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Editor’s note: The hyperdense middle cerebral artery sign (HMCAS) is a highly specific but not very sensitive marker of middle cerebral artery occlusion. Previous studies have suggested that this finding is associated with poor outcomes when patients are thrombolysed intravenously, and with an increased risk of symptomatic intracerebral hemorrhage (SICH). It has also been suggested that patients with HMCAS do not benefit from intravenous tissue plasminogen activator (tPA)and should not be considered for treatment with this agent.