Journal article
Streamlined Hyperacute Magnetic Resonance Imaging Protocol Identifies Tissue-Type Plasminogen Activator-Eligible Stroke Patients When Clinical Impression Is Stroke Mimic
Stroke (1970), Vol.47(4), pp.1012-1017
04/2016
DOI: 10.1161/STROKEAHA.115.011913
PMCID: PMC4811697
PMID: 26892282
Abstract
Stroke mimics (SM) challenge the initial assessment of patients presenting with possible acute ischemic stroke (AIS). When SM is considered likely, intravenous tissue-type plasminogen activator (tPA) may be withheld, risking an opportunity to treat AIS. Although computed tomography is routinely used for tPA decision making, magnetic resonance imaging (MRI) may diagnose AIS when SM is favored but not certain. We hypothesized that a hyperacute MRI (hMRI) protocol would identify tPA-eligible AIS patients among those initially favored to have SM.
A streamlined hMRI protocol was designed based on barriers to rapid patient transport, MRI acquisition, and post-MRI tPA delivery. Neurologists were trained to order hMRI when SM was favored and tPA was being withheld. The use of hMRI for tPA decision making, door-to-needle times, and outcomes were compared before hMRI implementation (pre-hMRI: August 1, 2011 to July 31, 2013) and after (post-hMRI, August 1, 2013, to January 15, 2015).
Post hMRI, 57 patients with suspected SM underwent hMRI (median MRI-order-to-start time, 29 minutes), of whom, 11 (19%) were diagnosed with AIS and 7 (12%) received tPA. Pre-hMRI, no tPA-treated patients were screened with hMRI. Post hMRI, 7 of 106 (6.6%) tPA-treated patients underwent hMRI to aid in decision making because of suspected SM (0% versus 6.6%; P=0.001). To ensure standard care was maintained after implementing the hMRI protocol, pre- versus post-hMRI tPA-treated cohorts were compared and did not differ: door-to-needle time (39 versus 37 minutes; P=0.63), symptomatic hemorrhage rate (4.5% versus 1.9%; P=0.32), and favorable discharge location (85% versus 89%; P=0.37).
A streamlined hMRI protocol permitted tPA administration to a small, but significant, subset of AIS patients initially considered to have SM.
Details
- Title: Subtitle
- Streamlined Hyperacute Magnetic Resonance Imaging Protocol Identifies Tissue-Type Plasminogen Activator-Eligible Stroke Patients When Clinical Impression Is Stroke Mimic
- Creators
- Colin P Derdeyn - From the Mallinckrodt Institute of Radiology (M.S.G., K.D.V., T.B., C.P.D., J.-M.L.), Department of Neurology (R.W., C.P.D., J.-M.L., A.L.F.), Division of Emergency Medicine (L.H., P.P.), and Department of Neurological Surgery (C.P.D.), Washington University School of Medicine, St Louis, MO; Department of Operational Excellence (B.G.H.) and Department of Emergency Services (J.W.), Barnes-Jewish Hospital, St Louis, MO; Department of Neuroradiology, University of Montreal, Montreal, Quebec, Canada (N.K.); and Department of Biomedical Engineering, Washington University, St Louis, MO (J.-M.L.)Manu S Goyal - From the Mallinckrodt Institute of Radiology (M.S.G., K.D.V., T.B., C.P.D., J.-M.L.), Department of Neurology (R.W., C.P.D., J.-M.L., A.L.F.), Division of Emergency Medicine (L.H., P.P.), and Department of Neurological Surgery (C.P.D.), Washington University School of Medicine, St Louis, MO; Department of Operational Excellence (B.G.H.) and Department of Emergency Services (J.W.), Barnes-Jewish Hospital, St Louis, MO; Department of Neuroradiology, University of Montreal, Montreal, Quebec, Canada (N.K.); and Department of Biomedical Engineering, Washington University, St Louis, MO (J.