Abstract
Acute stroke teams are challenged by IV-tPA decision making in patients with acute neurological symptoms when the diagnosis is unclear. The purpose of this study was to evaluate the ability of the rapid Brain Attack Team (BAT) MRI in selecting patients for IV-tPA administration who present acutely to the emergency room with stroke-like symptoms and an unclear diagnosis. Consecutive patients were identified who presented within 4.5 hours of onset of stroke-like symptoms and considered for treatment with IV-tPA. When the diagnosis was not clear, a 9-minute BAT MRI was obtained. Stroke risk factors and NIH stroke scale obtained on presentation were compared between patients in whom BAT MRI was obtained and those in whom BAT MRI was not obtained. Similarly, comparisons were made between patients in whom BAT MRI detected abnormalities and those in whom BAT MRI did not detect abnormalities. BAT MRIs were analyzed to determine if radiological findings impacted clinical management and discharge diagnosis. In a 30-month period, 432 patients presenting with acute stroke-like symptoms were identified. Of these patients, 82 received BAT MRI. Patients receiving BAT MRI were younger, more likely to be smokers, and less likely to be selected for IV-tPA administration compared to those in whom a more definitive diagnosis of stroke precluded a BAT MRI. Of the 82 BAT MRIs, 25 were read as positive for acute ischemia. The patients with acute ischemia on BAT MRI were older, more likely to be males, have a history of hypercholesterolemia and atrial fibrillation, and more likely to be selected for IV-tPA administration compared to those with a negative BAT MRI. Of the 57 BAT MRIs read as negative for acute ischemia or hemorrhage, discharge diagnoses included TIA, MRI negative stroke, conversion/functional disorder, and multiple other illnesses. In patients with acute stroke-like symptoms, BAT MRI may be used to confirm acute ischemic stroke, exclude stroke mimics, and assess candidacy for IV-tPA.
Highlights
Rapid diagnostic evaluation is essential to the effective treatment of acute ischemic stroke (AIS)
The two groups were similar in gender and race composition, prevalence of diabetes, hypercholesterolemia, coronary artery disease, atrial fibrillation, history of stroke/transient ischemic attacks (TIA) and NIH stroke scale (NIHSS) assessed on presentation
The patients with acute ischemia on Brain Attack Team (BAT) MRI were older, more likely to be males (72% vs. 47%; p=0.04), more likely to have hypercholesterolemia (60% vs. 28%; p=0.01), have atrial fibrillation (32% vs. 5%; p=0.003) and more likely to be selected for Intravenous tissue plasminogen activator (IV-tPA) administration (24% vs. 0%; p=0.001) compared to those in whom no acute ischemia was detected by Brain Attack Team MRI (BAT MRI) (Table 3)
Summary
Rapid diagnostic evaluation is essential to the effective treatment of acute ischemic stroke (AIS). Head CT can be performed quickly and is the standard of care when patients present acutely with symptoms suspicious for AIS. This mode of imaging, is not sensitive in detecting AIS and is primarily used to eliminate the possibility of a hemorrhage [4]. The purpose of this study was to evaluate the ability of the rapid Brain Attack Team (BAT) MRI in selecting patients for IV-tPA administration who present acutely to the emergency room with strokelike symptoms and an unclear diagnosis
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