Efficacy and safety of magnetic resonance imaging- vs. computed tomography-guided reperfusion in acute ischemic stroke: a systematic review and meta-analysis

Abstract

Objective Acute ischemic stroke (AIS) is a leading cause of death and disability. Timely reperfusion improves outcomes, but optimal patient selection depends on neuroimaging; CT is fast and widely available, whereas MRI offers greater precision in identifying salvageable brain tissue. This systematic review (SR) and meta-analysis evaluates the comparative effectiveness of MRI-guided reperfusion (MRI-R) vs. CT-guided reperfusion (CT-R) in adult AIS. Methods We conducted a PRISMA-compliant SR and searched PubMed, Embase, Cochrane Library, Web of Science, CINAHL and Google Scholar for English or Spanish studies comparing MRI-R vs. CT-R in adult AIS. Randomized trials, cohort, and case-control designs were included. Primary outcome was mortality; secondary outcomes were 90-day functional independence modified Rankin Scale (mRS) 0–2) and symptomatic intracranial hemorrhage (sICH). Data were pooled with a random-effects model; risk of bias was assessed using Cochrane RoB 2.0 and ROBINS-I tools. Results From 11,578 records, 13 studies (27,313 patients) met inclusion criteria. Meta-analysis of 11 studies (27, 197 patients) showed MRI-R was associated with increased 90-day mRS ≤2 (RR 1.28, 95 % CI 1.06–1.55; p = 0.01; I2 = 82.6 %), reduced mortality (RR 0.72, 95 % CI 0.62–0.84; p = 0.002; I2 = 0 %) and lowered sICH (RR 0.59, 95 % CI 0.45–0.78; p = 0.002; I2 = 7.6 %) compared with CT-R. Subgroup analyses by CT comparator type (NCCT-only or multimodal CT) and reperfusion strategy (IVT, MT, or both) for successful reperfusion and 90-day functional independence showed no statistically significant differences between groups. Conclusion MRI-R was associated with improved functional outcomes, reduced mortality and lower sICH rates than CT-guided strategies. However, these findings should not be interpreted as definitive superiority given the high heterogeneity in functional outcomes, baseline patient characteristic differences between imaging groups, and detected publication bias. CT remains essential for rapid hyperacute assessment, while in well-equipped centers, MRI can improve patient selection through detailed tissue characterization, provided this does not delay reperfusion and patients have no contraindications. Further, prospective, randomized studies are needed to confirm these findings. Systemic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420251165578, CRD420251165578