Case: A 69 y/o man with PMH of DM II, HTN, HLD, CVA (5/2016), severe AS s/p aortic valve replacement

(1/2017), HFpEF, afib s/p DC cardioversion and catheter ablation, PE/DVT s/p IVC filter, COPD, and OSA
presenting to the ED after loss of consciousness and a fall down the stairs. He complains of dizziness and
lightheadedness every time he gets really frustrated or emotional, and also is complaining of diplopia
and RLE weakness (new from this episode) but his L sided weakness is unchanged from his stroke in
05/2016. His CT head w/o contrast was negative the first day he presented in the ED. Orthostatics were
negative, and the echocardiogram and EKG were negative for any changes. The patient is in sinus
rhythm.

Question: Should this patient have received an MRI when he first presented to the ED? Should this
patient receive an MRI right now, Day 4 after hospitalization?

P (Patient): elderly (>65) man with several risk factors for stroke

I (Intervention): MRI

C (Comparison): no MRI

O (Outcome): possible missed stroke in this patient with increased chances due to his several risk factors
(history of prior stroke, DM II, HTN, HLD) and increased mortality and morbidity as a result, decreased
quality of life

Research strategy:

1) Accessed UpToDate
2) Looked up MRI head
3) Click on Neuroimaging of acute ischemic stroke
4) Scroll to Computed Tomography and Magnetic Resonance Imaging and CT versus MRI
techniques in hyperacute stroke
5) Also accessed Dynamed
6) Looked up Neuroimaging for acute stroke
7) Scroll to most appropriate imaging studies for evaluating focal neurologic deficits or suspected
stroke are

UpToDate is a fantastic resource for evidence-based clinical practice. It has peer reviewed articles on
pretty much any medical topic and gives information about clinical presentation/diagnostic steps as well
as different options for treatment depending. With regards to MRI vs CT in this patient, UpToDate talks
about the sensitivities and specificities of each imaging modality, and give suggestions regarding other
imaging modalities as well. It also provides information about what one would see on the actual image,
and has links to example images.

Validity and Efficacy: A systematic review published in 2010 from the American Academy of Neurology
(AAN) concluded that MRI (DWI) is superior to noncontrast CT for the diagnosis of acute ischemic stroke
in patients presenting within 12 hours of symptom onset. There have also been large single-center case
series that have been done, showing the sensitivity of DWI for acute stroke to be 90%.

Results: In CT scans performed within 6 hours of stroke onset, the prevalence of early CT signs of brain
infarction was only 61%. The Alberta stroke program early CT score (ASPECTS) was developed to provide
a method to assess ischemic changes on CT head and in a prospective study with 100 patients, the
ability to detect early ischemic changes by ASPECTS was similar on noncontrast CT and MRI (diffusion-
weighted imaging). There was a study conducted that evaluated ~350 patients referred due to suspicion
for acute stroke (217 had a final clinical diagnosis of acute stroke). All patients had both brain MRI and
head CT and it was found that acute ischemic stroke was detected in more patients by MRI than by CT
(46% vs 10%), the difference was statistically significant. Acute intracranial hemorrhage was similar with
MRI and CT (6% vs 7%). The sensitivity for the detection of any acute stroke was much greater for MRI
than for CT (83% vs 26%) while the specificity was similar (98% vs 97%).

Dynamed mentioned that MRI may be more sensitive than CT for ischemic stroke, but that a CT scan for
emergency management decisions in most cases is enough and that immediate CT is considered to be
the most cost-effective approach for evaluating an possible acute stroke, with a CT being sensitive and
specific for a hemorrhage within the first 8 days of a stroke.

Conclusion: In this patient with multiple risk factors for a stroke (history of prior stroke, DM II, HTN,
HLD) presenting with loss of consciousness, we may want to consider an MRI given that he has new
neurological complaints (RLE weakness, diplopia) and his CT head has been negative. The CT head is the
recommended first step for neuroimaging in the ED for a quick rule out, but after a negative workup for
orthostasis and cardiac reasons, its reasonable to consider an MRI to rule out a potential second stroke.