WORKFLOW METRICS AND FUNCTIONAL OUTCOMES IN AN MRI-FIRST PATHWAY FOR REVASCULARIZED ACUTE ISCHEMIC STROKE
Keywords:
Acute Ischemic Stroke, MRI, mRS, Putra Acute Stroke Protocol, Endovascular ThrombectomyAbstract
Background: MRI-first pathways prioritize tissue-based selection in acute ischemic stroke (AIS). This study evaluated workflow metrics and functional outcomes in revascularized AIS patients managed through an MRI-first protocol. Methods: We conducted a retrospective cohort study of 59 consecutive revascularized AIS patients managed with the Putra Acute Stroke Protocol at a comprehensive stroke center. Primary workflow metrics were door-to-imaging (DTI) and door-to-decision (DTD) times. The primary outcome was 90-day functional independence, defined as modified Rankin Scale (mRS) 0-2. Multivariable logistic regression was used to identify factors associated with a favourable outcome. Results: The MRI-first pathway identified 20.1% stroke mimics and 14.1% transient ischemic attacks before revascularization decisions. Among revascularized patients, median DTI was 45 minutes (IQR 35-69) and median DTD was 67 minutes (IQR 50-98), with a median imaging-to-decision interval of 22 minutes. In multivariable analysis, baseline NIHSS (aOR 0.887; 95% CI 0.800-0.984, p=0.023) and DTD time (aOR 1.022; 95% CI 1.000-1.044, p=0.048) were associated with a favourable 90-day outcome. Conclusion: In this selected cohort of revascularized patients managed through an MRI-first pathway, workflow performance was acceptable for a comprehensive stroke center, and favourable 90-day functional outcomes were achieved in two-thirds of patients. The observed positive association between longer door-to-decision time and favourable outcome should be interpreted cautiously, as it may reflect selection bias and residual confounding inherent to the retrospective design. Larger prospective multicenter studies are needed to confirm these findings.
Key words: acute ischemic stroke; magnetic resonance imaging; workflow metrics; door-to-imaging; door-to-decision; thrombolysis; thrombectomy
References
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344–e418. doi:10.1161/STR.0000000000000211.
Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, et al. MRI-guided thrombolysis for stroke with unknown time of onset. N Engl J Med. 2018;379(7):611–622. doi:10.1056/NEJMoa1804355.
Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378(8):708–718. doi:10.1056/NEJMoa1713973.
Rapillo CM, Dunet V, Pistocchi S, Salerno A, Darioli V, Bartolini B, et al. Moving from CT to MRI paradigm in acute ischemic stroke: feasibility, effects on stroke diagnosis and long-term outcomes. Stroke. 2024;55(5):1329–1338. doi:10.1161/STROKEAHA.123.045154.
Wardlaw JM, Chabriat H, de Leeuw FE, Debette S, Dichgans M, Doubal F, et al. European Stroke Organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke. Eur Stroke J. 2024;9(1):5–68. doi:10.1177/23969873231219416.
Bonura A, Musotto G, Rossi SS, Santoro F, Pillitteri P, Sferruzzi M, et al. Cerebri: a web-app to reduce door-to-treatment decision time and improve guideline adherence in acute ischemic stroke. Stroke. 2026;57(2):371–380. doi:10.1161/STROKEAHA.125.052997.
Muda AS, Khafiz MFA, Yaakob MNM, Rahim EA, Mahmood MK, Noh MSFM. Putra acute stroke protocol. CVNS. 2021;3(4):23–25. doi:10.32896/cvns.v3n4.12-14.
Shams Vahdati S, Ala A, Sadeghi-Hokmabadi E, Ghasemi H. Evaluation of door-to-needle stroke patients with thrombolytic activation code in Imam Reza educational center in Tabriz. Int J Aging. 2024;2:e16. doi:10.34172/ija.2024.e16.
Kumar S. Door-to-needle time in acute ischemic stroke: impact of imaging pathway on thrombolysis workflow—a single-center audit. Kauverian Med J. 2026;3(5):1–4.
Bathla G, Ajmera P, Mehta PM, Benson JC, Derdeyn CP, Lanzino G, et al. Statistical considerations in stroke imaging research: moving beyond the mean. AJNR Am J Neuroradiol. 2023;44(7):750–758. doi:10.3174/ajnr.A7872.
Al-Salahat A, Pirahanchi Y, Dhasakeerthi T, Nayar D, Almasri S, Verma K, et al. Current state and advancements of imaging in acute ischemic stroke: a practical review. Neurol Sci. 2026;47(1):29. doi:10.1007/s10072-025-08685-8.
Wintermark M, Sanelli PC, Albers GW, Bello JA, Derdeyn CP, Hetts SW, et al. Imaging recommendations for acute stroke and transient ischemic attack patients: a joint statement by the American Society of Neuroradiology, the American College of Radiology and the Society of NeuroInterventional Surgery. J Am Coll Radiol. 2013;10(11):828–832. doi:10.1016/j.jacr.2013.06.019.
Menon BK, Campbell BCV, Levi C, Goyal M. Role of imaging in current acute ischemic stroke workflow for endovascular therapy. Stroke. 2015;46(6):1453–1461. doi:10.1161/STROKEAHA.115.009160
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