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Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 41-42

Pseudo-hyperdense MCA sign: The value of comparing CT densities of vessels on both sides

Department of Neurosurgery, National Neurosciences Centre, Kolkata, West Bengal, India

Date of Submission04-Feb-2021
Date of Decision14-Jun-2021
Date of Acceptance18-Jul-2021
Date of Web Publication27-Aug-2021

Correspondence Address:
Dr. Prasad Krishnan
Department of Neurosurgery, National Neurosciences Centre, Kolkata, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcvs.jcvs_5_21

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Hyperdense middle cerebral artery (MCA) sign is a well-recognised sign of stroke radiology. However, less often reported is the pseudo 'hyperdense MCA sign' that looks ominous and may confound the clinician into thinking that he is dealing with a case of ischaemic stroke. We report a 56-year-old male who nearly underwent thrombolysis due to this sign seen on initial computed tomography imaging and highlight the way to avoid this pitfall.

Keywords: Hounsfield units, hyperdense middle cerebral artery sign, thromboembolic stroke

How to cite this article:
Krishnan P. Pseudo-hyperdense MCA sign: The value of comparing CT densities of vessels on both sides. J Cerebrovasc Sci 2021;9:41-2

How to cite this URL:
Krishnan P. Pseudo-hyperdense MCA sign: The value of comparing CT densities of vessels on both sides. J Cerebrovasc Sci [serial online] 2021 [cited 2021 Dec 1];9:41-2. Available from: http://www.jcvs.com/text.asp?2021/9/1/41/324818

  Introduction Top

A 56-year-old male presented with disorientation, slurred speech and generalised weakness of 2 hours duration. He was not a known diabetic but was a hypertensive on medications. A computed tomography (CT) scan of the brain revealed hyperdense middle cerebral artery (MCA) on the right side [Figure 1], and he was diagnosed as having an ischaemic stroke. He was being prepared for thrombolysis, and blood investigations were sent, and a magnetic resonance (MR) imaging scan was done. However, this showed no brightness on diffusion-weighted imaging and no restriction in apparent diffusion coefficient scans [Figure 2]. Flow voids in bilateral MCAs on T2-weighted imaging were seen. MR angiography also revealed patent MCA on both sides [Figure 3]. Thrombolysis was withheld. His blood reports revealed hyponatremia which was thought to be the cause of his symptoms. He recovered with conservative treatment in a few hours. Further investigations revealed haemoglobin of 13.5 g% and hypertriglyceridemia. The CT images were re-assessed, and the Hounsfield units (HU) density of the hyperdense artery was found to be 46 HU. Careful observation showed hyperdense dots of the contralateral peripheral MCA branches as well. A diagnosis of pseudohyperdense MCA sign was then made.
Figure 1: Computed tomography scan of the brain showing hyperdense middle cerebral artery on the right side. A hyperdense dot of the left middle cerebral artery branch is also visible on close examination on the left side

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Figure 2: Diffusion-weighted images (a and b) showing no parenchymal hyperintensity suggestive of an acute infarct. Apparent diffusion coefficient scans (c) also do not show any restriction

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Figure 3: (a) Axial T2 weighted image showing flow voids of middle cerebral artery on both sides. (b) Magnetic resonance angiography also reveals patent vessels bilaterally

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  Discussion Top

Hyperdense arteries on plain CT scan was first recognised as sign of thromboembolic stroke by Gács et al. in 1983.[1] It is due to focally high haematocrit following thrombus formation that has high attenuation values in the CT scan as compared to normal vessels with flowing blood.[2] The hyperdense MCA sign has been described as having high specificity[3] but relatively low sensitivity[4] (around 30% – as it may not always be present) and is the earliest CT scan finding in thromboembolic stroke.[2] Although considered to be a bad prognostic indicator,[5] it has been used to guide thrombolytic therapy[5],[6] in patients who present early.

However, there are a few conditions such as polycythemia vera[7] and cocaine ingestion[3] (where the blood viscosity is high), herpes simplex encephalitis[8] or contusions[3] (where surrounding parenchyma is more hypodense) and vessel wall calcification[3] where the artery may be seen in the absence of an intraluminal thrombus. These conditions will affect the contralateral vessels too and Koo et al.[8] have emphasised that in all true cases of the hyperdense MCA sign the ratio of HU densities of the involved to the non-involved MCA must be >1.2. Retrospectively, in our case, this was found to be 1.03 (46 HU and 44 HU for the right and left sided MCA, respectively).

To conclude, an awareness of the entity of pseudo 'hyperdense MCA sign' and the possible predisposing factors is essential to avoid a misdiagnosis of stroke and attendant overtreatment. In doubtful cases comparing the HU densities of both MCAs or performing MR imaging will clinch the diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Gács G, Fox AJ, Barnett HJ, Vinuela F. CT visualization of intracranial arterial thromboembolism. Stroke 1983;14:756-62.  Back to cited text no. 1
Jensen-Kondering U, Riedel C, Jansen O. Hyperdense artery sign on computed tomography in acute ischemic stroke. World J Radiol 2010;2:354-7.  Back to cited text no. 2
Jha B, Kothari M. Pearls and oysters: Hyperdense or pseudohyperdense MCA sign: A Damocles sword? Neurology 2009;72:e116-7.  Back to cited text no. 3
Leys D, Pruvo JP, Godefroy O, Rondepierre P, Leclerc X. Prevalence and significance of hyperdense middle cerebral artery in acute stroke. Stroke 1992;23:317-24.  Back to cited text no. 4
Kharitonova T, Ahmed N, Thorén M, Wardlaw JM, von Kummer R, Glahn J, et al. Hyperdense middle cerebral artery sign on admission CT scan--prognostic significance for ischaemic stroke patients treated with intravenous thrombolysis in the safe implementation of thrombolysis in stroke international stroke thrombolysis register. Cerebrovasc Dis 2009;27:51-9.  Back to cited text no. 5
Qureshi AI, Ezzeddine MA, Nasar A, Suri MF, Kirmani JF, Janjua N, et al. Is IV tissue plasminogen activator beneficial in patients with hyperdense artery sign? Neurology 2006 25;66:1171-4.  Back to cited text no. 6
Ben Salem D, Osseby GV, Rezaizadeh-Bourdariat K, Pastural G, Martin D, Brunotte F, et al. Spontaneous hyperdense intracranial vessels seen on CT scan in polycythemia cases. J Radiol 2003;84:605-8.  Back to cited text no. 7
Koo CK, Teasdale E, Muir KW. What constitutes a true hyperdense middle cerebral artery sign? Cerebrovasc Dis 2000;10:419-23.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3]


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