Attenuated corticomedullary contrast: An early cerebral computed tomography sign indicating malignant middle cerebral artery infarction - A case-control study

Background and Purpose-No neuroradiological markers have been characterized that support a timely decision for decompressive surgery in malignant midd le cerebral artery (MCA) infarction (mMCAI). This case-control study was de signed to analyze whether early cerebral CT (CCT) scanning provides reliabl e information for the prospective selection of stroke patients at risk of d eveloping mMCAI. Methods-Thirty-one pairs (n = 62) were formed with cases (mMCAI) and contro ls (acute but not malignant MCA infarction) closely matched in terms of age , sex, and stroke etiology, CCT was performed within 18 hours of stroke ons et and analyzed by a blinded neuroradiologist according to a defined panel of 12 CCT criteria. Results-In terms of predicting mMCAI, the criteria of extended MCA territor y hypodensities >67% and >50%, hemispheric brain swelling, midline shift, a nd hyperdense MCA sign exhibited high specificity (100%, 93.5%, 100%, 96.7% , and 83.9%, respectively) but low sensitivity (45.2%, 58.1%, 12.9%, 19.4%, and 70.9%, respectively). Two criteria yielded high sensitivity (subarachn oid space compressed, 100%; cella media compressed, 80.6%) but low specific ity (29% and 74.2%, respectively). The criterion of attenuated corticomedul lary contrast yielded both high specificity (96.8%) and sensitivity (87.1%) . The latter remained as the crucial criterion [Exp(B) = 90.8; 95% CI, 5.8 to 1427.5] in a 2-tailed logistic regression analysis with the strongest co rrelating parameters (Spearman correlation factor greater than or equal to 0.6 or less than or equal to-0.6). Conclusions-The analysis of CCT scans within 18 hours of stroke onset revea led an attenuated corticomedullary contrast as the crucial CCT criterion, w hich, with both sufficient sensitivity and specificity, predicted mMCAI wit h 95% certainty.