Addition of hyperacute MRI AIDS in patient selection, decreasing the use of endovascular stroke therapy.

Wisco, Dolora; Uchino, Ken; Saqqur, Maher; Gebel, James M; Aoki, Junya; Alam, Shazia; George, Pravin; Newey, Christopher R; Man, Shumei; Tateishi, Yohei; McNeil, Julie; Winfield, Michelle; Cheng-Ching, Esteban; Hui, Ferdinand K; Toth, Gabor; Bain, Mark; Rasmussen, Peter A; Masaryk, Thomas; Ruggieri, Paul; Hussain, Muhammad Shazam

BACKGROUND AND PURPOSE The failure of recent trials to show the effectiveness of acute endovascular stroke therapy (EST) may be because of inadequate patient selection. We implemented a protocol to perform pretreatment MRI on patients with large-vessel occlusion eligible for EST to aid in patient selection. METHODS We retrospectively identified patients with large-vessel occlusion considered for EST from January 2008 to August 2012. Patients before April 30, 2010, were selected based on computed tomography/computed tomography angiography (prehyperacute protocol), whereas patients on or after April 30, 2010, were selected based on computed tomography/computed tomography angiography and MRI (hyperacute MRI protocol). Demographic, clinical features, and outcomes were collected. Univariate and multivariate analyses were performed. RESULTS We identified 267 patients: 88 patients in prehyperacute MRI period and 179 in hyperacute MRI period. Fewer patients evaluated in the hyperacute MRI period received EST (85 of 88, 96.6% versus 92 of 179, 51.7%; P<0.05). The hyperacute-MRI group had a more favorable outcome of a modified Rankin scale 0 to 2 at 30 days as a group (6 of 66, 9.1% versus 33 of 140, 23.6%; P=0.01), and when taken for EST (6 of 63, 9.5% versus 17 of 71, 23.9%; P=0.03). On adjusted multivariate analysis, the EST in the hyperacute MRI period was associated with a more favorable outcome (odds ratio, 3.4; 95% confidence interval, 1.1-10.6; P=0.03) and reduced mortality rate (odds ratio, 0.16; 95% confidence interval, 0.03-0.37; P<0.001). CONCLUSIONS Implementation of hyperacute MRI protocol decreases the number of endovascular stroke interventions by half. Further investigation of MRI use for patient selection is warranted.