CT versus MRI for the Initial Assessment of Suspected Acute Stroke: A Systematic Review of Diagnostic and Management Outcomes

Abstract

While non-contrast computed tomography (NCCT) is widely used for its speed and availability, magnetic resonance imaging (MRI) offers superior diagnostic accuracy. The optimal first-line imaging strategy for suspected acute stroke remains debated. This study systematically reviews and compares the diagnostic accuracy, impact on management, workflow times, and patient outcomes of CT-based versus MRI-based imaging protocols. A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search of PubMed/MEDLINE, Web of Science, Scopus, and Embase was performed from inception through 2025. Eighteen studies were included. MRI, particularly diffusion-weighted imaging (DWI), demonstrated significantly higher sensitivity for detecting acute ischemia compared to NCCT. MRI-based selection was associated with a 50% reduction in thrombolysis administration to stroke mimics. However, MRI use consistently resulted in longer door-to-needle times (delays of 2 to 30 minutes). Evidence on functional outcomes was mixed; several large registry studies found no significant difference in 90-day functional independence or symptomatic intracranial hemorrhage (sICH) rates after adjusting for confounders, while others reported significantly improved safety profiles (lower sICH and mortality rates) and functional outcomes with MRI. MRI is the diagnostic gold standard for detecting acute ischemic stroke and reduces inappropriate thrombolysis. An optimal, hybrid approach is recommended: utilizing fast multimodal CT as a first-line tool to minimize delays, while reserving MRI for complex cases where its superior diagnostic capability is most impactful. These findings support a tailored imaging strategy to optimize both the efficiency and precision of acute stroke care.

Affiliated Institutions

• Imam Abdulrahman Bin Faisal University SA
• King Khalid University SA
• King Saud University SA
• University of Tabuk SA
• King Saud Medical City SA
• King Abdulaziz University SA
• King Fahad Specialist Hospital SA

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