• Registration
  • Login
JETem
  • Home
  • About
    • Aim and Scope
    • Our Team
    • Editorial Board
    • FAQ
  • Issues
    • Current Issue
    • Ahead of Print
    • Past Issues
  • Visual EM
    • Latest Visual EM
    • Search Visual EM
    • Thumbnail Library
  • For Authors
    • Instructions for Authors
    • Submit to JETem
    • Photo Consent
    • Policies
      • Peer Review Policy
      • Copyright Policy
      • Editorial Policy, Ethics and Responsibilities
      • Conflicts of Interest & Informed Consent
      • Open Access Policy
  • For Reviewers
    • Instructions for JETem Reviewers
    • Interested in Being a JETem Reviewer?
  • Topic
    • Abdominal / Gastroenterology
    • Administration
    • Board Review
    • Cardiology / Vascular
    • Clinical Informatics, Telehealth and Technology
    • Dermatology
    • EMS
    • Endocrine
    • ENT
    • Faculty Development
    • Genitourinary
    • Geriatrics
    • Hematology / Oncology
    • Infectious Disease
    • Miscellaneous
    • Neurology
    • Ob / Gyn
    • Ophthalmology
    • Orthopedics
    • Pediatrics
    • Procedures
    • Psychiatry
    • Renal / Electrolytes
    • Respiratory
    • Toxicology
    • Trauma
    • Ultrasound
    • Wellness
    • Wilderness
  • Modality
    • Curricula
    • Innovations
    • Lectures
    • Oral Boards
    • Podcasts
    • Simulation
    • Small Group Learning
    • Team Based Learning
    • Visual EM
  • Contact Us

Dense MCA Sign

Richard J Chen, MD* and Grant Wei, MD*

*Rutgers Robert Wood Johnson Medical School, Department of Emergency Medicine, New Brunswick, NJ

Correspondence should be addressed to Grant Wei, MD at weigr@rwjms.rutgers.edu

DOI: https://doi.org/10.21980/J8CS66Issue 2:3
NeurologyVisual EM
No ratings yet.

History of present illness:

A 77-year-old female presented to the emergency department after being found down at home, last seen normal 7 ½ hours prior to arrival. Patient had a history of hypertension, congestive heart failure, atrial fibrillation and breast cancer status post chemotherapy/radiation and lumpectomy. Physical exam showed right gaze preference, left facial droop and tongue deviation and flaccid left hemiplegia.

Significant findings:

A non-contrast computed tomography (CT) scan showed a hyperdensity along the right middle cerebral artery (MCA) consistent with acute thrombus. The red arrow highlights the hyperdensity in the annotated image.

Discussion:

The dense MCA sign can serve as an important tool in the diagnosis of acute stroke. It typically appears before other signs of infarct are apparent on CT imaging, and identifies an intracranial large artery occlusion and corresponding infarct, in the correct clinical setting.1 Calcifications in the same area of the brain could be mistaken for an MCA sign, but this sign carries a high specificity (95%) and lower sensitivity (52%) for arterial obstruction in ischemic stroke.2 Early identification allows for a wider array of treatment options for a patient with an ischemic stroke, including intra-venous or intra-arterial thrombolysis and mechanical thrombectomy.

This patient was subsequently taken for mechanical thrombectomy. Mechanical thrombectomy was chosen for this patient because the resources were available, and recent clinical trials have shown that newer types of mechanical thrombectomy have a positive functional outcome in patients with an ischemic stroke from an intracranial large artery occlusion, as compared to intravenous tissue plasminogen activator (tPa) alone.3,4,5,6  In facilities lacking the capability for mechanical thrombectomy, treatment considerations include rapid transfer to a facility with capability, or proceeding with intravenous tPa. After intervention, this patient had residual left sided deficits and dysarthria that were improved from presentation. She had an uncomplicated hospital course and was discharged to acute rehabilitation.

Topics:

Neurology, stroke, cerebral vascular accident, CVA, non-contrast head CT, MCA occlusion.

References:

  1. Leys D, Pruvo JP, Godefroy O, Rondepierre P, Leclerc X. Prevalence and significance of hyperdense middle cerebral artery in acute stroke. Stroke. 1992;23:317-324. doi: 1161/01.STR.23.3.317
  2. Mair G, Boyd EV, Chappell FM, von Kummer R, Lindley RI, Sandercock P, et al. Sensitivity and specificity of the Hyperdense Artery Sign for arterial obstruction in acute ischemic stroke. Stroke. 2015;46(1):102-107. doi: 10.1161/STROKEAHA.114.007036
  3. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke.  N Engl J Med.2015;372(1):11–20. doi: 10.1056/NEJMoa1411587
  4. Ding. Endovascular mechanical thrombectomy for acute ischemic stroke: a new standard of care. J Stroke. 2015;17(2):123-126. doi: 10.5853/jos.2015.17.2.123
  5. Lambrinos A, Schaink AK, Dhalla I, Krings T, Casaubon LK, Sikich N, et al. Mechanical thrombectomy in acute ischemic stroke: a systematic review. Can J Neurol Sci. 2016;43(4):455-460. doi: 10.1017/cjn.2016.30
  6. Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CB, Dippel DW, et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: A meta-analysis.  JAMA.  2016;316(12):1279-88.  doi: 10.1001/jama.2016.13647
Icon

Dense MCA Sign - Case Report

1 file(s) 362 KB
Download
Icon

Dense MCA Sign - Images

1 file(s) 831 KB
Download
CTIssue 2:3

Reviews:

No ratings yet.

Please rate this





Supracondylar Fracture

04 Jul, 17

Open Pneumothorax

04 Jul, 17
JETem is an online, open access, peer-reviewed journal-repository for EM educators

Most Viewed

  • Telemedicine Consult for Shortness of Breath Due to Sympathetic Crashing Acute Pulmonary Edema
  • Anticholinergic Toxicity in the Emergency Department
  • The Suicidal Patient in the Emergency Department Team-Based Learning Activity
  • Child Maltreatment Education: Utilizing an Escape Room Activity to Engage Learners on a Sensitive Topic
  • Acute Chest Syndrome

Visit Our Collaborators

About

Education

Learners should benefit from active learning. JETem accepts submissions of team-based learning, small group learning, simulation, podcasts, lectures, innovations, curricula, question sets, and visualEM.

Scholarship

We believe educators should advance through the scholarship of their educational work. JETem gives educators the opportunity to publish scholarly academic work so that it may be widely distributed, thereby increasing the significance of their results.

Links

  • Home
  • Aim and Scope
  • Current Issue
  • For Reviewers
  • Instructions for Authors
  • Contact Us

Newsletter

Sign up to receive updates from JETem regarding newly published issues and findings.

Copyright © 2016 JETem. All rights reserved.