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Using MRI in emergency departments; expensive choice, but sometimes the optimal means of evaluation

DOI: 10.4328/ACAM.20216 Received: 2020-05-22 Accepted: 2020-06-01 Published Online: 2020-06-03 Printed: 2020-06-30 Ann Clin Anal Med 2020;11(Suppl 3): S178-182 Corresponding Author: Betül Tiryaki Baştuğ, Department of Radiology, Eskişehir Osmangazi University Medical Faculty , Eskişehir, Turkiye. E-mail: betultryak@yahoo.com GSM: +90 5354101542 Corresponding Author ORCID ID: https://orcid.org/0000-0001-7793-7887 Abstract Aim: Making the right choice of imaging when dealing with emergency situations is crucial for emergency physicians. Magnetic resonance imaging (MRI) is an expensive choice, but sometimes the optimal means of evaluation. In this study, it was aimed to show how, how often, and for which pathologies we used MRI in our ED in the past year. Materials and Methods: This was a retrospective cohort study comparing resource utilization between September 2016 and September 2017 in a university hospital emergency department (ED). MRIs of the patients ordered during ED stay were accepted as EDbased MRIs. Result criteria included hospital resource utilization, demographics, and clinical characteristics. Descriptive statistics are presented with frequency, percentage, mean, standard deviation, and minimum and maximum values. A chi-square analysis was conducted to examine the relationships. Analyses were conducted using the SPSS 22.0 package program. Results: In the ED, MRI is available 24/7. MRI was performed on 954 (479 female, 475 male) patients. A total of 212 cranial, 604 diffusion, 57 lumbar, 40 cervical, 38 dorsal, two abdominal, and one orbital MRIs were performed. In most groups, the average age was over 40, and the age distribution was similar (p = 0.12). There was no significant sex difference except for lumbar MRI; its rates were nearly two times higher in men than in women. Lumbar MRI and diffusion MRI groups were admitted to the hospital mostly in the day hours (p = 0.03); in other groups, night and day admissions were almost the same. Discussion: MRI use in the ED has resulted in efficient patient management and substantial reductions in radiation dose.


Introduction
When diagnostic imaging is required, the ordinary approach in emergency departments (ED) has been to perform computed tomography (CT) rather than magnetic resonance imaging (MRI). The main reason is timing because CT is faster than MRI. Moreover, CT scans have been performed because of their availability. But if we can achieve maximum productivity with minimum wasted effort with MRI in ED, then MRI would probably be preferred over CT in some cases. Since MRI could potentially produce more informative diagnostic images of spinal cord damage, disc protrusions, and stroke pre-cursors, it is a better test for identifying soft tissue abnormalities. The reduction of the total radiation dose received by ED patients is another crucial point. Reducing the number of CT scans for patients, especially those under 40 years of age, is also critical because of their long life expectancy and cancer risk, and this was a significant reason for bringing MRI into the ED. For all these reasons, we wondered how, how often, and for which pathologies we used MRI in our ED in the past one year.

Study Design
This was a retrospective cohort study comparing resource utilization during the 12 months between September 2016 and September 2017 in a single ED in a university hospital. The study was approved by the institutional review board through expedited review.

Study Setting and Population
The study was performed at the Eskişehir Osmangazi University Medical Faculty Hospital. This is a large hospital which is a Level 3 trauma and stroke center. Medical data were obtained from the records in the ED. In this center, MRI was an available imaging modality and open 24 hours a day, seven days a week. Imaging was done after approval and notification by a radiologist.

Study Protocol
The electronic medical records database was queried using an automated query. Outcome measures included ED and hospital resource utilization, demographics, and clinical characteristics. MRI ordered during patients' ED stays (i.e., before ED discharge) were considered ED-based MRI. Demographics (age, sex) and clinical characteristics (chief complaint) were collected. The most appropriate MRI exams were considered for ED patients. This has minimized the time taken to perform scans. Total scanning time was shortened to even less than 10 minutes in most exams. The ED doctor can request MRI exams with radiologist's advice depending on the situation to minimize the time necessary for the MRI scan.

