Despite advances in imaging, the radiologic component of the tPA decision-making is predicated on a non-contrast CT head, guided by the clinical history and exam. Sometimes, however, the clinical exam or history can be confusing and the CT scan does not provide much additional diagnostic data; stroke mimics make up anywhere between 1-16% of the patients presenting with stroke-like symptoms at large institutions. The use of a hyperacute MRI (hMRI) can help differentiate strokes from stroke mimics, and potentially minimize tPA given to mimics and, perhaps more importantly, ensure that tPA is not withheld from patients who are suspected to be mimics, but are actually strokes.
Here, the authors report an institution-specific streamlined hMRI protocol in the setting of acute stroke. The hMRI protocol described here provides DWI/ADC, FLAIR, and T2*GRE sequences in just under 6 minutes. In order to avoid overutilization, physicians were instructed to order the hMRI only when the initial diagnostic impression was likely stroke mimic, but ischemic stroke could not be entirely ruled out and, if MRI was not available at their institution, the physician would not give the patient tPA. 57 patients, identified as stroke mimics, underwent the hMRI protocol, with 11 having the final diagnosis of stroke, 4 with the final diagnosis of TIA, and the remaining diagnoses being conversion disorder, seizure, complicated migraine, and other. Seven of the 11 stroke patients received IV tPA. There were no differences in door-to-needle, onset-to-needle, or door-to-arrival times for all IV tPA treated patients pre- and post-hMRI; however, the door-to-needle time for tPA treated patients screened with CT alone were significantly shorter than the 7 tPA patients screened with hMRI (37 minutes vs 112 minutes).
Although the overall metrics (door to needle, onset to needle, etc) did not change much with the institution of hMRI protocol, likely due to the minority of patients who went on to receive tPA under the protocol, using the hMRI protocol did lead to substantially longer door-to-needle times for patients who received tPA. However, longer door-to-needle times are preferable than withholding tPA, and it is probable that these patients, having been initially identified as stroke mimics, would not have received tPA otherwise. The use of a hMRI does have its limitations, given it is not widely available and many institutions may not have the resources to staff it emergently, but in institutions where the resources are available, it could potentially increase tPA usage to patients with strokes and decrease tPA usage to patients without strokes.
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Age Excludes Women from Intracerebral Hemorrhage Trials #ICH #GoRedforWomen https://t.co/UPTXGdOVDw
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Check out Highlights from the February 2021 issue of #Stroke, now available online. #AHAJournals https://t.co/d9DqBrpYTf https://t.co/GD1yr4Qj8k

Stroke February Cover Figure: Despite similar risk of #stroke recurrence, there are #sex-related differences in clinical features, patterns of acute ischemic lesions, etiology and outcomes after #TIA. #AHAJournals #GoRedforWomen @DaniVzquez @ictuslleida https://t.co/HOxV5szfZu https://t.co/H0YYYDSJh2

Lower rates of #women enrollment in #ICH trials may be due to older age of women (> 80y) and not selection bias in recruiting participants. #GoRedforWomen #AHAJournals #Stroke @tatianagreige https://t.co/TdeNJlS8Kt https://t.co/mXVerxm1dQ

#STROKE Prospective study found #pregnancy did not affect hemorrhagic risk among #women with #CavernousMalformations #CCM #GoRedforWomen #AHAJournals @NycoleKJosephMD https://t.co/dHayX9CqqH https://t.co/NytMfbqDrB

#STROKE Sex-related differences in #TIA presentation and outcomes: #Women were more likely to have non-definitive TIA events. However, those with definitive #TIA had higher risk of stroke recurrence #GoRedforWomen #AHAJournals @DaniVzquez @ictuslleida https://t.co/W35OsIoI1S https://t.co/DZXolRMihl

ADVANCES IN STROKE: Drs. Cheryl Bushnell & Moira K. Kapral @moirakapral summarize studies highlighting sex differences in efficacy of treatment and outcomes after #stroke. #GoRedforWomen #AHAJournals https://t.co/gN8slKvtQY
How do we ↑ #women enrollment in stroke clinical trials? Remove upper age limits as exclusion criterion, ↑ research on topic, & ↑ # of women leaders in #stroke clinical trials. #GoRedforWomen #AHAJournals https://t.co/v8AhlX4rGZ
#Women had lower risk for #stroke than men; however, this was dependent on age & type of stroke. Women had higher risk of #SAH throughout lifespan. #GoRedforWomen #AHAJournals @moirakapral @amyyu_md https://t.co/JPpw5a0mDJ https://t.co/DnlgJe6TxW

