The Hyperdense Middle Cerebral Artery Sign in Drip-and-Ship Models of Acute Stroke Management

BACKGROUND: Large vessel occlusion (LVO) leads to debilitating stroke and responds modestly to recombinant tissue plasminogen activator (rt-TPA). Early thrombectomy improves functional outcomes in selected patients with proximal occlusion but it is not available in all medical facilities. The best imaging modality for triage in an acute stroke setting in drip-and-ship models is still the subject of debate. OBJECTIVES: We aimed to assess the diagnostic value of millimeter-sliced noncontrast computed tomography (NCCT) hyperdense middle cerebral artery sign (HMCAS) in itself or associated with clinical data for early detection of LVO in drip-and-ship models of acute stroke management. METHODS: NCCT of patients admitted to the Erasme Hospital, ULB, Brussels, Belgium, for suspicion of acute ischemic stroke between January 1 and July 31, 2017, were collected. Patients with brain hemorrhages were excluded, leading to 122 cases. The presence of HMCAS on NCCT was determined via visual assessment by 6 raters blinded to all other data. An independent rater assessed the presence of LVO on digital subtraction angiography imaging or contrast-enhanced CT angiography (CTA). The sensitivity, false-positive rate (FPR), and accuracy of HMCAS and the dot sign to detect LVO were calculated. The interobserver agreement of HMCAS was assessed using Gwet's AC1 coefficient. Then, on a separate occasion, the first 2 observers rereviewed all NCCT provided with clinical clues. The sensitivity, FPR, and accuracy of HMCAS were recalculated. RESULTS: HMCAS was found in 21% of the cases and a dot sign was found in 9%. The mean HMCAS sensitivity was 62% (95% CI 45–79%) and its accuracy was 86% (95% CI 79–92%) for detecting LVO. The interobserver reliability coefficient was 80% for HMCAS. Combined with clinical information, HMCAS sensitivity increased to 81% (95% CI 68–94; p = 0.041) and accuracy increased to 91% (95% CI 86–96%). CONCLUSION: When clinical data are provided, detection of HMCAS on thinly sliced NCCT could be enough to decide on transfer for thrombectomy in drip-and-ship models of acute stroke management, especially in situations where CTA is less available and referral centers for thrombectomy fewer and further apart.