statdx/docs_md/articles/hyperattenuating-dense-artery_70b5e153-27a5-4871-aaf3-0942c49f02e0.md

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Hyperattenuating ("Dense") Artery	70b5e153-27a5-4871-aaf3-0942c49f02e0	key value 2bca6b86-1eca-4e93-b997-4e18913686a7 Hediyeh Baradaran, MD, MS key value 7cc3ba75-2642-4233-b9f6-0ce69ffe28f3 Sheri L. Harder, MD, FRCPC key value 8d5254e9-8dda-478b-8f08-bdee97a32c79 Karen L. Salzman, MD, FACR	name slug treeNodeId Brain brain 6d8829f1-14d7-45af-8675-255189aa526a name slug treeNodeId Differential Diagnosis differential-diagnosis a7fdd139-664e-4bb8-8d18-400e4733ff60 name slug treeNodeId Arteries arteries f5fee8ee-062f-41f2-b449-efcca9fb78f9 name slug treeNodeId Modality-Specific Imaging Findings modality-specific-imaging-findings 369f11e2-7476-4e44-89b6-0a28c866b3e9 name slug treeNodeId Hyperattenuating ("Dense") Artery hyperattenuating-dense-artery null	Brain	26d80075-82d0-4b92-b0c7-f1b0e5fbf5da	19	02/07/23	Hyperattenuating ("Dense") Artery	Brain, Differential Diagnosis, Arteries, Modality-Specific Imaging Findings, Hyperattenuating ("Dense") Artery	Hyperattenuating ("Dense") Artery | STATdx	Hyperattenuating ("Dense") Artery	DDX	true	Brain Differential Diagnosis Arteries Modality-Specific Imaging Findings Hyperattenuating ("Dense") Artery

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title: "Hyperattenuating ("Dense") Artery" docid: "70b5e153-27a5-4871-aaf3-0942c49f02e0" authors:

• key: "2bca6b86-1eca-4e93-b997-4e18913686a7" value: "Hediyeh Baradaran, MD, MS"
• key: "7cc3ba75-2642-4233-b9f6-0ce69ffe28f3" value: "Sheri L. Harder, MD, FRCPC"
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• "Brain"
• "Differential Diagnosis"
• "Arteries"
• "Modality-Specific Imaging Findings"
• "Hyperattenuating ("Dense") Artery"

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ESSENTIAL INFORMATION

• Key Differential Diagnosis Issues

  • Presence, localization of focal neurologic findings important
  • High hematocrit/hemoconcentration can mimic dense middle cerebral artery (MCA) sign - Compare to other intracranial vessels!
  • Diffuse low-density brain (anoxia, etc.) makes all vessels appear hyperdense, mimics thrombus or subarachnoid hemorrhage

• Helpful Clues for Common Diagnoses

  • PhysiologicHyperdensity - Circulating blood in arteries normally slightly hyperdense to brain: Especially prominent in newborns with unmyelinated, hypodense brain - Diffuse cerebral edema makes vessels appear hyperdense (false dense MCA sign)
  • CerebralIschemia-Infarction, Acute - Acute thrombus in affected vessel (e.g., true dense MCA sign) - Acute clot undergoes time-dependent decrease in density within first 5 hours after stroke onset
  • Recent IV Contrast Administration - History of prior imaging exam; more common and longer lasting in patients with renal clearance impairment

• Helpful Clues for Less Common Diagnoses

  • Atherosclerosis, Intracranial - ASVD with microcalcifications can mimic "dense" MCA
  • Polycythemia - All vessels (arteries, veins, dural sinuses) become hyperdense in polycythemia - Can be physiologic (elevated hematocrit in newborns, high altitude, etc.) - Numerous pathologic causes (cyanotic congenital heart disease, COPD, etc.)
  • Fusiform Aneurysm (ASVD, Non-ASVD) - Vertebrobasilar > anterior circulation - Thickened walls may appear hyperdense - Non-ASVD: Younger; inherited vasculopathy, immune disorder
  • Dissection - Most posterior circulation - Trauma most common etiology
  • Pseudoaneurysm - Trauma most common etiology

