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

Siraj Fahad  Wally; Khalid Saad H Aljohani; Mohammed Ahmed M. Alhanash; Nouf Atiq H Alsayed; Hajar Adel A Daghriri; Danah Mohsen A Albalawi; Sarah Hadi S Atawi; Fatimah Mohammed S  Alatawi; Mona Fahad S Alanazi; Faisal Mohammed Alamrani; Norah Saud A Bin  Mubrad; Maha Faisal M Aljohani; Abdulrahman Adeeb A  Aldamegh; Talal Adel S Alharthi

doi:10.54293/smhj.v6i1.180

Authors

Siraj Fahad Wally Assistant Professor, Radiology Department, Tabuk University, KSA.
Khalid Saad H Aljohani Medical Intern, Faculty of Medicine, University of Tabuk, Tabuk, KSA.
Mohammed Ahmed M. Alhanash Medical Intern, Faculty of Medicine, King Khalid University, Abha, KSA.
Nouf Atiq H Alsayed Medical Intern, Faculty of Medicine, King Abdulaziz University, Rabigh, KSA.
Hajar Adel A Daghriri Diagnostic Radiology Intern, Faculty of Applied Medical Sciences, King Khalid University, Abha, KSA. https://orcid.org/0009-0006-3229-2732
Danah Mohsen A Albalawi Medical Intern, Faculty of Medicine, University of Tabuk, Tabuk, KSA. https://orcid.org/0000-0002-8776-2264
Sarah Hadi S Atawi Medical Intern, Faculty of Medicine, University of Tabuk, Tabuk, KSA. https://orcid.org/0009-0001-4402-0973
Fatimah Mohammed S Alatawi Medical Intern, Faculty of Medicine, University of Tabuk, Tabuk, KSA.
Mona Fahad S Alanazi Medical Intern, Faculty of Medicine, University of Tabuk, Tabuk, KSA. https://orcid.org/0009-0003-8054-3485
Faisal Mohammed Alamrani Medical Intern, Faculty of Medicine, University of Tabuk, Tabuk, KSA.
Norah Saud A Bin Mubrad Medical Student, Faculty of Medicine, University of Tabuk, Tabuk, KSA. https://orcid.org/0009-0003-9679-6807
Maha Faisal M Aljohani General Practitioner, King Fahad Specialist Hospital, Tabuk, KSA.
Abdulrahman Adeeb A Aldamegh Medical Intern, Faculty of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, KSA.
Talal Adel S Alharthi Medical Intern, King Saud University, Riyadh, KSA. https://orcid.org/0009-0004-0294-8572

DOI:

https://doi.org/10.54293/smhj.v6i1.180

Keywords:

acute stroke, systematic review, computed tomography, magnetic resonance imaging, diagnostic accuracy, thrombolysis, thrombectomy, workflow, patient 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.