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Efficient Multimodal MRI Evaluation for Endovascular Thrombectomy of Anterior Circulation Large Vessel Occlusion
Kunakorn Atchaneeyasakul1, David S Liebeskind1, Reza Jahan1
1RRMC-UCLA Comprehensive Stroke Center, 710 Westwood Plaza, Los Angeles 90095, CA ,United States.
Background:
MRI and CT modalities are both current standard-of-care options for initial imaging in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). MR provides greater lesion conspicuity and spatial resolution, but few series have demonstrated multimodal MR may be performed efficiently.
Methods:
In a prospective comprehensive stroke center registry, we analyzed all anterior circulation LVO thrombectomy patients between 2012-2017 who: (1) arrived directly by EMS from the field, and (2) had initial NIHSS ≥6. Center imaging policy was multimodal MRI (including DWI/GRE/MRA w/wo PWI) as the initial evaluation in all patients without contraindications, and multimodal CT (including CT with CTA, w/wo CTP) in the remainder.
Results:
Among 106 EMS-arriving endovascular thrombectomy patients, initial imaging was MRI 62.3%, CT in 37.7%. MRI and CT patients were similar in age (72.5 vs 71.3), severity (NIHSS 16.4 v 18.2), and medical history, though MRI patients had longer onset-to-door times. Overall, door-to-needle (DTN) and door-to-puncture (DTP) times did not differ among MR and CT patients, and were faster for both modalities in 2015-2017 versus 2012-2014. In the 2015-2017 period, for MR-imaged patients, the median DTN 42m (IQR 34-55) surpassed standard (60m) and advanced (45m) national targets and the median DTP 86m (IQR 71-106) surpassed the standard national target (90m).
Conclusions:
AIS-LVO patients can be evaluated by multimodal MR imaging with care speeds faster than national recommendations for door-to-needle and door-to-puncture times. With its more sensitive lesion identification and spatial resolution, MRI remains a highly viable primary imaging strategy in acute ischemic stroke patients, though further workflow efficiency improvements are desirable.
Insights
Multimodal MRI is an efficient primary imaging strategy for acute ischemic stroke with large vessel occlusion (AIS-LVO), meeting and exceeding national targets for door-to-needle and door-to-puncture times.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- Acute ischemic stroke due to large vessel occlusion (AIS-LVO) requires prompt imaging for effective treatment.
- Both MRI and CT are standard-of-care, but MRI offers superior lesion conspicuity and resolution.
- Previous studies have not consistently demonstrated the efficiency of multimodal MRI in acute settings.
Purpose of the Study:
- To evaluate the efficiency and outcomes of using multimodal MRI as the primary imaging modality for AIS-LVO patients.
- To compare the door-to-needle (DTN) and door-to-puncture (DTP) times between MRI and CT imaging pathways.
- To assess if multimodal MRI can be performed efficiently within established stroke treatment timelines.
Main Methods:
- A prospective registry analysis of 106 anterior circulation LVO thrombectomy patients arriving via EMS with NIHSS ≥6.
- Patients received either multimodal MRI (DWI/GRE/MRA w/wo PWI) or multimodal CT (CT/CTA w/wo CTP) as their initial imaging.
- Data from 2012-2017 were analyzed, with a focus on comparing imaging modalities and time metrics.
Main Results:
- Multimodal MRI was used in 62.3% of patients, CT in 37.7%.
- Demographics and stroke severity were similar between MRI and CT groups, though MRI patients had longer onset-to-door times.
- In 2015-2017, MRI patients achieved median DTN of 42 minutes and DTP of 86 minutes, surpassing national targets.
Conclusions:
- Multimodal MRI is a viable and efficient primary imaging strategy for AIS-LVO patients.
- Care speeds for MRI imaging in AIS-LVO surpass national recommendations for DTN and DTP times.
- While efficient, further workflow optimization for multimodal MRI in acute stroke is beneficial.
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