#STROKE Inconsistent sex differences in adverse outcomes between #CarotidEndarterectomy and #CarotidStenting for severe symptomatic #CarotidStenosis: Is sex a #CEA vs. #CAS effect modifier? #GoRedforWomen #AHAJournals https://t.co/AuVz6UffiU https://t.co/zVE7YY1eMm

German #stroke registry: #Women had higher disability on admission, but after adjustment, had lower mortality & better functional outcomes. #IVtPA disparities improved along study yrs, & women received #EVT more often #GoRedforWomen @andkarch @annabonkhoff https://t.co/yRYanFc5s9 https://t.co/bKCYn4vJ3S

#STROKE Large cohort study in the #UK shows higher incidence of first-ever stroke and subsequent major adverse outcomes in #women #GoRedforWomen #AHAJournals @rkakyea @GeorgeNtaios https://t.co/V4HT2uvH7r https://t.co/AiG35NXkyd

The Feb. issue of #Stroke is now available online. Check out the issue for the latest Original Contributions, Advances in Stroke, Topical Reviews, Comments and Opinions, and more. The issue also features a series of #GoRedforWomen articles. #AHAJournals https://t.co/D5ZHKltHQf https://t.co/JEQEDC91fi

Contributors
Elizabeth M. Aradine, DO*
Yasmin Aziz, MD
Alan C. Cameron, MB ChB, BSc (Hons), MRCP*
Isabella Canavero, MD
Kat Dakay, DO*
Saurav Das, MD
Wern Yew Ding, MBChB, MRCP
Tolga Daniel Dittrich, MD
Melanie R. F. Greenway, MD
Parneet Grewal, MD*
Deepak Gulati, MD*
Ying Gue, MB ChB, PhD
Maria Gutierrez, MD
Jennifer Harris, MD*
Sara Hassani, MD, MHS
Kathryn S. Hayward, PhD, PT*
Muhammad Rizwan Husain, MD
Abdullah Ibish, MD
Richard Jackson, MD*
Nurose Karim, MD
Gurmeen Kaur, MBBS*
Muhammad Taimoor Khan, MD*
Manya Khrlobyan, DO, MS
Song J. Kim, MD
Andy Lim, MBBS, BMedSci, MBA, FACEM, GAICD
Ammad Mahmood, MBChB, BMedSci
Sishir Mannava, MD
Csilla Manoczki, MD
Lukas Mayer, MD
Thomas Meinel, MD
Mei Ngun, MBBS
Kevin O’Connor, MD
Piyush Ojha, MBBS, MD, DM*
Lin Kooi Ong, PhD*
Raffaele Ornello, MD*
Tyler Owens, DO
Lina Palaiodimou, MD*
Lauren A. Peruski, DO
Robert W. Regenhardt, MD, PhD*
Alejandro Rodríguez-Vázquez, MD
Jeffrey Russ, MD, PhD
Setareh Salehi Omran, MD
Aurora Semerano, MD
Vera Sharashidze, MD
Shashank Shekhar, MD, MS*
Ravinder-Jeet Singh, MBBS, DM*
Burton J. Tabaac, MD*
Ericka Samantha Teleg, MD
Francesca Tinelli, MS
Melissa Trotman-Lucas, PhD*
Walter Valesky, MD
Tamaya Van Criekinge, PT*
Christopher Wilkins, MD
Sohei Yoshimura, MD, PhD
Elena Zapata-Arriaza, MD, PhD*
*Senior Blogger
Categories
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- “You can observe a lot just by watching:” more clinical data is better when diagnosing childhood stroke.
- A look at another ASPECT of the ASPECTS score
- A New Tool to Quantify Severity, Extent and Course of Focal Cerebral Arteriopathy of Childhood Could Be Used for Treatment Trials
- A Non-Invasive Approach to Monitor Mechanical Thrombectomy Patients Using Near-Infrared Spectroscopy
- A Stitch in Time? Onset to Imaging Time Does Not Correlate with DWI Volume in Large Anterior Circulation Occlusions
- Absolute Monocyte Count Associated with early ICH Mortality
- Acute Stroke Neuroimaging, Endovascular Reperfusion Therapy and Outcome
- Add Some Color To Your Life: using color-coded FLAIR to detect signal change more reliably
- Antiplatelet use is associated with intraplaque hemorrhage. Is this clinically significant?
- Arterial Spin Labeling MRI Estimation of Antegrade and Collateral Flow in Unilateral Middle Cerebral Artery Stenosis
- Arterial wall remodeling in intracranial stenosis with high resolution MRI
- Article Commentary: “Cerebral Blood Flow Predicts the Infarct Core”
- Article Commentary: “Clot-Based Radiomics Predict a Mechanical Thrombectomy Strategy for Successful Recanalization in Acute Ischemic Stroke”
- Article Commentary: “Early Brain Imaging Shows Increased Severity of Acute Ischemic Strokes With Large Vessel Occlusion in COVID-19 Patients”
