Middle Cerebral Artery (MCA) Susceptibility Sign at Susceptibility-based Perfusion MR Imaging: Clinical Importance and Comparison with Hyperdense MCA Sign at CT 1

PURPOSE: To describe the radiologic findings of susceptibility changes in acute middle cerebral artery (MCA) thromboembolism detected with three-dimensional (3D) susceptibility-based perfusion magnetic resonance (MR) imaging and to compare the detectability and clinical value of this sign with those of the hyperdense MCA sign at computed tomography (CT).

MATERIALS AND METHODS: Twenty-three patients (mean age, 55 years) underwent CT and MR imaging within the first 6 hours after the onset of acute MCA stroke. The hyperdense MCA sign at CT and the presence of susceptibility changes in acute thromboembolism as depicted on T2*-weighted 3D perfusion MR images were assessed. The presence of each sign was correlated with clinical presentation.

RESULTS: The sensitivity of the hyperdense MCA sign at CT was 54% (negative predictive value, 71%) compared with 82% (negative predictive value, 86%) for the susceptibility changes at MR imaging. There were no false-positive CT or MR readings. The presence of the MCA susceptibility sign correlated positively with the initial clinical presentation (χ2 = 7.987, P = .009, Spearman ρ = 0.589). However, neither of the signs was a predictor for clinical outcome in cases of spontaneous MCA stroke.

CONCLUSION: In addition to the information traditionally provided with reconstructed perfusion parameter maps, 3D susceptibility-based perfusion MR images allow the identification of acute MCA thromboembolism with a sensitivity higher than that of CT.


