title: Hyperdense middle cerebral artery sign: can it be used to select intra-arterial versus intravenous thrombolysis in acute ischemic stroke?
abstract: 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, baseline (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.
authors.affiliation: NJ Neuroscience Institute, JFK Medical Center, Seton Hall University School of Graduate Medical Education, Edison, USA.
authors.forename: Pinky
authors.initials: P
authors.lastname: Agarwal
authors.forename: Sanjeev
authors.initials: S
authors.lastname: Kumar
authors.forename: Subramanian
authors.initials: S
authors.lastname: Hariharan
authors.forename: Noam
authors.initials: N
authors.lastname: Eshkar
authors.forename: Piero
authors.initials: P
authors.lastname: Verro
authors.forename: Barry
authors.initials: B
authors.lastname: Cohen
authors.forename: Souvik
authors.initials: S
authors.lastname: Sen
mesh_terms: D000208:Acute Disease; D000368:Aged; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000473:pathology; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000473:pathology*; D007269:Injections, Intra-Arterial; D007275:Injections, Intravenous; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000473:pathology; D011237:Predictive Value of Tests; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D014057:Tomography, X-Ray Computed
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator