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Review ArticleSYSTEMATIC REVIEW/META-ANALYSIS

Magnetic Resonance Imaging versus Noncontrast Computed Tomography for Selecting Patients with Acute Ischemic Stroke of Large Vessel Occlusion for Endovascular Thrombectomy: A Systematic Review and Meta-Analysis

Seyed Behnam Jazayeri, Sherief Ghozy, Alireza Hasanzadeh, Mohamed Elfil, Ali Ahmadzade, Ehsan Naseh, Alzhraa S. Abbas, Ramanathan Kadirvel, Alejandro A. Rabinstein and David F. Kallmes
American Journal of Neuroradiology April 2025, ajnr.A8775; DOI: https://doi.org/10.3174/ajnr.A8775
Seyed Behnam Jazayeri
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J., A.H., A.H.), From the Department of Radiology (S.G.,R.K., D.F.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Department of Neurology (M.E.), University of Miami/Jackson Health System, Miami, FL, USA, 5-Iran University of Medical Sciences (E.N.), Tehran, Iran, Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN, USA
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Sherief Ghozy
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J., A.H., A.H.), From the Department of Radiology (S.G.,R.K., D.F.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Department of Neurology (M.E.), University of Miami/Jackson Health System, Miami, FL, USA, 5-Iran University of Medical Sciences (E.N.), Tehran, Iran, Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN, USA
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Alireza Hasanzadeh
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J., A.H., A.H.), From the Department of Radiology (S.G.,R.K., D.F.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Department of Neurology (M.E.), University of Miami/Jackson Health System, Miami, FL, USA, 5-Iran University of Medical Sciences (E.N.), Tehran, Iran, Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN, USA
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Mohamed Elfil
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J., A.H., A.H.), From the Department of Radiology (S.G.,R.K., D.F.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Department of Neurology (M.E.), University of Miami/Jackson Health System, Miami, FL, USA, 5-Iran University of Medical Sciences (E.N.), Tehran, Iran, Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN, USA
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Ali Ahmadzade
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J., A.H., A.H.), From the Department of Radiology (S.G.,R.K., D.F.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Department of Neurology (M.E.), University of Miami/Jackson Health System, Miami, FL, USA, 5-Iran University of Medical Sciences (E.N.), Tehran, Iran, Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN, USA
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Ehsan Naseh
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J., A.H., A.H.), From the Department of Radiology (S.G.,R.K., D.F.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Department of Neurology (M.E.), University of Miami/Jackson Health System, Miami, FL, USA, 5-Iran University of Medical Sciences (E.N.), Tehran, Iran, Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN, USA
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Alzhraa S. Abbas
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J., A.H., A.H.), From the Department of Radiology (S.G.,R.K., D.F.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Department of Neurology (M.E.), University of Miami/Jackson Health System, Miami, FL, USA, 5-Iran University of Medical Sciences (E.N.), Tehran, Iran, Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN, USA
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Ramanathan Kadirvel
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J., A.H., A.H.), From the Department of Radiology (S.G.,R.K., D.F.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Department of Neurology (M.E.), University of Miami/Jackson Health System, Miami, FL, USA, 5-Iran University of Medical Sciences (E.N.), Tehran, Iran, Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN, USA
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Alejandro A. Rabinstein
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J., A.H., A.H.), From the Department of Radiology (S.G.,R.K., D.F.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Department of Neurology (M.E.), University of Miami/Jackson Health System, Miami, FL, USA, 5-Iran University of Medical Sciences (E.N.), Tehran, Iran, Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN, USA
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David F. Kallmes
From the Tehran University of Medical Sciences, Tehran, Iran (S.B.J., A.H., A.H.), From the Department of Radiology (S.G.,R.K., D.F.K.) Mayo Clinic, Rochester, Minnesota, Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota, Department of Neurology (M.E.), University of Miami/Jackson Health System, Miami, FL, USA, 5-Iran University of Medical Sciences (E.N.), Tehran, Iran, Evidence-based Practice Center, Kern Center for the Science of Healthcare Delivery (A.S.A.), Mayo Clinic, Rochester, MN, USA and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN, USA
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ABSTRACT

BACKGROUND: Neuroimaging in the acute phases after the onset of the stroke symptoms is necessary to determine large vessel occlusion presence as well as the extent of the ischemic insult before deeming eligibility for endovascular thrombectomy (EVT).

