Moving From CT to MRI Paradigm in Acute Ischemic Stroke: Feasibility, Effects on Stroke Diagnosis and Long-Term Outcomes

Abstract

BACKGROUND: The relative value of computed tomography (CT) and magnetic resonance imaging (MRI) in acute ischemic stroke (AIS) is debated. In May 2018, our center transitioned from using CT to MRI as first-line imaging for AIS. This retrospective study aims to assess the effects of this paradigm change on diagnosis and disability outcomes. METHODS: We compared all consecutive patients with confirmed diagnosis of AIS admitted to our center during the MRI-period (May 2018–August 2022) and an identical number of patients from the preceding CT-period (December 2012–April 2018). Univariable and multivariable analyses were performed to evaluate outcomes, including the number and delay of imaging exams, the rate of missed strokes, stroke mimics treated with thrombolysis, undetermined stroke mechanisms, length of hospitalization, and 3-month disability. RESULTS: The median age of the 2972 included patients was 76 years (interquartile range, 65–84), and 46% were female. In the MRI-period, 80% underwent MRI as first acute imaging. The proportion of patients requiring a second acute imaging modality for diagnostic ± revascularization reasons increased from 2.1% to 5% ( P unadj <0.05), but it decreased in the subacute phase from 79.0% to 60.1% ( P adj <0.05). In thrombolysis candidates, there was a 2-minute increase in door-to-imaging delay ( P adj <0.05). The rates of initially missed AIS diagnosis was similar (3.8% versus 4.4%, P adj =0.32) and thrombolysis in stroke mimics decreased by half (8.6% versus 4.3%; P adj <0.05). Rates of unidentified stroke mechanism at hospital discharge were similar (22.8% versus 28.1%; P adj =0.99). The length of hospitalization decreased from 9 (interquartile range, 6–14) to 7 (interquartile range, 4–12) days ( P adj =0.62). Disability at 3 months was similar (common adjusted odds ratio for favorable Rankin shift, 0.98 [95% CI, 0.71–1.36]; P adj =0.91), as well as mortality and symptomatic intracranial hemorrhage. CONCLUSIONS: A paradigm shift from CT to MRI as first-line imaging for AIS seems feasible in a comprehensive stroke center, with a minimally increased delay to imaging in thrombolysis candidates. MRI was associated with reduced thrombolysis rates of stroke mimics and subacute neuroimaging needs.