Cost and Utility of Routine Contrast-Enhanced Neck MRA in a Pediatric MRI Stroke Evaluation Protocol

Area of Science:

• Pediatric Neurology
• Neuroradiology
• Vascular Imaging

Background:

• Cervical arterial dissection is a significant cause of stroke in children.
• Pediatric stroke work-ups often include brain MRI sequences.
• Concerns exist about missing cervical arterial dissection in pediatric stroke cases.

Purpose of the Study:

• To evaluate the diagnostic yield of routine contrast-enhanced 3D neck MR angiography (MRA) in pediatric stroke work-ups.
• To determine if neck MRA detects cervical arterial abnormalities when standard brain MRI findings are normal.
• To assess the cost-effectiveness of routine neck MRA in pediatric stroke protocols.

Main Methods:

• Retrospective review of institutional PACS data for pediatric stroke protocol MRIs (September 2010 - June 2017).
• Included patients under 18 years with DWI, gradient recalled-echo/SWI, circle of Willis MRA, and contrast-enhanced 3D neck MRA.
• Analyzed cases where brain MRI findings were reported as normal.

Main Results:

• Only one case (0.15%) showed abnormal neck MRA findings with normal brain MRI results (DWI, SWI/GRE, and CoW MRA).
• 681 patients were screened, highlighting the rarity of positive findings in this cohort.
• Routine neck MRA in this setting yielded minimal additional diagnostic information.

Conclusions:

• Routine contrast-enhanced neck MRA has an extremely low diagnostic yield in pediatric stroke patients with normal initial brain MRI findings.
• The addition of neck MRA to routine pediatric stroke MRI protocols is not cost-effective.
• Neck MRA should be reserved for cases with initial abnormalities on brain sequences or specific clinical indications like atypical presentations or recurrent strokes.