Computed tomographic determinants of neurologic deterioration in patients with large middle cerebral artery infarctions

Objective: To identify specific radiographic features on computed tomographic (CT) imaging that can predict neurologic deterioration in patients with large middle cerebral artery (MCA) infarctions. Patients and Methods: We performed a 10-year retrospective review from January 1, 1991, through December 31, 2001, of medical records and CT scans of patients with large MCA infarctions. Neurologic deterioration was defined as progressive drowsiness or signs of herniation. The CT scans were grouped into 3 periods according to time after ictus. Radiographic features reviewed included hyperdense middle cerebral artery sign (HMCAS), more than a 50% loss of MCA territory, sulcal effacement, loss of lentiform nucleus or insular ribbon, and septal and pineal shift. Demographic and radiographic variables were compared by using t tests and the Fisher exact test. Prognostic values were calculated for all significant radiographic variables. Results: Thirty-four CT scans in 22 patients before neurologic deterioration were compared with 47 scans obtained in 14 patients without neurologic worsening. There were no demographic differences between groups. Initial analysis revealed that early (<12 hours) involvement of more than 50% of the MCA territory (P=.047; odds ratio [OR], 14.02; 95% confidence interval [CI], 1.04-189.42) and the HMCAS at any time (P<.001; OR, 21.6; 95% CI, 3.54-130.04) were independent predictors of neurologic deterioration. The positive predictive power for early involvement of more than 50% of the MCA and the HMCAS was 0.75 and 0.91, respectively. Conclusion: The HMCAS and early CT evidence of more than 50% MCA involvement are predictive of neurologic deterioration in patients with large MCA infarcts.