  • 1 von Kummer R, Holle R, Rosin L, Forsting M, Hacke W. Does arterial recanalization improve outcome in carotid artery stroke?. Stroke 1995; 26:581-587. Crossref, MedlineGoogle Scholar
  • 2 Barber PA, Darby DG, Desmonds PM, et al. Prediction of stroke outcome with echo planar perfusion- and diffusion-weighted MRI. Neurology 1998; 51:418-426. Crossref, MedlineGoogle Scholar
  • 3 Rordorf G, Koroshetz WJ, Copen WA, et al. Regional ischemia and ischemic injury in patients with acute middle cerebral artery stroke as defined by early diffusion-weighted and perfusion-weighted MRI. Stroke 1998; 29:939-943. Crossref, MedlineGoogle Scholar
  • 4 Lutsep HL, Albers GW, DeCrespigny A, et al. Clinical utility of diffusion-weighted magnetic resonance imaging in the assessment of ischemic stroke. Ann Neurol 1997; 41:574-580. Crossref, MedlineGoogle Scholar
  • 5 Flacke S, Keller E, Hartmann A, et al. Improved diagnosis of early infarcts by the combined use of perfusion- and diffusion-weighted imaging. Rofo Fortschr Geb Röntgenstr Neuen Bildgeb Verfahr 1998; 168:493-501. CrossrefGoogle Scholar
  • 6 Welch KM, Windham J, Knight RA, et al. A model to predict the histopathology of human stroke using diffusion and T2-weighted magnetic resonance imaging. Stroke 1995; 26:1983-1989. Crossref, MedlineGoogle Scholar
  • 7 Heiss WD. Flow thresholds for functional and morphological damage of the brain tissue. Stroke 1983; 14:329-331. Crossref, MedlineGoogle Scholar
  • 8 Villringer A, Rosen B, Belliveau JW, et al. Dynamic imaging with lanthanide chelates in normal brain: contrast due to magnetic susceptibility effects. Magn Reson Med 1988; 6:164-174. Crossref, MedlineGoogle Scholar
  • 9 Rosen BR, Belliveau JM, Buchbinder BR, et al. Contrast agents and cerebral hemodynamics. Magn Reson Med 1991; 19:285-292. Crossref, MedlineGoogle Scholar
  • 10 Zierler KL. Theoretical basis of indicator-dilution methods for measuring blood flow and volume. Circ Res 1965; 16:393-407. Google Scholar
  • 11 Ostergaard L, Weiskoff RM, Chesler DA, Gyldensted C, Rosen BR. High resolution measurement of cerebral blood flow using intravascular tracer bolus passage. I. Mathematical approach and statistical analysis. Magn Reson Med 1996; 36:715-725. Google Scholar
  • 12 Fisel CR, Ackerman JL, Buxton RB, et al. MR contrast due to microscopically heterogeneous magnetic susceptibility: numeric simulations and applications to cerebral physiology. Magn Reson Med 1991; 17:336-347. Crossref, MedlineGoogle Scholar
  • 13 Teitelbaum GP, Ortega HV, Vinitski S, et al. Optimization of gradient-echo imaging parameters for intracaval filters and trapped thromboemboli. Radiology 1990; 174:1013-1019. LinkGoogle Scholar
  • 14 Atlas SW, Thulborn KR. MR detection of hyperacute parenchymal hemorrhage of the brain. AJNR Am J Neuroradiol 1998; 19:1471-1477. MedlineGoogle Scholar
  • 15 Yock DH. CT demonstration of cerebral emboli. J Comput Assist Tomogr 1981; 5:190-196. Crossref, MedlineGoogle Scholar
  • 16 Gacs G, Fox AJ, Barnett HJM, Vinuela F. CT visualization of intracranial arterial thromboembolism. Stroke 1983; 14:756-762. Crossref, MedlineGoogle Scholar
  • 17 Pressman BD, Tourje EJ, Thompson JR. An early sign of ischemic infarction: increased density in a cerebral artery. AJNR Am J Neuroradiol 1987; 8:645-648. Google Scholar
  • 18 Leys D, Pruvo MD, Godefroy O, Rondepierre P, Leclerc X. Prevalence and significance of hyperdense middle cerebral artery in acute stroke. Stroke 1992; 23:317-324. Crossref, MedlineGoogle Scholar
  • 19 Bozzao L, Bastianello S, Fantozzi LM, Angeloni U, Argentino C, Fieschi C. Correlation of angiographic and sequential CT findings in patients with evolving cerebral infarction. AJNR Am J Neuroradiol 1989; 8:645-648. Google Scholar
  • 20 Saito I, Segawa H, Shiokawa Y, Taniguchi M, Tsutsumi K. Middle cerebral artery occlusion: correlation of computed tomography and angiography with clinical outcome. Stroke 1987; 18:863-868. Crossref, MedlineGoogle Scholar
  • 21 van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJY, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988; 19:604-607. Crossref, MedlineGoogle Scholar
  • 22 Moonen CTW, Liu G, van Gelderen P, Sobering G. A fast gradient-recalled MRI technique with increased sensitivity to dynamic susceptibility. Magn Reson Med 1992; 30:68-72. Google Scholar
  • 23 Liu G, Sobering G, Duyn J, Moonen CTW. A functional MRI technique combining principles of echo-shifting with a train of observations (PRESTO). Magn Reson Med 1993; 30:764-768. Crossref, MedlineGoogle Scholar
  • 24 Keller E, Folkers PJM, Flacke S, et al. Evaluation of whole brain 3D perfusion in the diagnosis of cerebrovascular disorders (abstr) In: Proceedings of the Sixth Meeting of the International Society for Magnetic Resonance in Medicine. Berkeley, Calif: International Society for Magnetic Resonance in Medicine, 1998; 1271. Google Scholar
  • 25 Tsuchida C, Yamada H, Maeda Y, et al. Evaluation of peri-infarcted hypoperfusion with T2*-weighted dynamic MRI. J Magn Reson Imaging 1997; 7:518-525. Crossref, MedlineGoogle Scholar
  • 26 Soerensen AG, Buonanna FS, Gonzalez RG, et al. Hyperacute stroke: evaluation with combined multisection diffusion-weighted and hemodynamically weighted echo-planar MR imaging. Radiology 1996; 199:391-401. LinkGoogle Scholar
  • 27 Tsuura M. Diffusion and perfusion MRI study on cerebral ischemia in a rat embolism model. No To Shinkei 1996; 48:659-666. MedlineGoogle Scholar
  • 28 von Kummer R, Meyding-Lamade U, Forsting M, et al. Sensitivity and prognostic value of early CT in occlusion of the middle cerebral artery trunk. AJNR Am J Neuroradiol 1994; 15:9-15. MedlineGoogle Scholar
  • 29 Horowitz SH, Zito JL, Donnarumma R, Patel M, Alvir J. Computed tomographic-angiographic findings within the first five hours of cerebral infarction. Stroke 1991; 22:1245-1253. Crossref, MedlineGoogle Scholar
  • 30 Tomsick T, Brott T, Olinger C, et al. Hyperdense middle cerebral artery sign: incidence and quantitative significance. Neuroradiology 1989; 31:312-315. Crossref, MedlineGoogle Scholar
  • 31 Tomsick T, Brott T, Barsan W, et al. Prognostic value of the hyperdense middle cerebral artery sign on CT: efficacy in detecting middle cerebral artery thrombosis. AJNR Am J Neuroradiol 1990; 11:473-477. MedlineGoogle Scholar
  • 32 Zorzon M, Mase G, Pozzi-Mucelli F, et al. Increased density in the middle cerebral artery by nonenhanced computed tomography: prognostic value in acute cerebral infarction. Eur Neurol 1993; 33:256-259. Crossref, MedlineGoogle Scholar
  • 33 Launes J, Ketonen L. Dense middle cerebral artery sign: an indicator of poor outcome in middle cerebral artery area infarction. J Neurol Neurosurg Psychiatry 1987; 50:1550-1552. Crossref, MedlineGoogle Scholar
  • 34 Tomsick T, Brott T, Barsan W, et al. Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultra early thrombolytic therapy. AJNR Am J Neuroradiol 1996; 17:79-85. MedlineGoogle Scholar
  • 35 Tong DC, Yenari MA, Albers GW, O'Brian M, Marks MP, Moseley ME. Correlation of perfusion- and diffusion-weighted MRI with NIHSS score on acute (<6.5 hour) ischemic stroke. Neurology 1998; 50:864-870. Crossref, MedlineGoogle Scholar

Article History

Published in print: May 2000