Diagnosing acute stroke with magnetic resonance imaging (MRI) calls for caution: computed tomography (CT) is preferable for standard care

Abstract

This is the second of an unplanned series of articles about the doubts that arise when young doctors have to care for medical experts. The availability and quality of evidence that medical experts have built up may not help novice doctors in friendly clinical decision-making (i.e., whether a treatment will do more good than harm). In the first article we analysed the case of Emeritus Professor Crow, an intermediate-risk patient for pulmonary embolism in whom the benefit of thrombolysis was disputable [1]. Today we face another difficult decision: whether magnetic resonance imaging (MRI) is preferable to computed tomography (CT) for diagnosing acute stroke. You are the physician on duty at the emergency department (ED), when Professor Peacock, a 71-year-old professor of neurology, enters with a right hemiplegia [2]. While starting to collect clinical data and ordering studies, you remember that, five years ago, you attended Prof. Peacock’s speech at the National Stroke Conference. As he is supposed to be a field expert in stroke management, you feel under pressure. You would like to engage Prof. Peacock in every phase of diagnosis and treatment: the physician-patient is well-informed, and his decision may follow different strategies from less-informed patients [3]. Then too, you are well aware that, to disseminate their opinions and dominance, experts commonly disagree with young doctors, so it would be wise to listen to his advice. Unfortunately, he is aphasic. As his wife reports, he started complaining about walking and other motor disorders about an hour prior to admission. There is still time for thrombolysis, if there are no contraindications. The resident on duty, who recently attended a course on neuroimaging, recalls that MRI is excellent for identifying ischemic brain lesions. ‘We should offer him the most recent and innovative management’, the resident is convinced. ‘I’ve never requested an MRI for a suspected acute stroke’ you reply in a low voice, adding ‘What if there is a brain haemorrhage? Are you sure MRI is sufficiently sensitive in identifying cerebral bleeding?’‘No data were presented, only opinions’ the resident whispers. Despite the low voice, Prof. Peacock’s wife understands the doubt we are facing. She confidently presents a conclusion based on implicit values about the best: ‘He needs a cerebral MRI’ cutting off any further discussion for a moment. You are astonished. ‘Am I acting like a stubborn old physician refusing to utilise new technologies, or are the experts blindly trusting that new technologies can only be beneficial?’ Before calling the stroke experts on duty, you decide to take a quiet look at the Cochrane Library. The A. Squizzato (&) Department of Clinical Medicine, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, U.O. Medicina I–Ospedale di Circolo, VialeBorri 57, 21100 Varese, Italy e-mail: alexsquizzo@libero.it