Hyperdense Middle Cerebral Artery Sign
Hyperdense Middle Cerebral Artery Sign
A previously healthy 32-year-old woman had a fall from her bicycle with a questionable loss of consciousness. The mechanism of fall was unclear at the time of presentation. The only injuries noted by the patient were abrasions to her face, elbow, and knee on the left side. The patient went home initially and later complained of a headache. Approximately 2 h later, she was noted by her spouse to have "confusing speech" and was taken to the nearest Emergency Department (ED). In the ED, she was noted to be initially alert and oriented with no recall of the fall, followed by a rapid decline in mental status. She became unresponsive to commands, with generalized seizure-like activity noted by ED staff. There was no known alcohol or drug ingestion before the event. The patient did not have any history of migraines, cerebrovascular accident (CVA), seizure disorder, or connective tissue disorder. There was no family history of CVA or blood disorders. No significant abnormality was reported in her vital signs. Her Glasgow Coma Scale score in the community hospital was reported to be < 8, and physical examination was significant for unequal pupils, with the right pupil larger than the left. The patient underwent rapid sequence intubation and was intubated via orotracheal route without any difficulty. She received mannitol for presumed brain herniation and vecuronium post-intubation for continued paralysis prior to being transferred to the trauma center.
Vital signs on arrival at the trauma center were: temperature of 37.8°C (100°F), blood pressure 135/73 mm Hg, heart rate 79 beats/min, and oxygen saturation of 94 with bag mask ventilation; Glasgow Coma Scale was score 3T. In the trauma center, the patient underwent a non-contrast head computed tomography (CT) scan and CT scan of the cervical spine. There was no evidence of any fracture or bleeding. The radiologist reported that CT images of the brain showed a prominent middle cerebral artery of unknown significance and no evidence of acute cervical spine injury (Figure 1).
(Enlarge Image)
Figure 1.
Non-contrast image of head CT scan showing hyperdense middle cerebral artery sign (arrows).
The patient was admitted to the Surgical Intensive Care Unit. There were no electrolyte abnormalities, and a toxicological screen was negative. About 2 h after arrival at the trauma center, the Neurosurgery team noted that the patient had decreased movement of the right side. A repeat head CT scan performed about 12 h after presentation showed a dense area of infarct in the left middle cerebral artery territory (Figure 2).
(Enlarge Image)
Figure 2.
Large infarct in the middle cerebral artery territory (arrows).
The patient also had a magnetic resonance imaging study/magnetic resonance angiogram of the head and neck, which showed a large ischemic infarct in the left middle cerebral artery (MCA) territory and multiple acute infarcts in the right frontal, temporal, occipital and left frontal, parietal, and left thalamus, likely embolic in nature. There was extracranial narrowing of the left internal carotid artery from bifurcation to the base of the skull, with likely hematoma around the lumen.
A diagnosis of extracranial vascular dissection with extension of luminal thrombus was made from the imaging studies obtained.
Anticoagulation was deferred in the acute setting due to extensive infarct and risk of bleeding into the infarction. After a prolonged hospital stay, the patient was started on Coumadin (Bristol-Myers Squibb Co., Princeton, NJ) for prevention of further embolic strokes. She was transferred to a rehabilitation facility with dense right-sided hemiplegia and aphasia.
A previously healthy 32-year-old woman had a fall from her bicycle with a questionable loss of consciousness. The mechanism of fall was unclear at the time of presentation. The only injuries noted by the patient were abrasions to her face, elbow, and knee on the left side. The patient went home initially and later complained of a headache. Approximately 2 h later, she was noted by her spouse to have "confusing speech" and was taken to the nearest Emergency Department (ED). In the ED, she was noted to be initially alert and oriented with no recall of the fall, followed by a rapid decline in mental status. She became unresponsive to commands, with generalized seizure-like activity noted by ED staff. There was no known alcohol or drug ingestion before the event. The patient did not have any history of migraines, cerebrovascular accident (CVA), seizure disorder, or connective tissue disorder. There was no family history of CVA or blood disorders. No significant abnormality was reported in her vital signs. Her Glasgow Coma Scale score in the community hospital was reported to be < 8, and physical examination was significant for unequal pupils, with the right pupil larger than the left. The patient underwent rapid sequence intubation and was intubated via orotracheal route without any difficulty. She received mannitol for presumed brain herniation and vecuronium post-intubation for continued paralysis prior to being transferred to the trauma center.
Vital signs on arrival at the trauma center were: temperature of 37.8°C (100°F), blood pressure 135/73 mm Hg, heart rate 79 beats/min, and oxygen saturation of 94 with bag mask ventilation; Glasgow Coma Scale was score 3T. In the trauma center, the patient underwent a non-contrast head computed tomography (CT) scan and CT scan of the cervical spine. There was no evidence of any fracture or bleeding. The radiologist reported that CT images of the brain showed a prominent middle cerebral artery of unknown significance and no evidence of acute cervical spine injury (Figure 1).
(Enlarge Image)
Figure 1.
Non-contrast image of head CT scan showing hyperdense middle cerebral artery sign (arrows).
The patient was admitted to the Surgical Intensive Care Unit. There were no electrolyte abnormalities, and a toxicological screen was negative. About 2 h after arrival at the trauma center, the Neurosurgery team noted that the patient had decreased movement of the right side. A repeat head CT scan performed about 12 h after presentation showed a dense area of infarct in the left middle cerebral artery territory (Figure 2).
(Enlarge Image)
Figure 2.
Large infarct in the middle cerebral artery territory (arrows).
The patient also had a magnetic resonance imaging study/magnetic resonance angiogram of the head and neck, which showed a large ischemic infarct in the left middle cerebral artery (MCA) territory and multiple acute infarcts in the right frontal, temporal, occipital and left frontal, parietal, and left thalamus, likely embolic in nature. There was extracranial narrowing of the left internal carotid artery from bifurcation to the base of the skull, with likely hematoma around the lumen.
A diagnosis of extracranial vascular dissection with extension of luminal thrombus was made from the imaging studies obtained.
Anticoagulation was deferred in the acute setting due to extensive infarct and risk of bleeding into the infarction. After a prolonged hospital stay, the patient was started on Coumadin (Bristol-Myers Squibb Co., Princeton, NJ) for prevention of further embolic strokes. She was transferred to a rehabilitation facility with dense right-sided hemiplegia and aphasia.