Inpatient Brain MRI/MRA for Suspected Stroke: Adherence to ACR AUC at a Community Hospital

Purpose: MRI use in the evaluation of strokes has increased substantially in recent decades, contributing to higher hospital costs and potential overutilization. Prior studies suggest that certain inpatient MRI exams for stroke represent low-value imaging with limited impact on management. This quality improvement project evaluated the appropriateness of inpatient brain MRI and MRA utilization for suspected CVA at a large community hospital, with the goal of identifying opportunities to improve adherence to American College of Radiology (ACR) Appropriateness Criteria, enhance imaging efficiency, and reduce unnecessary utilization.

Methods/Materials: All inpatient brain MRI/MRA studies performed from January-March 2025 for CVA work-up were retrospectively reviewed. Studies ordered with the indication “stroke suspected” were included. Appropriateness was assessed through chart review and application of the 2024 ACR AUC, supplemented by neuroradiologist review. Of 116 studies identified, 3 were excluded for miscoded indications, leaving 113 studies for analysis. Each was categorized as “appropriate,” “may be appropriate,” or “usually not appropriate.”

Results: Among 113 inpatient MRI/MRA studies, 18 (16%) were deemed “may be appropriate” or “usually not appropriate”. Common reasons included altered mental status without focal deficit (n=6), nonspecific dizziness without central vertigo features (n=5), and contrast administration without clear indication (n=4). One study was ordered for progressed gait ataxia with a known etiology.

Conclusions: Inpatient brain MRI utilization for CVA evaluation showed a 16% rate of potentially inappropriate imaging, frequently related to nonfocal symptoms or unnecessary contrast use. These findings underscore opportunities to strengthen adherence to ACR Appropriateness Criteria, promote evidence-based ordering, and optimize resource allocation. Planned next steps include targeted provider education, refinement of institutional ordering pathways, and similar analyses at additional hospitals.