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title: "Hyperattenuating (\"Dense\") Artery"
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docid: "70b5e153-27a5-4871-aaf3-0942c49f02e0"
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authors:
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- key: "2bca6b86-1eca-4e93-b997-4e18913686a7"
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value: "Hediyeh Baradaran, MD, MS"
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- key: "7cc3ba75-2642-4233-b9f6-0ce69ffe28f3"
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value: "Sheri L. Harder, MD, FRCPC"
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- key: "8d5254e9-8dda-478b-8f08-bdee97a32c79"
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value: "Karen L. Salzman, MD, FACR"
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breadcrumbs:
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-
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name: "Brain"
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slug: "brain"
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treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
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-
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name: "Differential Diagnosis"
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slug: "differential-diagnosis"
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treeNodeId: "a7fdd139-664e-4bb8-8d18-400e4733ff60"
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-
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name: "Arteries"
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slug: "arteries"
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treeNodeId: "f5fee8ee-062f-41f2-b449-efcca9fb78f9"
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-
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name: "Modality-Specific Imaging Findings"
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slug: "modality-specific-imaging-findings"
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treeNodeId: "369f11e2-7476-4e44-89b6-0a28c866b3e9"
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-
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name: "Hyperattenuating (\"Dense\") Artery"
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slug: "hyperattenuating-dense-artery"
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treeNodeId: null
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category: "Brain"
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documentVersionId: "26d80075-82d0-4b92-b0c7-f1b0e5fbf5da"
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imageCount: 19
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lastUpdated: "02/07/23"
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pageDescription: "Hyperattenuating (\"Dense\") Artery"
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pageKeywords: "Brain, Differential Diagnosis, Arteries, Modality-Specific Imaging Findings, Hyperattenuating (\"Dense\") Artery"
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pageTitle: "Hyperattenuating (\"Dense\") Artery | STATdx"
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enhancedTitle: "Hyperattenuating ("Dense") Artery"
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type: "DDX"
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references: true
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breadcrumbs:
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- "Brain"
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- "Differential Diagnosis"
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- "Arteries"
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- "Modality-Specific Imaging Findings"
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- "Hyperattenuating (\"Dense\") Artery"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Presence, localization of focal neurologic findings important
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- High hematocrit/hemoconcentration can mimic dense middle cerebral artery (MCA) sign
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- Compare to other intracranial vessels!
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- Diffuse low-density brain (anoxia, etc.) makes all vessels appear hyperdense, mimics thrombus or subarachnoid hemorrhage
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- ## Helpful Clues for Common Diagnoses
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- **Physiologic****H****yperdensity**
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- Circulating blood in arteries normally slightly hyperdense to brain: Especially prominent in newborns with unmyelinated, hypodense brain
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- Diffuse cerebral edema makes vessels appear hyperdense (false dense MCA sign)
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- **Cerebral****I****schemia-Infarction, Acute**
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- Acute thrombus in affected vessel (e.g., true dense MCA sign)
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- Acute clot undergoes time-dependent decrease in density within first 5 hours after stroke onset
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- **Recent IV Contrast Administration**
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- History of prior imaging exam; more common and longer lasting in patients with renal clearance impairment
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- ## Helpful Clues for Less Common Diagnoses
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- **Atherosclerosis, Intracranial**
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- ASVD with microcalcifications can mimic "dense" MCA
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- **Polycythemia**
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- All vessels (arteries, veins, dural sinuses) become hyperdense in polycythemia
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- Can be physiologic (elevated hematocrit in newborns, high altitude, etc.)
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- Numerous pathologic causes (cyanotic congenital heart disease, COPD, etc.)
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- **Fusiform Aneurysm (ASVD, Non-ASVD)**
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- Vertebrobasilar > anterior circulation
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- Thickened walls may appear hyperdense
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- Non-ASVD: Younger; inherited vasculopathy, immune disorder
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- **Dissection**
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- Most posterior circulation
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- Trauma most common etiology
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- **Pseudoaneurysm**
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- Trauma most common etiology
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- ## Helpful Clues for Rare Diagnoses
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- **Devices and Complications**
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- Coils, balloons, stents, methacrylate, etc.
