Prominent vessel sign

Last revised by Rohit Sharma on 16 Feb 2024

The prominent vessel sign, or prominent hypointense vessel sign, is a radiological sign appreciated on susceptibility weighted imaging (SWI) that is described most commonly in patients with acute ischemic stroke.

The sign describes hypointense blooming artifact seen on SWI brain MRI within multiple intracranial blood vessels in a region of cerebral ischemic penumbra 1-6. The sign is caused by an increased oxygen extraction fraction in ischemic cerebral tissue, which results in an increased concentration of paramagnetic deoxyhemoglobin in draining veins and capillaries 1-6. Radiographically, these blood vessels are generally cerebral veins, including either or both of:

  • cortical veins: sometimes referred to as the cortical vessel sign 1,3-6

  • subependymal and medullary veins: sometimes referred to as the brush sign 1,3-6, although not exclusively in the context of ischemic stroke as this same sign is also used in the context of moyamoya disease and cerebral venous sinus thrombosis 7,8

Presence of a prominent vessel sign in acute ischemic stroke has a number of clinical implications:

  • in ischemic stroke caused by anterior circulation large vessel occlusion, a positive prominent vessel sign has been found in most studies to correlate with poor collaterals, and thus, a poorer overall functional prognosis 1-3

  • a positive prominent vessel sign may be associated with a cardioembolic etiology of ischemic stroke, whereby it is postulated that collaterals have not had time to develop; this contrasts with ischemic stroke caused by long-standing steno-occlusive arterial disease whereby there is more time for collaterals to develop 1,4

Presence of a positive brush sign (a subset of the prominent vessel sign) in non-ischemic stroke contexts, such as in moyamoya disease and cerebral venous sinus thrombosis, is also associated with increased severity of the underlying pathology 7,8.

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