Diagnostics and Medical Technology Med Sci Monit, 2000; 6(5): 1027-1030

Hyperacute infarction: early CT findings

Mohamed Abdalla, Romana Bogusawska, Renata Poniatowska

Department of Neuroradiology, Institute of Psychiatry and Neurology, Warsaw, Poland

key words: cerebral infarcts, computed tomography, lentiform nucleus, insular ribbon, middle cerebral artery

SUMMARY

The aim of our study is to determine how early and reliably ischemic brain infarcts can be detected on CT scan-
ning. We report two cases of an early CT finding of acute ischemic infarcts where CT examination was obtained
within the first 3 hours of onset of neurological symptoms. CT examination showed blurred outlines and
decreased attenuation of the left lentiform nucleus, loss of the white-gray matter interface in the left insular cor-
tex and left cortical global hypoattenuation with obliteration of left cortical sulci in one patient. In second
patient CT showed the following: hyperdense left middle cerebral artery, loss of clear margins of left lentiform
nucleus, subtle focal cortical hypodensity in the left fronto-parietal area with signs of mass effect in the form of
ventricular compression.
CT is still the first choice in the deferential diagnosis of acute stroke. Although older literature positions have
suggested that CT was negative during the first 48 hours, modern CT technology can demonstrate positive find-
ings even in the first 3 hours of onset. This is important in patients with acute stroke, as thrombolytic therapy
when elected, has to be given within the first 36 hours after onset of symptoms.
To determine how early and reliably ischemic brain infarcts can be detected on CT scanning, we report two
cases of an early CT finding of acute ischemic infarcts where CT examination was obtained within the first 3
hours of onset of neurological symptoms.

INTRODUCTION ogy, signs of early ischemia can often be detected

In clinical settings, CT is still the first choice in the
deferential diagnosis of acute stroke. It is a widely
available in most community hospitals, relatively
inexpensive, rapid modality of investigation; the
scan time on the latest generation of scanners is
currently less than 1 minute. This is extremely
important in patients with acute stroke, as throm-
bolytic therapy when elected, has to be given with-
in the first 36 hours after onset of symptom. For
these reasons, CT has become the initial imaging
modality of choice to exclude intracranial hemor-
rhage (ICH) in evaluating patients with acute neu-
rological dysfunction.
Older literature described a negative CT in the first
24 hours. More recently, with modern CT technol-
even in the hyperacute stage (less than 3 hours).
Several reports have described high incidence of
positive findings even within the first 3 hours of
onset [13], though it is stated that overall sensitivi-
ty of CT in early stroke is poor.
CASE REPORT
Case 1
A 31-year-old man with history of heart disease
and heavy smoking, noticeable weakness of the
right side of his body. He was immediately referred
to a physician who found right side hemiparesis,
CT scan performed 6 hours after the onset of
symptoms showed blurred outlines and decreased

Received: 2000.03.08 Correspondence address: Mohamed Abdalla MD, Department of Neuroradiology, Institute of Psychiatry and Neurology,
Accepted: 2000.08.20 Al. Sobieskiego 1/9, 02-957 Warsaw, Poland