• Helpful Clues for Rare Diagnoses

  • Devices and Complications - Coils, balloons, stents, methacrylate, etc. - Embolized foreign bodies, calcified atheromata can cause hyperattenuating vessel sign

References

Selected References

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
2. 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
3. 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
4. Derraz I et al: Impact of white matter hyperintensity burden on outcome in large-vessel occlusion stroke. Radiology. 304(1):145-52, 2022
5. 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
6. Fukutomi H et al: Location-weighted versus volume-weighted mismatch at MRI for response to mechanical thrombectomy in acute stroke. Radiology. ePub, 2022
7. Grand T et al: Benefit of mechanical thrombectomy in acute ischemic stroke related to calcified cerebral embolus. J Neuroradiol. 49(4):317-23, 2022
8. 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
9. 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
10. 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
11. 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
12. 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
13. 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
14. 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

Images

Selected Images

Physiologic Hyperdensity Axial NECT shows a hyperdense middle cerebral artery (MCA) and basilar arteries 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.

Physiologic Hyperdensity Axial NECT shows a hyperdense middle cerebral artery (MCA) and basilar arteries 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.

Physiologic Hyperdensity Axial NECT shows bilateral dense MCA signs and ↑ density in venous structures in an anoxic patient with diffuse cerebral edema. Low-density brain makes the normal vascular structures appear hyperdense.

Cerebral Ischemia-Infarction, Acute Axial NECT shows ↑ density in the left MCA (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 .

Cerebral Ischemia-Infarction, Acute Axial NECT in the same patient 48 hours later shows a large left MCA distribution infarct with hemorrhagic transformation . Infarct in the basal ganglia indicates involvement of lenticulostriate arteries, which typically arise from the proximal MCA.

Cerebral Ischemia-Infarction, Acute Axial NECT shows ↑ density related to a dot sign in a distal left MCA branch , representing acute thrombus. Hypodensity related to early infarct is seen in the adjacent brain parenchyma.

Atherosclerosis, Intracranial Axial NECT shows calcification in the supraclinoid internal carotid arteries , a common location for intracranial atherosclerosis. Intracranial atherosclerosis is associated with atherosclerosis of the carotids, coronaries, aorta, renal arteries, and iliofemoral system.

Fusiform Aneurysm (ASVD, Non-ASVD) Axial NECT shows a large, hyperdense basilar artery related to a fusiform aneurysm. Atherosclerotic calcification and hyperdensity is also present in the proximal left MCA .

Devices and Complications Axial NECT shows embolized hyperdense material in the left MCA in an IV drug abuser, possibly secondary to talc powder. Adjacent hypodense parenchyma is related to a subacute infarct.

Additional Images

Physiologic Hyperdensity Axial NECT demonstrates relatively hyperdense internal carotid arteries in this neonate. Note the corresponding ↑ density of the transverse sinuses .

Physiologic Hyperdensity Axial NECT shows false dense MCA sign in a patient with diffuse cerebral edema. Low-density brain makes normal MCA and cerebellum appear hyperdense.

Cerebral Ischemia-Infarction, Acute Axial NECT suggests increased linear density in the left sylvian branches , more evident when compared to the normal appearing right-sided branches .

Fusiform Aneurysm (ASVD, Non-ASVD) Axial NECT shows extensive calcification in the internal carotid and MCS and a dilated hyperdense basilar artery with peripheral calcification .

Fusiform Aneurysm (ASVD, Non-ASVD) Axial NECT shows a nonatherosclerotic fusiform aneurysm of the MCA with a lobulated hyperdense mass seen in the left sylvian fissure .

Pseudoaneurysm Axial NECT shows a hyperdense lesion 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.

Pseudoaneurysm Axial CTA in the same patient reveals communication with the right internal carotid artery .

Devices and Complications Axial NECT shows a coil in the left internal carotid artery.

Polycythemia Axial NECT shows hyperdense arteries as well as veins and dural sinuses in a patient with markedly elevated hematocrit. Polycythemia can mimic a CECT scan but vessels are usually not as dense.

Dissection Axial NECT shows high-density thrombus in the internal carotid artery related to dissection of the left internal carotid artery just above the carotid bulb (not shown).

Physiologic Hyperdensity Coronal NECT shows ↑ density in the vascular structures compatible with physiologic hyperdensity.