Bilateral hyperdense middle cerebral arteries: Stroke sign or not?

Hyperdense middle cerebral artery (MCA) is a classic sign of acute thromboembolic disease. Simultaneous bilateral occurrence is uncommon and traditionally attributed to physiological hemoconcentration or attributable to imaging artifact. We present the case of a 71-year-old man whose admission noncontrast computed tomography (CT) demonstrated bilateral hyperdense middle cerebral arteries without other radiographic evidence of acute stroke. CT angiography confirmed bilateral MCA, M1 segment vascular occlusion and follow-up noncontrast CT demonstrated MCA territory infarctions.