Morning Report

Morning Report: Hyperdense MCA Stroke

Presenter: Sri Patel, DO

Topic: Hyperdense MCA Stroke


60 yo M presents as a stroke in the field PMHx afib, recent valve repair on Coumadin. Patient had L face droop, L arm, L leg weakness 50min PTA with a fall from chair.

VS 140  110/90  99%  16  98.6

Patient improving upon arrival, no focal deficits. STAT CTH performed, patient decompensated with worsening deficits on the L. CTH showed dense thrombus in the R MCA, patient taken to cath lab for endovascular retrieval.

Patient improved post-op to 5/5 strength bilaterally.

Learning Points:

  • hyperdense MCA sign reported in 17%-50% of patients with an MCA distribution ischemic stroke; approx. 100% sensitive, 30% specific
  • 70-84% of patients with hyperdense MCA sign treated with IV tPA have poor outcome; IA tPA showed better outcome in a 2008 prospective study (53% improved vs 23% (IV)
  • know the absolute contraindications to tPA

EBM Article:

Mattle HP, Arnold M, Georgiadis D, et al. Comparison of intraarterial and intravenous thrombolysis for ischemic stroke with hyperdense middle cerebral artery sign. Stroke. 2008;39(2):379–383.

Berkhemer et al. “A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke.” The New England Journal of Medicine. (2015). 372:1. 11-20.


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