Magnetic Resonance Imaging or Computed Tomography for Suspected Acute Stroke: Association of Admission Image Modality with Acute Recanalization Therapies, Workflow Metrics, and Outcomes

Abstract

Objective To examine rates of intravenous thrombolysis (IVT), mechanical thrombectomy (MT), door‐to‐needle (DTN) time, door‐to‐puncture (DTP) time, and functional outcome between patients with admission magnetic resonance imaging (MRI) versus computed tomography (CT). Methods An observational cohort study of consecutive patients using a target trial design within the nationwide Swiss‐Stroke‐Registry from January 2014 to August 2020 was carried out. Exclusion criteria included MRI contraindications, transferred patients, and unstable or frail patients. Multilevel mixed‐effects logistic regression with multiple imputation was used to calculate adjusted odds ratios with 95% confidence intervals for IVT, MT, DTN, DTP, and good functional outcome (mRS 0–2) at 90 days. Results Of the 11,049 patients included (mean [SD] age, 71 [15] years; 4,811 [44%] women; 69% ischemic stroke, 16% transient ischemic attack, 8% stroke mimics, 6% intracranial hemorrhage), 3,741 (34%) received MRI and 7,308 (66%) CT. Patients undergoing MRI had lower National Institutes of Health Stroke Scale (median [interquartile range] 2 [0–6] vs 4 [1–11]), and presented later after symptom onset (150 vs 123 min, p < 0.001). Admission MRI was associated with: lower adjusted odds of IVT (aOR 0.83, 0.73–0.96), but not with MT (aOR 1.11, 0.93–1.34); longer adjusted DTN (+22 min [13–30]), but not with longer DTP times; and higher adjusted odds of favorable outcome (aOR 1.54, 1.30–1.81). Interpretation We found an association of MRI with lower rates of IVT and a significant delay in DTN, but not in DTP and rates of MT. Given the delays in workflow metrics, prospective trials are required to show that tissue‐based benefits of baseline MRI compensate for the temporal benefits of CT. ANN NEUROL 2022;92:184–194

Reporting of Observational Studies Explicitly Aiming to Emulate Randomized Trials

“…We retrieved 3133 unique records, of which 200 were included in the review (Figure 1). All reasons for excluding records after full-text review are given in eAppendix 6 in Supplement 1.…”

Late Window Imaging Selection for Endovascular Therapy of Large Vessel Occlusion Stroke: An International Survey

“…Regarding the time delay due to advanced imaging, several studies showed that advanced imaging led to longer door-to-puncture 12,18,19 and door-to-needle times. 35 In 1 report, time delays to treatment might not be as critical for functional outcome after thrombectomy in patients who present in the extended time window (6-24 hours) compared with patients in the early time window. 27 In this survey, 78% of respondents believed that a delay of 20 minutes or less was acceptable to obtain advanced imaging prior to thrombectomy.…”

Neuroimaging of Acute Ischemic Stroke: Multimodal Imaging Approach for Acute Endovascular Therapy

“…95,96 The use of MRI as the primary modality in patients presenting with AIS has increased over the years. 97 MRI is as accurate as CT for the detection of hyperacute hemorrhage using susceptibility-weighted images (SWI). 98 MRI is also more sensitive than CT to detect subtle hemorrhagic changes within the ischemic lesion.…”

“…The use of MRI as the primary modality in patients presenting with AIS has increased over the years [ 97 ]. MRI is as accurate as CT for the detection of hyperacute hemorrhage using susceptibility-weighted images (SWI) [ 98 ].…”