupled with mechanical thrombectomy, with recanalization rates up to 87%.6,7 There is increasing evidence that IAT has a therapeutic role in large artery occlusions.8,9 In addition, faster time to angiographic reperfusion is a predictor of good clinical outcome with IAT.10 Thus, there is a need for a quick and accurate strategy to identify IV rtPA nonresponders with large artery occlusion to select those patients who would benefit from IAT. Mechanical Embolus Removal in Cerebral Ischemia (MERCI), Multi MERCI, and Solitaire With the Intention For Thrombectomy (SWIFT) are just a few of the studies that have used the concept of IV rtPA failure as inclusion criteria to enroll subjects in their studies. But what exactly is the definition of IV tPA nonresponder or failure? To date, there is no clear and consistent designation for this subgroup in the stroke literature. How do the characteristics of the clot influence response to IV rtPA? Is there a time window that should define IV rtPA failure? Should imaging modalities to assess vessel recanalization be used to define IV rtPA failure? Should early clinical change be criteria to differentiate IV rtPA responders from nonresponders? Accurate and rapid identification …

The Relationship Between Baseline Blood Pressure and Computed Tomography Findings in Acute Stroke

High blood pressure (BP) is present in approximately 80% of patients with acute ischemic stroke and is independently associated with poor outcome. There are few data examining the relationship between admission BP and acute CT findings. TAIST was a randomized controlled trial assessing 10 days of treatment with tinzaparin versus aspirin in 1489 patients with acute ischemic stroke (<48 hr) with admission BP of </=220/120 mmHg. CT brain scans were performed before randomization and after 10 days. The relationships between baseline BP and adjudicated CT findings were assessed. Odds ratios per 10 mmHg change in BP were calculated. Higher systolic BP (SBP) was associated with abnormal CT scans because of independent associations with chronic changes of leukoariosis (OR, 1.12; 95% CI, 1.05-1.17) and old infarction (OR, 1.12; 95% CI, 1.06-1.17) at baseline, and signs of visible infarction at day 10 (OR, 1.06; 95% CI, 1.00-1.13). A lower SBP was associated with signs of acute infarction (OR, 0.94; 95% CI, 0.89-0.99). Hemorrhagic transformation, dense middle cerebral artery sign, mass effect, and cerebral edema at day 10 were not independently associated with baseline BP. Although high baseline BP is independently associated with a poor outcome after stroke, this was not shown to be through an association with increased hemorrhagic transformation, cerebral edema, or mass effect; trial design may be suboptimal to detect this. Higher SBP is associated with visible infarction on day 10 scans. The influence of changing BP in acute stroke on CT findings is still to be ascertained.

CLINICAL DETERIORATION FOLLOWING IMPROVEMENT IN THE NINDS rt-PA STROKE TRIAL

P234 Background and Objective: Little is known about cerebral arterial reocclusion after successful thrombolysis. In the absence of arteriographic information, the NINDS rt-PA Stroke Trial investigators prospectively identified clinical deterioration following improvement (DFI) as a possible surrogate marker of cerebral arterial reocclusion following rt-PA-induced recanalization. Also, we identified any significant clinical deterioration (CD) even if not preceded by improvement. We aimed to determine the incidence of DFI and CD in each treatment group, identify baseline or post-treatment variables predictive of DFI or CD, and determine any relationship between DFI, CD and clinical outcome. Methods: DFI was defined as any 2 point deterioration on the NIHSS following an initial 2 point improvement after treatment. CD was defined as any 4 point worsening after treatment compared to baseline. All data were collected prospectively by investigators blinded to treatment allocation. A non-contrast brain CT was mandated whenever a 2 point deterioration occurred. All cases were validated by a central review committee. Results: DFI was identified in 81 of the 624 patients (13%); 44 treated with rt-PA and 37 with placebo (p=0.48). DFI occurred more often in patients with higher baseline NIHSS. CD within the first 24 hours occurred in 98 patients (16% of all patients); 43 given rt-PA and 55 placebo (p=0.19). Baseline variables associated with CD were less frequent use of pre-stroke aspirin and higher incidence of early CT changes of edema or mass effect, or dense middle cerebral artery sign. Patients with CD had higher rates of increased serum glucose and fibrin degradation products (FDP), and they also had higher rates of symptomatic intracranial hemorrhage and death. Patients who experienced either DFI or CD were less likely to have a 3 month favorable outcome. Conclusions: We found no association between DFI, CD and rt-PA treatment, and no clinical evidence to suggest reocclusion. Deterioration was strongly associated with stroke severity and poor outcome, and was less frequent in patients whose stroke occurred while they were on aspirin.

Increased density in the middle cerebral artery by nonenhanced computed tomography. Prognostic value in acute cerebral infarction.

In order to consider the prognostic value of hyperdensity of the middle cerebral artery (MCA), we studied retrospectively the medical records of 80 consecutive patients with the diagnosis of ischemic stroke who underwent a non-enhanced computed tomography no longer than 24 h after the onset of the symptoms. To determine the mortality and disability, a follow-up of 30 days was obtained. Mortality does not differ significantly in acute ischemic stroke patients with and without increased density of MCA. When disability, calculated with the Rankin scale, is considered, the two groups are different since patients with hyperdensity of the middle cerebral artery (MCA) have a significantly worse outcome. The two groups do not differ for age, sex, the presence of atrial fibrillation, hypertension, diabetes, myocardial infarction and/or angina, and these factors do not influence the prognosis being equally present in the dead and in the survivors. In the multivariate discriminant analysis with stepwise variable selection, the dense MCA sign was significantly correlated either to mortality or to disability, along with atrial fibrillation, age and diabetes. We conclude that the dense MCA sign can be a useful prognostic factor in the early phase of ischemic stroke.

Prognostic value of the dense middle cerebral artery sign in patients with acute ischemic stroke

The presence of a dense appearance of the horizontal part of the middle cerebral artery (the "dense middle cerebral artery sign") was looked for on CT scans taken on admission in 90 consecutive patients with ischemic stroke in the carotid artery distribution. The outcome of the 14 patients with the sign was poorer than that of 76 patients without the sign (Odds ratio 4.3). We suggest that this sign could be a useful prognostic variable in the acute phase of an ischemic stroke.

Dense middle cerebral artery sign: an indicator of poor outcome in middle cerebral artery area infarction.

Thirteen patients with a dense appearance of the horizontal part of the middle cerebral artery (MCA) "dense middle cerebral artery sign" in CT scans taken within 24 hours after onset of ischaemic stroke had considerably poorer prognosis than controls with stroke, but without the sign. A hyperdense appearance of the MCA is known to be associated with thromboembolism, but dense middle cerebral artery sign is also an early warning of a large infarction, brain oedema and poor prognosis in infarction in the MCA area.