-M.L.)Jennifer Williams - From the Mallinckrodt Institute of Radiology (M.S.G., K.D.V., T.B., C.P.D., J.-M.L.), Department of Neurology (R.W., C.P.D., J.-M.L., A.L.F.), Division of Emergency Medicine (L.H., P.P.), and Department of Neurological Surgery (C.P.D.), Washington University School of Medicine, St Louis, MO; Department of Operational Excellence (B.G.H.) and Department of Emergency Services (J.W.), Barnes-Jewish Hospital, St Louis, MO; Department of Neuroradiology, University of Montreal, Montreal, Quebec, Canada (N.K.); and Department of Biomedical Engineering, Washington University, St Louis, MO (J.-M.L.)Brian G Hoff - From the Mallinckrodt Institute of Radiology (M.S.G., K.D.V., T.B., C.P.D., J.-M.L.), Department of Neurology (R.W., C.P.D., J.-M.L., A.L.F.), Division of Emergency Medicine (L.H., P.P.), and Department of Neurological Surgery (C.P.D.), Washington University School of Medicine, St Louis, MO; Department of Operational Excellence (B.G.H.) and Department of Emergency Services (J.W.), Barnes-Jewish Hospital, St Louis, MO; Department of Neuroradiology, University of Montreal, Montreal, Quebec, Canada (N.K.); and Department of Biomedical Engineering, Washington University, St Louis, MO (J.-M.L.)Naim Khoury - From the Mallinckrodt Institute of Radiology (M.S.G., K.D.V., T.B., C.P.D., J.-M.L.), Department of Neurology (R.W., C.P.D., J.-M.L., A.L.F.), Division of Emergency Medicine (L.H., P.P.), and Department of Neurological Surgery (C.P.D.), Washington University School of Medicine, St Louis, MO; Department of Operational Excellence (B.G.H.) and Department of Emergency Services (J.W.), Barnes-Jewish Hospital, St Louis, MO; Department of Neuroradiology, University of Montreal, Montreal, Quebec, Canada (N.K.); and Department of Biomedical Engineering, Washington University, St Louis, MO (J.-M.L.)Rebecca Wiesehan - From the Mallinckrodt Institute of Radiology (M.S.G., K.D.V., T.B., C.P.D., J.-M.L.), Department of Neurology (R.W., C.P.D., J.-M.L., A.L.F.), Division of Emergency Medicine (L.H., P.P.), and Department of Neurological Surgery (C.P.D.), Washington University School of Medicine, St Louis, MO; Department of Operational Excellence (B.G.H.) and Department of Emergency Services (J.W.), Barnes-Jewish Hospital, St Louis, MO; Department of Neuroradiology, University of Montreal, Montreal, Quebec, Canada (N.K.); and Department of Biomedical Engineering, Washington University, St Louis, MO (J.-M.L.)Laura Heitsch - From the Mallinckrodt Institute of Radiology (M.S.G., K.D.V., T.B., C.P.D., J.-M.L.), Department of Neurology (R.W., C.P.D., J.-M.L., A.L.F.), Division of Emergency Medicine (L.H., P.P.), and Department of Neurological Surgery (C.P.D.), Washington University School of Medicine, St Louis, MO; Department of Operational Excellence (B.G.H.) and Department of Emergency Services (J.W.), Barnes-Jewish Hospital, St Louis, MO; Department of Neuroradiology, University of Montreal, Montreal, Quebec, Canada (N.K.); and Department of Biomedical Engineering, Washington University, St Louis, MO (J.-M.L.)Peter Panagos - From the Mallinckrodt Institute of Radiology (M.S.G., K.D.V., T.B., C.P.D., J.-M.L.), Department of Neurology (R.W., C.P.D., J.