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- Embolized foreign bodies, calcified atheromata can cause hyperattenuating vessel sign
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## References
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# Selected References
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1. [Figurelle ME et al: Viz.ai Implementation of stroke augmented intelligence and communications platform to improve indicators and outcomes for a comprehensive stroke center and network. AJNR Am J Neuroradiol. 44(1):47-53, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=36574318%5Bpmid%5D)
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1. [Legrand L et al: FLAIR vascular hyperintensities as a surrogate of collaterals in acute stroke: DWI matters. AJNR Am J Neuroradiol. 44(1):26-32, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=36521962%5Bpmid%5D)
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1. [Lu SS et al: Automated estimation of quantitative lesion water uptake as a prognostic biomarker for patients with ischemic stroke and large-vessel occlusion. AJNR Am J Neuroradiol. 44(1):33-9, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=36549850%5Bpmid%5D)
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1. [Derraz I et al: Impact of white matter hyperintensity burden on outcome in large-vessel occlusion stroke. Radiology. 304(1):145-52, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35348382%5Bpmid%5D)
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1. [DiBella EVR et al: Beyond diffusion tensor MRI methods for improved characterization of the brain after ischemic stroke: a review. AJNR Am J Neuroradiol. 43(5):661-9, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35272983%5Bpmid%5D)
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1. [Fukutomi H et al: Location-weighted versus volume-weighted mismatch at MRI for response to mechanical thrombectomy in acute stroke. Radiology. ePub, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36194114%5Bpmid%5D)
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1. [Grand T et al: Benefit of mechanical thrombectomy in acute ischemic stroke related to calcified cerebral embolus. J Neuroradiol. 49(4):317-23, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35183595%5Bpmid%5D)
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1. [Regenhardt RW et al: Symmetric CTA Collaterals Identify Patients With Slow-progressing Stroke Likely To Benefit From Late Thrombectomy. Radiology. 302(2):400-7, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=34726532%5Bpmid%5D)
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1. [Zhou Y et al: CT hyperdense artery sign and the effect of alteplase in endovascular thrombectomy after acute stroke. Radiology. 305(2):410-8, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35819327%5Bpmid%5D)
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1. [Heo JH et al: Computed tomography-based thrombus imaging for the prediction of recanalization after reperfusion therapy in stroke. J Stroke. 19(1):40-9, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28178411%5Bpmid%5D)
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1. [López-Cuevas R et al: Downstream migration and fragmentation of a spontaneous calcific embolus after thrombolysis in a patient with ischemic stroke. J Stroke Cerebrovasc Dis. 25(10):e165-6, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27499273%5Bpmid%5D)
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1. [Pikija S et al: Intracranial thrombus morphology and composition undergoes time-dependent changes in acute ischemic stroke: a CT densitometry study. Int J Mol Sci. 17(11), 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27886084%5Bpmid%5D)
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1. [Walker BS et al: Calcified cerebral emboli, a "do not miss" imaging diagnosis: 22 new cases and review of the literature. AJNR Am J Neuroradiol. 35(8):1515-9, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24651819%5Bpmid%5D)
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1. [Christian BA et al: Showered calcific emboli to the brain, the 'salted pretzel' sign, originating from the ipsilateral internal carotid artery causing acute cerebral infarction. Stroke. 40(5):e319-21, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19286589%5Bpmid%5D)
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## Images
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### Selected Images
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**Physiologic Hyperdensity**
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*Axial NECT shows a hyperdense middle cerebral artery (MCA) <img src='img/arrows/CS.png'/> and basilar arteries <img src='img/arrows/CO.png'/> in this patient with dehydration. Typically, the circle of Willis arteries are mildly hyperdense compared with normal brain parenchyma. Vessels become prominent in normal newborns with unmyelinated, hypodense brain.*
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**Physiologic Hyperdensity**
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*Axial NECT shows a hyperdense middle cerebral artery (MCA) <img src='img/arrows/CS.png'/> and basilar arteries <img src='img/arrows/CO.png'/> in this patient with dehydration. Typically, the circle of Willis arteries are mildly hyperdense compared with normal brain parenchyma. Vessels become prominent in normal newborns with unmyelinated, hypodense brain.*
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**Physiologic Hyperdensity**
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*Axial NECT shows bilateral dense MCA signs <img src='img/arrows/CS.png'/> and ↑ density in venous structures in an anoxic patient with diffuse cerebral edema. Low-density brain makes the normal vascular structures appear hyperdense.*
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**Cerebral Ischemia-Infarction, Acute**