PURPOSE: To evaluate the clinical outcomes in acute ischemic stroke patients selected for EVT based on initial imaging; non-contrast computed tomography (NCCT) compared to those selected using magnetic resonance imaging (MRI).

DATA SOURCES: PubMed, Embase, Scopus, and Web of Science were searched from inception to August, 2024.

STUDY SELECTION: We included observational studies comparing functional independence (mRS 0-2), successful reperfusion (TICI 2b-3), symptomatic intracerebral hemorrhage (sICH) or mortality in patients selected for EVT using NCCT±CT angiography versus MRI ±MR angiography. We excluded studies that used perfusion imaging in their patient selection for EVT.

DATA ANALYSIS: Data were pooled using random-effects model, and heterogeneity was assessed using I2 statistics. A subgroup analysis was performed to determine the effect of treatment window (<6h vs >6h from last known well). The quality of eligible studies was assessed by using Newcastle Ottawa Scale.

DATA SYNTHESIS: Seven studies (n=3,940 patients) met the inclusion criteria. Two studies had low risk of bias and others had some concerns. Patients with MRI selection showed better chances of functional independence (Odds ratio (OR), 1.85 [95% CI, 1.28-2.67]; p<0.01, I2=45%), lower rates of sICH (OR 0.59, 95% CI 0.39–0.89; p=0.01, I2=0%), reduced 90 days mortality (OR 0.63, 95% CI 0.51–0.78; p<0.01, I2=0%) and no difference in successful reperfusion (OR 0.99, 95% CI 0.62–1.58; p=0.95, I2=0%) compared to NCCT in patients treated within 6 hours of stroke onset. There were no significant differences in any endpoints between MRI and NCCT for patients treated beyond 6 hours.

LIMITATIONS: Our meta-analysis comprised only observational studies, with different populations and imaging protocols limiting the strength of the conclusions.

CONCLUSIONS: Within the crucial <6-hour window, MRI's superior patient selection justifies its use despite longer acquisition times. Beyond 6 hours, the focus should shift to rapid EVT access rather than imaging modality choice, as the benefits of MRI diminish.

ABBREVIATIONS: EVT = Endovascular Thrombectomy; IVT = Intravenous Thrombolysis; AIS-LVO = Acute Ischemic Stroke-Large Vessel Occlusion

Footnotes

  • Disclosure of potential conflicts of interest: R.K. received research support from NIH, Cerenovus Inc, Medtronic, Endovascular Engineering, Insera Therapeutics, Frontior Bio, Sensome Inc, Endomimetics, Ancure LLC, Neurogami Medical, MIVI Biosciences, Monarch Biosciences, Stryker Inc, Piraeus Medical, MIVI Biosciences and Bionaut Labs. D.F.K. holds equity in Nested Knowledge, Superior Medical Editors, and Conway Medical,Marblehead Medical and Piraeus Medical. He receives grant support from MicroVention, Medtronic, Balt, and Insera Therapeutics; has served on the Data Safety Monitoring Board for Vesalio; and received royalties from Medtronic.

  • © 2025 by American Journal of Neuroradiology

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Accepted Manuscript
Seyed Behnam Jazayeri, Sherief Ghozy, Alireza Hasanzadeh, Mohamed Elfil, Ali Ahmadzade, Ehsan Naseh, Alzhraa S. Abbas, Ramanathan Kadirvel, Alejandro A. Rabinstein, David F. Kallmes
Magnetic Resonance Imaging versus Noncontrast Computed Tomography for Selecting Patients with Acute Ischemic Stroke of Large Vessel Occlusion for Endovascular Thrombectomy: A Systematic Review and Meta-Analysis
American Journal of Neuroradiology Apr 2025, ajnr.A8775; DOI: 10.3174/ajnr.A8775

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Accepted Manuscript
Magnetic Resonance Imaging versus Noncontrast Computed Tomography for Selecting Patients with Acute Ischemic Stroke of Large Vessel Occlusion for Endovascular Thrombectomy: A Systematic Review and Meta-Analysis
Seyed Behnam Jazayeri, Sherief Ghozy, Alireza Hasanzadeh, Mohamed Elfil, Ali Ahmadzade, Ehsan Naseh, Alzhraa S. Abbas, Ramanathan Kadirvel, Alejandro A. Rabinstein, David F. Kallmes
American Journal of Neuroradiology Apr 2025, ajnr.A8775; DOI: 10.3174/ajnr.A8775
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