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Diagnostics and Medical Technology
attenuation of the left lentiform nucleus, loss of the
gray-white matter interface in the left insular cortex
(loss of insular ribbon) and left cortical global
hypoattenuation with obliteration of left cortical
sulci.
Case 2
A 48-year-old man with history of hypertension
and diabetes noticed sudden weakness in the right
side of his body. Admitted to neurology clinic, an
urgent CT was performed within 6 hours.
CT showed the following:
hyperdense left middle cerebral artery HDMCA,
loss of clear margins of left lentiform nucleus,
subtle focal cortical hypodensity in the left fron-
to-parietal area with signs of mass effect in the
form of ventricular compression.
DISCUSSION
CT is routinely used in diagnosis and evaluation of
the extent of acute cerebral infarct. A few years
ago, the role of CT in the setting of hyperacute
stroke was only to exclude other similar conditions
mimicking acute ischemic stroke (subarachnoid or
intracerebral hemorrhage, tumor, etc.).
Now the role of CT is changing from peripheral to
more central one. It is the most widely available
tool in determining which patients are eligible for
specific anti-stroke treatment. Although older litera-
ture suggested that CT was negative during the first
48 hours, more recent studies have demonstrated
positive findings even in the first 3 hours of onset.
Any understanding of imaging changes in diagnostic
methods after the ischemic insult requires a famil-
iarity with pathophysiological changes that ensue
after interruption of blood supply.
Normal cerebral blood flow remains within the
range of 5055 ml/100 g of brain tissues/minute. If
cerebral blood flow decreases to 15 ml/100 g/min,
a loss of electrical activity occurs within seconds
[4,5]. Within one hour there is a depletion of cellu-
lar energy (ATP) with shift to anaerobic glycolysis.
Therefore, ion pumps within the cell membrane
are unable to continue their function. As the ATP
level drops and membrane potential falls, there is
an influx of sodium and potassium into the cells.
Water follows this ionic influx, in addition tissue
acidosis resulting from anaerobic metabolism fur-
ther accelerates osmotic water diffusion into the
1028
cells. This shift of water into intracellular compart-
ment results in cytotoxic edema [6]. This early
edema is responsible for early CT findings in acute
ischemic infarction.
On the other hand, a relatively more tolerant
endothelial cells do not manifest histopathological
changes until 4 to 12 hours after ischemic insult.
These cells are responsible for the tight cell junc-
tions that make up the blood-brain barrier. With
the break down of that barrier, vasogenic edema
develops where water and protein flood from
intracellular compartments into the extracellular
space. The x-ray attenuation seen with CT scan-
ning is directly proportional to tissue water con-
tent. Any increase in tissue water content results in
decrease in x-ray attenuation. A number of CT
findings have been identified, which generally
involve loss of appreciation of the attenuation dif-
ference between gray matter and white matter.
They include the following:
Obscured boundaries of the lentiform nucleus
(pallidum, putamen) which is predominantly gray
matter and the surrounding white matter tracks
from the internal and external capsules. It is
more obvious in the putamen, therefore the lat-
eral margin of the internal capsule is the first to
be blurred. This sign was first described by
Tomura et al. in 1988 [1] as slight hypoattenua-
tion recognized as early as 1 hour after the onset
of symptoms, the deep MCA territory seems
extremely sensitive because the lenticulostriate
arteries supply end zone territories and account
for this sign.
Loss of clear margin between the insular cortex
(gray matter) and external and extreme capsule
(white matter) loss of insular ribbon, anatomi-
cally, insular ribbon refers to the claustrum,
extreme capsule and insular cortex. This sign,
however, is a frequent early sign of ischemia
requiring high CT resolution because of the prox-
imity and delicate arrangement of those struc-
tures. It was first described by Truwit et al. in
1990. The blood supply to the insular ribbon is
mainly provided by claustral arteries arising from
the M2 segment of the MCA.
Focal cortical hypoattenuation. Due to focal cor-
tical edema lead to loss of normal attenuation
between cortical gray and white matter, with
compression of CSF spaces leading to relative
obliteration of cortical sulci. Hemispheric sulcal
 Abdalla M et al Hyperacute infarction: early CT findings

Figure 1. a) CT scan done 3 hours after the onset of neurological symptoms shows blurred lateral margin on the left internal capsule with obliteration
of the left lateral sulcus. b) Indistinct demarcation between white and gray matter of the left cerebral cortex with effacement of cortical sulci
in the fronto-temporal area. c) Control CT after 5 days after the onset of symptoms shows focal hypodensity in the left fronto-temporal area
with clear mass effect as compressed left lateral ventricle.