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*Axial NECT shows ↑ density in the left MCA <img src='img/arrows/CO.png'/> (dense MCA sign) in a patient with acute right-sided symptoms. The density is from acute thrombus within the vessel. Note the associated loss of gray-white differentiation in the MCA territory <img src='img/arrows/BO.png'/>.*
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**Cerebral Ischemia-Infarction, Acute**
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*Axial NECT in the same patient 48 hours later shows a large left MCA distribution infarct <img src='img/arrows/CS.png'/> with hemorrhagic transformation <img src='img/arrows/WO.png'/>. Infarct in the basal ganglia indicates involvement of lenticulostriate arteries, which typically arise from the proximal MCA.*
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**Cerebral Ischemia-Infarction, Acute**
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*Axial NECT shows ↑ density related to a dot sign in a distal left MCA branch <img src='img/arrows/CS.png'/>, representing acute thrombus. Hypodensity related to early infarct is seen in the adjacent brain parenchyma.*
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**Atherosclerosis, Intracranial**
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*Axial NECT shows calcification in the supraclinoid internal carotid arteries <img src='img/arrows/BS.png'/>, a common location for intracranial atherosclerosis. Intracranial atherosclerosis is associated with atherosclerosis of the carotids, coronaries, aorta, renal arteries, and iliofemoral system.*
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**Fusiform Aneurysm (ASVD, Non-ASVD)**
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*Axial NECT shows a large, hyperdense basilar artery <img src='img/arrows/CO.png'/> related to a fusiform aneurysm. Atherosclerotic calcification and hyperdensity is also present in the proximal left MCA <img src='img/arrows/WS.png'/>.*
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**Devices and Complications**
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*Axial NECT shows embolized hyperdense material <img src='img/arrows/WS.png'/> in the left MCA in an IV drug abuser, possibly secondary to talc powder. Adjacent hypodense parenchyma <img src='img/arrows/CS.png'/> is related to a subacute infarct.*
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### Additional Images
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**Physiologic Hyperdensity**
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*Axial NECT demonstrates relatively hyperdense internal carotid arteries <img src='img/arrows/WS.png'/> in this neonate. Note the corresponding ↑ density of the transverse sinuses <img src='img/arrows/WC.png'/>.*
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**Physiologic Hyperdensity**
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*Axial NECT shows false dense MCA sign in a patient with diffuse cerebral edema. Low-density brain makes normal MCA <img src='img/arrows/WS.png'/> and cerebellum <img src='img/arrows/WO.png'/> appear hyperdense.*
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**Cerebral Ischemia-Infarction, Acute**
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*Axial NECT suggests increased linear density in the left sylvian branches <img src='img/arrows/WS.png'/>, more evident when compared to the normal appearing right-sided branches <img src='img/arrows/WC.png'/>.*
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**Fusiform Aneurysm (ASVD, Non-ASVD)**
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*Axial NECT shows extensive calcification in the internal carotid and MCS <img src='img/arrows/BS.png'/> and a dilated hyperdense basilar artery with peripheral calcification <img src='img/arrows/BO.png'/>.*
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**Fusiform Aneurysm (ASVD, Non-ASVD)**
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*Axial NECT shows a nonatherosclerotic fusiform aneurysm of the MCA with a lobulated hyperdense mass seen in the left sylvian fissure <img src='img/arrows/WS.png'/>.*
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**Pseudoaneurysm**
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*Axial NECT shows a hyperdense lesion <img src='img/arrows/WS.png'/> in the region of the cavernous sinus representing a large pseudoaneurysm in this 31-year-old man with a remote history of skull base fracture.*
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**Pseudoaneurysm**
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*Axial CTA in the same patient reveals communication with the right internal carotid artery <img src='img/arrows/WS.png'/>.*
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**Devices and Complications**
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*Axial NECT shows a coil <img src='img/arrows/WS.png'/> in the left internal carotid artery.*
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**Polycythemia**
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*Axial NECT shows hyperdense arteries <img src='img/arrows/WS.png'/> as well as veins and dural sinuses <img src='img/arrows/WO.png'/> in a patient with markedly elevated hematocrit. Polycythemia can mimic a CECT scan but vessels are usually not as dense.*
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**Dissection**
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*Axial NECT shows high-density thrombus in the internal carotid artery <img src='img/arrows/WC.png'/> related to dissection of the left internal carotid artery just above the carotid bulb (not shown).*
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**Physiologic Hyperdensity**
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*Coronal NECT shows ↑ density in the vascular structures compatible with physiologic hyperdensity.*
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