title: Acute stroke with hyperdense middle cerebral artery sign benefits from IV rtPA.
abstract: OBJECTIVE
  The current management of acute ischemic stroke is intravenous (IV) recombinant tissue plasminogen activator (rtPA). The presence of a hyperdense middle cerebral artery sign (HMCAS) on pre-treatment head computed tomogram (CT) is considered a poor prognostic sign. We compared the clinical outcome in IV rtPA-treated patients with and without a HMCAS.
  
  
  METHODS
  Retrospective analysis of prospectively collected cases treated with IV rtPA within three hours. Inclusion criteria were the presence of: i) an anterior circulation stroke; ii) a pre-treatment CT available; iii) a pre-treatment National Institutes of Health (NIH) stroke scale (NIHSS) score; and iv) a modified Rankin Score (mRS) at three months.
  
  
  RESULTS
  One hundred and thirty patients were eligible for the analysis, 64 (49%) had a HMCAS. The HMCAS group had a trend toward a higher mean (+/-SD) pre-treatment NIHSS score compared to the non-HMCAS group (13.9+/-6 vs. 12.2+/-6; p=0.12). Accordingly, there were more patients with severe strokes (NIHSS>10) in the HMCAS group compared to the non-HMCAS one (48/64=75% vs. 35/66=53%; p=0.009). The mean (+/-SD) NIHSS score 24 hours after treatment was 10.6 (+/-8) in the HMCAS group and 8.3 (+/-7) in the non-HMCAS group (p=0.08). In a multiple logistic regression analysis, the only independent predictor of poor outcome (mRS 3-6) was pre-treatment NIHSS score (p<0.001).
  
  
  CONCLUSIONS
  Patients with a HMCAS receiving IV rtPA did not fare worse at three months despite a greater proportion of patients with more severe strokes. Based on the current knowledge, IV rtPA remains a good treatment for patients with a HMCAS within three hours of symptom onset.
authors.affiliation: Department of Clinical Neurological Sciences, London Health Sciences Center, University of Western Ontario, London, ON, Canada.
authors.forename: M C
authors.initials: MC
authors.lastname: Tartaglia
authors.forename: S
authors.initials: S
authors.lastname: Di Legge
authors.forename: G
authors.initials: G
authors.lastname: Saposnik
authors.forename: V
authors.initials: V
authors.lastname: Jain
authors.forename: R
authors.initials: R
authors.lastname: Chan
authors.forename: M
authors.initials: M
authors.lastname: Bussière
authors.forename: V
authors.initials: V
authors.lastname: Hachinski
authors.forename: C
authors.initials: C
authors.lastname: Frank
authors.forename: K
authors.initials: K
authors.lastname: Hesser
authors.forename: D
authors.initials: D
authors.lastname: Pelz
mesh_terms: D000208:Acute Disease / Q000628:therapy; D000368:Aged; D000369:Aged, 80 and over; D004185:Disability Evaluation; D004632:Emergency Medical Services / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000188:drug therapy* / Q000473:pathology / Q000503:physiopathology; D007275:Injections, Intravenous / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000187:drug effects* / Q000473:pathology / Q000503:physiopathology; D011993:Recombinant Fusion Proteins / Q000008:administration & dosage; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy* / Q000473:pathology / Q000503:physiopathology; D013995:Time; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D011993:Recombinant Fusion Proteins; D010959:Tissue Plasminogen Activator