- Article Commentary: “Resting-State Functional Connectivity Magnetic Resonance Imaging and Outcome after Acute Stroke”
- Assessing Mismatch Using DWI and FLAIR Predicts Favorable Outcome Following Recanalization With IV-tPA
- Author Interview: Dr. Mayank Goyal on "Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging”
- Author Interview: Prof. Marc Ribo on “Deep Learning Based Software to Identify Large Vessel Occlusion on Noncontrast Computed Tomography”
- Author Interview: Ramin Zand, MD, and Vida Abedi, PhD
- Author Interview: Seung-Hoon Lee, MD, PhD
- Blending In: The use of the CT “Blend sign” to Predict Early Hematoma Growth
- Blocked drains and Amyloid deposition – Role of white matter perivascular spaces
- Blood Biomarkers in Ischemic Stroke
- Brain MRI findings fail to suspect Fabry disease in young patients with an acute cerebrovascular event
- Can ambulatory cardiac telemetry tell us more than we know?
- Carotid Intima-Media Thickness and Cognitive Impairment in Older Adults
- Cerebral blood flow and cerebral small vessel disease: the chicken and egg situation
- Cerebral hemodynamics in chronic carotid occlusion: a novel approach to study “Penumbra” in chronic intracranial hypoperfusion
- Cerebral Microbleeds and Intracerebral Hemorrhage
- Circumferential Aneruysmal Wall Enhancement on MRI as a Marker of Aneurysm Instability
- Clear as Mud - Heterogeneity in the Workup of Cryptogenic Stroke
- Clinical outcome beyond 6 hours in acute infarction may depend on degree of ischemia
- Clinically Relevant IV-TPA Related Intracerebral Hemorrhage
- Cohort Gives Insight into the State of Current Treatments and Outcomes for Pediatric Cavernous Sinus Thrombosis
- Collateral Circulation Status as Assessed by MR-Perfusion Modulates Relationship Between Time and Development of FLAIR Signal
- Collaterals vs. Time in the Natural History of Acute Ischemic Stroke
- Comprehensive evaluation of the relationship of abnormal brain lesions and cognitive function
- Contrast Enhanced Ultrasound: The Wave of the Future for evaluation of Carotid Arteries?
- Cortical Morphology and White Matter Hyperintensities
- Cortical Venous Filling in Dynamic CTA Predicts Clinical Outcome in Proximal MCA Occlusion
- CT based measurements of peri-hematomal edema in intracerebral hemorrhage: Moving us one step closer
- CT perfusion based selection inadequate for stratifying patients for intra-arterial treatment
- CTP to recanalization time: the key for accurate determination of infarct core?
- Determining Rates of Dementia in Stroke/TIA Patients – The Impact of Selection Bias
- Differential effect of baseline CTA Collaterals on Clinical Outcome in patients enrolled in the IMS-III trial
- Does an ER admission and CT scan examination for peripheral vertigo reflect an increased risk for stroke in the short term?
- Does an increase in parent vessel diameter predict the occurrence of a stroke in that territory?
- Does plaque echolucency increase risk for ipsilateral stroke in patients with asymptomatic Carotid stenosis?
- Does stroke cause reactive amyloid-beta deposition in nondemented patients? Results from a 11C-PiB-PET longitudinal cohort
- Examining the relationship between cerebrovascular disease burden and cognition
- Experimental CT Perfusion parameter a good surrogate for angiographic collaterals in large artery acute ischemic stroke
- Explicit Diagnostic Criteria: Gaining Ground in the Perpetual Struggle to Elucidate TIA
- FLAIR Vascular Hyperintensities in Bordezone Strokes
- FLAIR-rSI is Time, and Time is Brain, so FLAIR-rSI is Brain?
- Follow up imaging is clinically and economically futile in patients with peri-mesencephalic subarachnoid hemorrhage
- Fractional Anisotropy Change in Acute Phase of Stroke and its Correlation with Motor Recovery at 3 Months
- Genetic Factors that Impact White Matter Hyperintensities Increase Risk of Lacunar Stroke