Figure 2. a) First CT 3 hours after the onset of neurological symptoms shows unilateral hyperintense left middle cerebral artery. b) Blurred margins of
left lentiform nucleus. c) Control CT 4 days after the onset of neurological symptoms with clear focal hypodensity in the left fronto-temporal
area with massive mass effect in the form of compressed lateral ventricle and midline shift. d) Disappearance of visible left middle cerebral
artery which indicates lysis of the intra-arterial embolus; this confirms the vanishing nature of this sign.

effacement [1-3]. Major mass effect with midline
shift does not appear before 12 hours after the
stroke onset.
To study the prevalence of these finding, Toumora
et al. [1] evaluated CT scans within the first 6 hours
of ictus in 25 patients with involvement of the mid-
dle cerebral artery MCA territory. 23 patients
(92%) demonstrated obscuring of the lentiform
nucleus. Another study by Bozzao et al. [7] evalu-
ated CT scans performed four hours from onset in
36 patients with supratentorial stroke. 25 patients
(69%) had abnormal CT, 14 patients obscuring of
the lentiform nucleus alone, 5 patients findings
both in the lentiform nucleus and cerebral cortex,
6 patients changes only in the cerebral cortex.
Horowitz et al. [8] scanned 50 patients within the
first 3 hours. 28 patients (56%) showed evidence of
acute infarction on the first CT. These findings
included lentiform nucleus obscuring alone in 2
cases, hypodensity alone in 7, hypodensity with
mass effect in 15, and mass effect alone in 4
patients.
Another early highly specific, but less sensitive, sign
that has been extensively described is the unilateral
hyperdense middle cerebral artery sign HMCAS,
which is usually present in the first horizontal part
(M1). The specificity of this sign can reach 100%,
but sensitivity is rather low, about 50% in the best
conditions. It is the reflection of a hyperintense
embolus or thrombus lodged in this segment,

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Diagnostics and Medical Technology
defined as part of the MCA that is denser than its
contralateral counterpart or any other vessel of
similar size shown by an unenhanced CT where
the density could not be attributed to calcification
and disappears on bone window, the incidence of
which has been greatly varied between 1% and
50%. This wide variation has been attributed to
slice thickness and whether strict or loose defini-
tion criteria have been followed [810].
The presence of hyperdense MCA has been con-
sidered as a poor prognostic sign associated with
severe neurological deficit and an indicator of
extensive infarct area. However, it is still uncertain
if HMCAS alone has any prognostic value [11,12].
REFERENCES:
1. Tomura N, Uemura K, Inugami A et al: Early CT finding in cerebral
infarction: obscuration of lentiform nucleus. Radiology, 1988; 168:
463-467
2. Truwit CL, Barkovich AJ, Gean-Marton A et al: Loss of insular rib-
bon: another early CT sign of acute cerebral infarction. Radiology,
1990; 176: 801-806
3. Von Kummer R, Allen KL, Holle R et al: Acute stroke: usefulness of
early CT finding before thrombolytic therapy. Radiology, 1997; 205:
327-333
1030
4. Bell BA, Symon L, Branston NM: CBF and time threshold for the for-
mation of ischemic cerebral edema, and effect of reperfusion in
baboons. J Neurosurgery, 1985; 62: 31-41
5. Schuir FJ, Hossman KA: Experimental brain infarction in cats.
Stroke, 1980; 11: 593-601
6. Raichle ME: The pathophysiology of brain ischemia. Ann Neurol,
1983; 13: 2-10
7. Bozzao L, Bastianello S, Fantozzi LM et al: Correlation of angio-
graphic and sequential CT finding in patients with evolving cerebral
infarction. AJNR, 1989; 10: 1215-1222
8. Horowitz SH, Zito JL, Donnarumma R et al: Computed tomographic
-angiographic finding within the first five hours of cerebral infarction.
Stroke, 1991; 22: 1245-1253
9. Pressman BD, Tourje EJ, Thompson JR: An early sign of ischemic
infarction increased density in the middle cerebral artery. AJNR, 1987;
8: 645-648
10. Schueirer G, Huk W: The unilateral hyperdense middle cerebral
artery: An early CT sign of embolism or thrombus. Neuroradiology,
1988; 30: 120-122
11. Tomscik T, Brot T, Barsan W et al: Prognostic value of hyperdense
middle cerebral artery sign stroke scale score before thrombolytic ther-
apy. AJNR, 1996; 17: 79-85
12. Leys D, Pruvo JP, Godefroy O et al: Prevalence and significance of
hyperdense middle cerebral artery in acute stroke. Stroke, 1992; 23:
317-324
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