Hyperdense MCA sign in Acute Ischemic Stroke


Noncontrast CT Brain showing dense MCA sign in left sylvian pressure
CT Brain (done 3.5 hours after symptom onset showing early signs of left MCA territory infarction
CT Brain (done 13 hours after the first scan) shows an established in the left MCA territory

55-year old gentleman, known diabetic and hypertensive presented with symptoms of right hemiplegia and aphasia of three hours duration. He was evaluated for possible thrombolytic treatment.

CT brain done (3.5 hours after stroke symptom onset) showed a dense (also referred to as hyperdense) MCA sign (yellow arrow in the 1st image). Thrombosis of middle cerebral artery (MCA) in sylvian fissure is responsible for hyperdense MCA sign.

Whenever we notice dense MCA sign, it usually suggests a malignant MCA territory infarction in the involved cerebral hemisphere. This sign usually develops within 90 minutes of symptom onset.

Subtle or early signs of MCA territory infarct: Infarct in brain CT is usually seen as hypodensity in the affected area, however, this finding may be missing in the hyperacute or early phase. In this phase, the following signs should be looked for on the CT brain:

1. Loss of gray-white matter differentiation, 2. Effacement of cerebral sulci, 3. Attenuation of lentiform nucleus. These findings can be seen in second CT image.

Dense MCA sign indicates a large hemispheric infarct, and is usually associated with poorer outcomes. In our patient, we thrombolysed with intravenous tissue plasminogen activator. Patient showed clinical improvement after thrombolytic therapy.

Published by Dr Sudhir Kumar MD (Medicine) DM (Neurology)

I am a doctor with 25 years experience. I have worked as a neurologist for about 20 years. Educating public and healthcare professionals is very dear to me. This is possible due to my interactions with thousands of patients and their caregivers. I salute the patients who suffer and it is our duty to minimise suffering by preventing diseases and ensuring prompt diagnosis and treatment of those already affected.

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