-M.L., A.L.F.), Division of Emergency Medicine (L.H., P.P.), and Department of Neurological Surgery (C.P.D.), Washington University School of Medicine, St Louis, MO; Department of Operational Excellence (B.G.H.) and Department of Emergency Services (J.W.), Barnes-Jewish Hospital, St Louis, MO; Department of Neuroradiology, University of Montreal, Montreal, Quebec, Canada (N.K.); and Department of Biomedical Engineering, Washington University, St Louis, MO (J.-M.L.)Katie D Vo - From the Mallinckrodt Institute of Radiology (M.S.G., K.D.V., T.B., C.P.D., J.-M.L.), Department of Neurology (R.W., C.P.D., J.-M.L., A.L.F.), Division of Emergency Medicine (L.H., P.P.), and Department of Neurological Surgery (C.P.D.), Washington University School of Medicine, St Louis, MO; Department of Operational Excellence (B.G.H.) and Department of Emergency Services (J.W.), Barnes-Jewish Hospital, St Louis, MO; Department of Neuroradiology, University of Montreal, Montreal, Quebec, Canada (N.K.); and Department of Biomedical Engineering, Washington University, St Louis, MO (J.-M.L.)Tammie Benzinger - From the Mallinckrodt Institute of Radiology (M.S.G., K.D.V., T.B., C.P.D., J.-M.L.), Department of Neurology (R.W., C.P.D., J.-M.L., A.L.F.), Division of Emergency Medicine (L.H., P.P.), and Department of Neurological Surgery (C.P.D.), Washington University School of Medicine, St Louis, MO; Department of Operational Excellence (B.G.H.) and Department of Emergency Services (J.W.), Barnes-Jewish Hospital, St Louis, MO; Department of Neuroradiology, University of Montreal, Montreal, Quebec, Canada (N.K.); and Department of Biomedical Engineering, Washington University, St Louis, MO (J.-M.L.)Jin-Moo Lee - From the Mallinckrodt Institute of Radiology (M.S.G., K.D.V., T.B., C.P.D., J.-M.L.), Department of Neurology (R.W., C.P.D., J.-M.L., A.L.F.), Division of Emergency Medicine (L.H., P.P.), and Department of Neurological Surgery (C.P.D.), Washington University School of Medicine, St Louis, MO; Department of Operational Excellence (B.G.H.) and Department of Emergency Services (J.W.), Barnes-Jewish Hospital, St Louis, MO; Department of Neuroradiology, University of Montreal, Montreal, Quebec, Canada (N.K.); and Department of Biomedical Engineering, Washington University, St Louis, MO (J.-M.L.)Andria L Ford - From the Mallinckrodt Institute of Radiology (M.S.G., K.D.V., T.B., C.P.D., J.-M.L.), Department of Neurology (R.W., C.P.D., J.-M.L., A.L.F.), Division of Emergency Medicine (L.H., P.P.), and Department of Neurological Surgery (C.P.D.), Washington University School of Medicine, St Louis, MO; Department of Operational Excellence (B.G.H.) and Department of Emergency Services (J.W.), Barnes-Jewish Hospital, St Louis, MO; Department of Neuroradiology, University of Montreal, Montreal, Quebec, Canada (N.K.); and Department of Biomedical Engineering, Washington University, St Louis, MO (J.-M.L.). forda@neuro.wustl.edu
- Resource Type
- Journal article
- Publication Details
- Stroke (1970), Vol.47(4), pp.1012-1017
- Publisher
- United States
- DOI
- 10.1161/STROKEAHA.115.011913
- PMID
- 26892282
- PMCID
- PMC4811697
- ISSN
- 0039-2499
- eISSN
- 1524-4628
- Grant note
- P50 NS055977 / NINDS NIH HHS R01 NS085419 / NINDS NIH HHS K23 NS069807 / NINDS NIH HHS UL1 TR000448 / NCATS NIH HHS UL1 TR001425 / NCATS NIH HHS
- Language
- English
- Date published
- 04/2016
- Academic Unit
- Neurology; Radiology; Iowa Neuroscience Institute; Neurosurgery
- Record Identifier
- 9984020757602771
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