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Hyperdense middle cerebral artery sign predicts favorable outcome in patients undergoing mechanical thrombectomy

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Abstract

Non-contrast computer tomography detects the presence of hyperdense middle cerebral artery sign (HMCAS). Studies on the prognostic value of HMCAS among patients undergoing mechanical thrombectomy (MT) are conflicting. A retrospective analysis of consecutive patients with acute ischemic stroke due to middle cerebral artery occlusion, presenting with or without HMCAS, who underwent MT, was performed. We enrolled 191 patients (HMCAS +, n = 140; HMCAS –, n = 51). Prevalence of successful recanalization was significantly higher in patients with HMCAS than in those without HMCAS (92.1% versus 74.5%, p = 0.001). Patients with HMCAS had a better clinical outcome than those HMCAS – (54.3% versus 37.3%, p = 0.037, for three-month favorable outcome; 62.9% versus 39.3%, p = 0.004, for major neurological improvement at discharge; 8.6% versus 19.6%, p = 0.035, for in-hospital mortality; 14.3% versus 27.5%, p = 0.035, for intracranial hemorrhage; 2.9% versus 17.6%, p = 0.001, for symptomatic intracranial hemorrhage). Multivariate analyses confirmed that HMCAS represents an independent predictor of three-month favorable outcome (OR 2.48, 95% CI 1.10–5.58, p = 0.028), major neurological improvement at discharge (OR 2.40, 95% CI 1.09–5.20, p = 0.030), in-hospital mortality (OR 0.29, 95% CI 0.010–0.81, p = 0.018), presence of ICH (OR 0.49, 95% CI 0.25–0.97, p = 0.042) and presence of SICH (OR 0.16, 95% CI 0.04–0.63, p = 0.009). HMCAS presence predicts favorable outcome in patients undergoing MT. This result may indicate that hyperdense clots are more likely to respond to MT than isodense ones. This effect is mediated by reduction in hemorrhagic transformation.

Highlights

Hyperdense middle cerebral artery sign on native non-contrast computer tomography predicts severe brain ischemia and poor functionally outcome in patients with acute ischemic stroke not treated with recanalization therapies and in those receiving intravenous thrombolysis.

Prevalence of successful recanalization after mechanical thrombectomy was significantly higher in patients with than in those without hyperdense middle cerebral artery sign.

Patients with hyperdense middle cerebral artery sign had a significantly better clinical outcome than those without hyperdense middle cerebral artery sign.

These very promising results might affect clinical practice of neurologists and interventional radiologists/neuroradiologists.

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Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Code availability

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    Authors and Affiliations

    1. Stroke Unit, Udine University Hospital, Piazzale S. Maria della Misericordia 15, 33100, Udine, Italy

      Giovanni Merlino, Simone Lorenzut, Francesco Janes & Francesco Bax

    2. Clinical Neurology, Udine University Hospital, Udine, Italy

      Giovanni Merlino, Yan Tereshko, Sara Pez, Gian Luigi Gigli, Francesco Janes, Francesco Bax & Mariarosaria Valente

    3. Division of Neuroradiology, Udine University Hospital, Udine, Italy

      Daniele Bagatto

    4. Dipartimento di Area Medica (DAME), University of Udine, Udine, Italy

      Gian Luigi Gigli & Mariarosaria Valente

    5. Division of Vascular and Interventional Radiology, Udine University Hospital, Udine, Italy

      Massimo Sponza, Alessandro Vit, Vladimir Gavrilovic & Nicola Marotti

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    1. Giovanni Merlino
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    Contributions

    Conceptualization, G.M. and Y.T.; methodology, G.M., and Y.T.; software, S.P., S.L., F.J., and F.B.; validation, G.L.G. and M.V.; formal analysis, G.M.; investigation, Y.T., S.P., D.B., S.L., F.J. and F.B.; resources, M.S., A.V., V.G. and N.M; data curation, G.M.; writing—original draft preparation, G.M.; writing—review and editing, G.M.; visualization, G.L.G; supervision, M.V.

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    Correspondence to Giovanni Merlino.

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    The study conformed to the Declaration of Helsinki of the World Medical Association and was approved by the local ethics committee (Ref. No. CEUR-2020-Os-173).

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    Merlino, G., Tereshko, Y., Pez, S. et al. Hyperdense middle cerebral artery sign predicts favorable outcome in patients undergoing mechanical thrombectomy. J Thromb Thrombolysis 55, 312–321 (2023). https://doi.org/10.1007/s11239-022-02731-4

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