- Getting Hot in Here: Increased Temperature Difference Values in Culprit Carotid Arteries by Microwave Radiometry
- Hide and Seek: Using Cardiac MRI to Find a Hidden Clot in ESUS
- High Sensitivity of Diffusion- and Perfusion-Weighted Imaging for Diagnosing Acute Stroke
- Hints of the Heart: Predictors of Finding Occult Atrial Fibrillation after Stroke
- Imaging may help fill knowledge lacunae in lacunar strokes!
- Improved Diagnostic Accuracy of Non-Occlusive Intracranial Vasculopathies With the Use of Vessel Wall Imaging
- In Search for a Potential Biomarker for Small Vessel Disease: Is Plasma Aβ Level the Answer?
- In Search of an IV-tPA Biomarker for LVO
- Increased motor cortex functional connectivity after subcortical stroke: An anatomic correlate to stroke recovery
- Infarct Distribution Following Endovascular Therapy in Large Vessel Occlusion Stroke
- Infarct Growth in the Early Time Windows: The Time Paradox
- Intracerebral Hemorrhage Shape Predicts the Risk of Intracerebral Hematoma Expansion
- Intracranial Arterial Remodeling and the Risk of Stroke
- Intracranial Atherosclerosis and Coronary Atherosclerosis: Two Twigs from the Same Vascular Branch
- Is a CT Within 6 Hours of Headache Onset Enough to Rule Out SAH?
- Ischemic Penumbra and the Race Against Time. Or Is It?
- It’s tough to make predictions, especially about the future but DWI reversal after tPA for stroke helps
- Knocking Down Barriers: Relevance of BBB Disruption after Endovascular Treatment of Ischemic Stroke
- Large Core at Presentation Does Not Essentially Translate Into Poor Outcomes, May Be Amenable to Treatment in Select Patients
- Location, Location, Location: Post-Stroke Cognitive Outcome Determined by Location of Stroke
- Looking Beyond the Primary Infarction: Remote Regional Brain Atrophy After Stroke
- Looking for markers to predict cerebral amyloid angiopathy and cerebral superficial siderosis
- Magnetic resonance “black blood” thrombus imaging found to have high sensitivity and specificity for cerebral venous sinus thrombosis in small prospective study
- MALCOLM: Identifying a maximum core lesion threshold in patients undergoing endovascular therapy
- Meta-Analysis Concludes Utility of CTA Spot Sign is Dependent Upon Timing and is Not Sufficient to Predict Hematoma Expansion in Acute ICH
- Migraine and small vessel disease: cause or effect?
- Missed Strokes in the ED: An Opportunity for Systems Change
- More Than Meets the Eye: Widespread White Matter Changes After Ischemic Stroke
- More Than Meets the MRI: Texture Analysis Shows Normal Appearing White Matter is Not So Normal in SVD, Predicts Cognitive Impairment and Decline
- MPRAGE - All the Rage for Identifying Basilar Intraplaque Hemorrhage
- MRI marker helps determine clot composition in acute stroke
- MRI-Based Assessment of Carotid Plaque Morphology
- Multimodal Stroke CT in the COVID-19 Era: More With Less
- Natural history of MR in minor ischemic stroke
- New multimodal imaging technique may lead to one-stop-shop for treatment of acute large vessel occlusion
- NIHSS Item Profiles as Predictor of Patient Outcome
- Non-disabling DWI negative strokes – Outcomes
- Novel means of identifying & quanitfying occult antegrade flow with brain vessel occlusion, a predictor of early recanalization
- On Brains and Machines: Artificial Intelligence and Stroke
- Optical Coherence Tomography: New Insights into Cerebral Vasculature
- Patient Selection for Endovascular Thrombectomy
- Perfusion MRI in Perinatal Stroke
- Peri-Hematomal Edema - It is Not The Leaky Blood Brain Barrier But What is it Then?
- Peri-Procedural Silent and Clinical Infarctions in Cardiovascular Procedures
- Poor collateral status is associated with poor clinical outcomes
- Predicting convalescent rehabilitation outcomes in ischemic stroke patients
- Predicting Hemorrhagic Transformation Following tPA Using CT and CT Perfusion Images
