Hyperdense middle cerebral artery sign: Can it be used to select intra-arterial versus intravenous thrombolysis in acute ischemic stroke?

Pinky Agarwal, Sanjeev Kumar, Subramanian Hariharan, Noam Eshkar, Piero Verro, Barry Cohen, Souvik Sen

Research output: Contribution to journalArticle

60 Scopus citations


Background: Stroke patients with a hyperdense middle cerebral artery sign (HMCAS) may respond less favorably to intravenous (IV) thrombolysis. Objective: To compare outcomes of patients with and without early CT findings treated with IV versus intra-arterial (IA) recombinant tissue plasminogen activator (rtPA). Methods: Initial and 24-hour CT scans of the head were evaluated in 83 consecutive stroke patients (66 on IV rtPA, 17 on IA rtPA). Time permitting, a CT angiogram was performed immediately after the initial CT scan to ascertain major cerebral artery occlusion. Demographics and etiological stroke subtype, times to thrombolysis and CT scan, base-line (prethrombolysis) and 24-hour National Institutes of Health stroke scale (NIHSS) score, discharge NIHSS score and 90-day modified Rankin scale (mRS) were recorded. The initial CT of these patients was examined for early signs of stroke. The 24-hour scan was reviewed for the presence of infarct, hemorrhage and persistence of HCMAS. Results: A favorable outcome, indicated by a significant improvement in the discharge NIHSS score, was noted with IA rtPA, irrespective of the presence (p = 0.001) or absence (p = 0.01) of HCMAS. A less favorable outcome in discharge NIHSS score was noted with IV rtPA in patients with HCMAS (p = not significant) than those without the sign (p < 0.001). A similar proportion of patients with HCMAS exhibited a neurological improvement at 24 h as those without the sign in the IA rtPA group (p = 0.9). However, a smaller proportion of patients with HCMAS exhibited a neurological improvement at 24 h than those without the sign in the IV rtPA group (p = 0.005). The results were similar using 90-day mRS ≤1 as an indicator of significant persistent improvement (p = 1.0 for IA rtPA and 0.04 for IV rtPA group). Conclusions: In a small sample, patients with HMCAS appeared to respond better to IA than IV rtPA.

Original languageEnglish (US)
Pages (from-to)182-190
Number of pages9
JournalCerebrovascular Diseases
Issue number2-3
StatePublished - 2004
Externally publishedYes



  • Acute ischemic stroke
  • Hyperdense middle cerebral artery sign
  • Intra-arterial thrombolysis
  • Intravenous thrombolysis
  • M2 'dot' sign
  • Recanalization

ASJC Scopus subject areas

  • Clinical Neurology

Cite this