Hyperdense middle cerebral artery sign in multidetector computed tomography: Definition, occurrence, and reliability analysis

Background: The hyperdense middle cerebral artery sign (HMCAS) is one of the early changes seen on the computed tomography in acute ischemic stroke of MCA territory.
Aims: To evaluate the reliability of subjective evaluation of HMCAS on CT performed at multidetector CT (MDCT) and evaluated in the Picture Archiving Communication Systems, to define objective criteria for HMCAS and to find out if there are any predictors for the occurrence of HMCAS.
Materials and Methods: CTs of 121 consecutive patients (mean age of 70 years) treated with thrombolytic therapy were retrospectively evaluated by two neuroradiologists both subjectively and objectively with respect to HMCAS.
Results: HMCAS was subjectively found in 32% of study population. The interobserver and intraobserver agreement were substantial (K value of 0.69 and 0.80, respectively) and increased to almost perfect (Kvalue of 0.86) when the reader provided with clinical information. The HMCAS was found twice as often in male patients. Patients with HMCAS were three years younger than those whose baseline CT did not show HMCAS. A 100% sensitivity achieved when objective criteria were defined as combination of MCA_attenuation ≥ 46HU and MCA_ratio > 1.2 (using oval ROIs) and MCA_attenuation ≥ 50 HU and MCA_ratio of > 1.4 (using pixel sized ROIs).
Conclusion: Performing CT examinations on MDCT and assessment of the images in PACS might have contributed to improvement of the reliability of evaluating HMCAS on CT by enabling an objective evaluation of this sign with measurements of attenuation value in the course of MCA using oval or pixel sized ROIs as well as estimation of MCA_ratio .