PMID- 26892282
OWN - NLM
STAT- MEDLINE
DCOM- 20160909
LR  - 20181113
IS  - 1524-4628 (Electronic)
IS  - 0039-2499 (Linking)
VI  - 47
IP  - 4
DP  - 2016 Apr
TI  - Streamlined Hyperacute Magnetic Resonance Imaging Protocol Identifies Tissue-Type
      Plasminogen Activator-Eligible Stroke Patients When Clinical Impression Is Stroke
      Mimic.
PG  - 1012-7
LID - 10.1161/STROKEAHA.115.011913 [doi]
AB  - BACKGROUND AND PURPOSE: 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. METHODS: 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). RESULTS: 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). CONCLUSIONS: A streamlined hMRI protocol permitted tPA
      administration to a small, but significant, subset of AIS patients initially
      considered to have SM.
CI  - (c) 2016 American Heart Association, Inc.
FAU - Goyal, Manu S
AU  - Goyal MS
AD  - 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.).
FAU - Hoff, Brian G
AU  - Hoff BG
AD  - 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.).
FAU - Williams, Jennifer
AU  - Williams J
AD  - 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.).
FAU - Khoury, Naim
AU  - Khoury N
AD  - 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.).
FAU - Wiesehan, Rebecca
AU  - Wiesehan R
AD  - 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.).
FAU - Heitsch, Laura
AU  - Heitsch L
AD  - 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.).
FAU - Panagos, Peter
AU  - Panagos P
AD  - 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.).
FAU - Vo, Katie D
AU  - Vo KD
AD  - 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.).
FAU - Benzinger, Tammie
AU  - Benzinger T
AD  - 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.).
FAU - Derdeyn, Colin P
AU  - Derdeyn CP
AD  - 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.).
FAU - Lee, Jin-Moo
AU  - Lee JM
AD  - 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.).
FAU - Ford, Andria L
AU  - Ford AL
AD  - 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.
LA  - eng
GR  - K23 NS069807/NS/NINDS NIH HHS/United States
GR  - R01 NS085419/NS/NINDS NIH HHS/United States
GR  - P50 NS055977/NS/NINDS NIH HHS/United States
GR  - UL1 TR000448/TR/NCATS NIH HHS/United States
GR  - UL1 TR001425/TR/NCATS NIH HHS/United States
PT  - Journal Article
PT  - Research Support, N.I.H., Extramural
DEP - 20160218
PL  - United States
TA  - Stroke
JT  - Stroke
JID - 0235266
RN  - 0 (Fibrinolytic Agents)
RN  - EC 3.4.21.68 (Tissue Plasminogen Activator)
SB  - IM
MH  - Administration, Intravenous
MH  - Adult
MH  - Aged
MH  - Brain Ischemia/drug therapy/*pathology
MH  - Clinical Decision-Making
MH  - Diagnosis, Differential
MH  - Female
MH  - Fibrinolytic Agents/*therapeutic use
MH  - Humans
MH  - Magnetic Resonance Imaging/*methods
MH  - Male
MH  - Middle Aged
MH  - Stroke/drug therapy/*pathology
MH  - Tissue Plasminogen Activator/*therapeutic use
MH  - Treatment Outcome
PMC - PMC4811697
MID - NIHMS755806
OTO - NOTNLM
OT  - magnetic resonance imaging
OT  - stroke
OT  - therapy
OT  - thrombolytic
OT  - tissue-type plasminogen activator
EDAT- 2016/02/20 06:00
MHDA- 2016/09/10 06:00
CRDT- 2016/02/20 06:00
PHST- 2015/10/23 00:00 [received]
PHST- 2016/01/20 00:00 [accepted]
PHST- 2016/02/20 06:00 [entrez]
PHST- 2016/02/20 06:00 [pubmed]
PHST- 2016/09/10 06:00 [medline]
AID - STROKEAHA.115.011913 [pii]
AID - 10.1161/STROKEAHA.115.011913 [doi]
PST - ppublish
SO  - Stroke. 2016 Apr;47(4):1012-7. doi: 10.1161/STROKEAHA.115.011913. Epub 2016 Feb
      18.