Criteria for Emergency Brain MRI During Stroke-Alert

Evgeny Sidorov; Courtney Iser; Nidhi Kapoor; Bappaditya Ray; Juliane Chainakul; Chao Xu; Andrei V Alexandrov; David Lee Gordon

doi:10.1016/j.jstrokecerebrovasdis.2021.105890

Criteria for Emergency Brain MRI During Stroke-Alert

J Stroke Cerebrovasc Dis. 2021 Aug;30(8):105890. doi: 10.1016/j.jstrokecerebrovasdis.2021.105890. Epub 2021 Jun 6.

Authors

Evgeny Sidorov¹, Courtney Iser², Nidhi Kapoor³, Bappaditya Ray⁴, Juliane Chainakul², Chao Xu⁵, Andrei V Alexandrov⁶, David Lee Gordon⁷

Affiliations

¹ Department of Neurology, University of Oklahoma Health Sciences Center, 920 S.L.Young Blvd #2040, Oklahoma City, OK 73104, USA; Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, 1100 N Lindsay Ave., Oklahoma City, OK 73104, USA. Electronic address: evgeny-sidorov@ouhsc.edu.
² Department of Neurology, University of Oklahoma Health Sciences Center, 920 S.L.Young Blvd #2040, Oklahoma City, OK 73104, USA.
³ University of Arkansas, Department of Neurology 4301 W. Markham St., Slot 500 Little Rock, AR 72205, USA.
⁴ Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX 75390, USA.
⁵ Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, 801 N.E. 13th Street, Oklahoma City, OK 73104 USA.
⁶ Department of Neurology, University of Tennessee Health Science Center, 847 Monroe Ave Suite M226, Memphis, TN 38163.
⁷ Department of Neurology, University of Oklahoma Health Sciences Center, 920 S.L.Young Blvd #2040, Oklahoma City, OK 73104, USA; Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, 1100 N Lindsay Ave., Oklahoma City, OK 73104, USA.

PMID: 34107417
DOI: 10.1016/j.jstrokecerebrovasdis.2021.105890

Abstract

Objectives: Intravenous (IV) tissue plasminogen activator (tPA) should be given to patients with acute ischemic stroke (AIS) and avoided in stroke mimics (SM). Select use of emergency brain magnetic resonance imaging (eMRI-brain) in stroke-alerts aids diagnosis, but accepted utilization criteria for eMRI-brain do not currently exist. We developed criteria for eMRI-brain and report the yield of eMRI-brain in stroke-alert patients.

Materials and methods: We developed three history-based criteria for performing eMRI-brain during stroke-alerts: (1) history of previous similar deficits, (2) change in consciousness at onset of symptoms, (3) symptom presentation consistent with migraine aura. We then performed a retrospective chart review of patients who presented as a stroke-alert over a 5-year period and determined how these criteria affected administration of IV tPA to AIS and SM patients.

Results: Among 3,512 stroke-alerts, 230 (8.1%) patients met our criteria for eMRI-brain exams: 217 (92.6%) had SM and 17 (7.4%) had AIS. Our IV tPA decision-making analysis showed that based on eMRI-brain IV tPA was less frequently administered to SM patients (PCC-0.841, p=0.036) with less failures to administer IV tPA to patients with AIS (PCC -0.907, p-value=0.013, Pearson correlation coefficient). No patients became ineligible for IV tPA due to MRI-related time delays.

Conclusions: Our history based criteria for performing eMRI-brain during stroke-alerts show a high yield of stroke mimics. Selective eMRI-brain improves decision-making accuracy regarding IV tPA administration.

Keywords: Emergency MRI; IV tPA; MRI indication; Stroke mimics; Stroke-alert.

MeSH terms

Brain / diagnostic imaging*
Brain / physiopathology
Clinical Decision Rules*
Clinical Decision-Making*
Diagnosis, Differential
Emergency Service, Hospital*
Fibrinolytic Agents / administration & dosage
Humans
Infusions, Intravenous
Magnetic Resonance Imaging*
Predictive Value of Tests
Retrospective Studies
Stroke / diagnostic imaging*
Stroke / drug therapy
Stroke / physiopathology
Thrombolytic Therapy
Tissue Plasminogen Activator / administration & dosage
Treatment Outcome

Substances

Fibrinolytic Agents
Tissue Plasminogen Activator