- Prediction factors for paroxysmal atrial fibrillation? The results of the TRELAS study
- Prediction models for functional outcome in acute ischemic stroke patients. Closer to the truth?
- Presence of cerebral microbleeds is not associated with an increased risk of poor 3-month outcomes after tPA for acute ischemic stroke
- Prevalence of Cerebellar Cortical Infarct Cavities: Correlation with Risk Factors and MRI Markers of Cerebrovascular Disease
- Rate of Contrast Extravasation on CTA Further Predicts Hematoma Expansion
- Relevance of Carotid Plaque Characteristics for Ischemic Stroke and Coronary Heart Disease
- Residual High Grade Stenosis of the Extracranial ICA after Treatment
- Risk stratification for paroxysmal atrial fibrillation using EKG metric a useful tool in acute ischemic stroke patients
- Severe leukoaraiosis attenuates classic NIHSS-bias of dominant hemispheric infarction.
- Small Vessel Disease is Associated With a Worse Outcome After Intracranial Hemorrhage
- Spinning to an Answer: Use of Arterial Spin Labeling for Arterial Occlusion Localization
- Square the circle: CTP or DWI for hyperacute stroke decision-making?
- Streamlined Hyperacute MRI Identifies tPA Eligible Stroke Patients Among Stroke Mimics
- Stroke Mechanism Suggested by Thrombus Permeability on CT Angiography
- Strokes Take Us Off Tract: White Matter Ischemic Changes in Hyperacute Ischemic Stroke
- Sum of Its Parts: NIHSS Item Profiles as a Predictor of Patient Outcome
- T2’ Mapping draws a finer line between dead brain and penumbra
- Technological advances in the calculation of hematoma volumes
- The Association of C-Reactive Protein and Amyloid Blood Biomarkers with Advanced Imaging Markers
- The continued search to better prognosticate patients receiving IV tPA External Validation of the BASIS and M1-BASIS in Thrombolysed Patients
- The Leakage Sign: A New Predictor for Hematoma Expansion in ICH
- The MoCA 5-minute Protocol for Cognitive Impairment Screening in Stroke/TIA Patients
- The MRI Spot Sign: A Marker of Clinical outcomes in Patients with Primary ICH
- The Swelling is Telling: Presence of Brain Edema Regardless of Stroke Severity Predicts Outcome
- Thrombus Length Estimation on Delayed Gadolinium-Enhanced T1
- Tick Tock Goes the Collateral Clock
- Ultrasound and clinical predictors of recurrent ischemia in symptomatic internal carotid artery occlusion
- Underneath the Surface: Sulcal Effacement with Preserved Gray-White Junction may be a sign of Reversible Ischemia
- Using CT Perfusion to Predict Hemorrhagic Transformation
- Using MRI-based Techniques for Easier Recognition of Hemodynamic Failure in Chronic Cerebrovascular Steno-Occlusive Disease
- Utility of screening digital subtraction angiography for cerebral vasospasm
- What Makes a Lacune?
- What’s the best way to predict outcome after endovascular treatment for stroke?
- When It Comes to Brain Hemorrhage: Location Matters
- White Matter Hyperintensity and Brain Atrophy — A New Imaging Measure of Cognitive Impairment
- ►epidemiology and genetics (92)
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- ►World Stroke Day (17)
Archives
Posts
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Carotid Artery Stenting vs Endarterectomy: Are Risks Different in Women and Men?
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Age Excludes Women from Intracerebral Hemorrhage Trials
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Characterizing Coronavirus and Stroke: A Review of “Acute Cerebrovascular Events in Hospitalized COVID-19 Patients”
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Article Commentary: “Risk of Distal Embolization From tPA (Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment”
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Routine CT Perfusion Imaging as Therapeutic Decision Support in LVO: Too Much of a Good Thing?
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