Data Analysis
In the analysis of the data, descriptive statistics are presented with frequency, percentage, mean, standard deviation, and minimum and maximum values. A chi-square analysis was conducted with the aim of examining the relationship among age, sex, and the proportion of admission hours according to the groups. Analyses were performed using the SPSS 22.0 package program.

Results
In the past one year, MRI was performed on 954 patients hospitalized in the ED. These patients included 479 females and 475 males. Cranial MRI was performed on 212 patients, diffusion MRI on 604 patients, lumbar MRI on 57 patients, cervical MRI on 40 patients, dorsal MRI on 38 patients, abdominal MRI on two patients, and orbital MRI on one patient. In all of these groups, the average age, except for orbital and abdominal MRI, was over 40. All abdominal MRI group patients were between 19 and 40 years of age. In the brain MRI group, 2% of the patients were between 0 and 18 years old, 22% between 19 and 40 years old, 36% between 41 and 65 years old, and 40% over 65 years old. In the diffusion MRI group, 1% of the patients were between 0 and 18 years old, 14% between 19 and 40 years old, 37% between 41 and 65 years old, and 49% over 65 years old. In the orbital MRI group, patients were between 0 and 18 years old. In the cervical MRI group, 3% of the patients were between 0 and 18 years old, 26% between 19 and 40 years old, 40% between 41 and 65 years old, and 25% over 65 years old. In the dorsal MRI group, 3% of patients were between 0 and 18 years old, 24% between 19 and 40 years old, 42% between 41 and 65 years old, and 32% were over 65 years old. In the lumbar MRI group, 8.8% of patients were between 0 and 18 years old, 26.3% between 19 and 40 years old, 40.4% between 41 and 65 years old, and 24.6% over 65 years old ( Table 1). The age groups were similar according to patient groups (p = 0.12). All of the abdominal MRI and orbital MRI group patients (100%) were female. In the brain MRI group, 48% of the patients were male and 52% were female. In the diffusion MRI group, 49% of the patients were male and 51% were female. In the lumbar MRI group, 65% of the patients were male and 35% were female. In the cervical MRI group, 45% of the patients were male and 55% were female. In the dorsal MRI group, 45% of the patients were male and 55% were female (Table 2). Sex distribution was different according to groups, because the lumbar region group was composed of male patients with a higher incidence than in the other groups (p = 0.04). The mean age of patients was 33.5 ± 2.12 years in the abdominal MRI group, 65.07 ± 19.32 in the brain MRI group, 61.58 ± 17.30 in the diffusion MRI group, 22 in the orbital MRI group, 48.15 ± 18.61 in the cervical MRI group, 53.53 ± 18.08 in the dorsal MRI group, and 49.37 ± 18.22 in the lumbar MRI group (Table 3). Fifty percent of patients in the abdominal MRI group were admitted between 08:00-17:00 and 17:01-07:59. In the brain MRI group, 49% of the patients were admitted between 08:00 and 17:00 and 51% between 17:01 and 07:59. In the diffusion MRI group, 57% of the patients were admitted between 08:00 and 17:00 and 51% between 17:01 and 07:59. In the lumbar MRI group, 59% of patients were admitted between 08:00 and 17:00 and 50% between 17:01 and 07:59. Fifty percent of the cervical MRI group patients were admitted between 08:00-17:00 and 17:01-07:59. Forty-five percent of the patients in the dorsal MRI group were admitted between 08:00 and 17:00 and 55% between 17:01 and 07:59. When the abdominal MRI and orbital MRI groups were excluded, it was found that the lumbar MRI and diffusion MRI groups were admitted to the hospital mostly between 08:00 and 17:00 (p = 0.03).

Discussion
Making the right choice of imaging is crucial for emergency physicians. MRI is an expensive choice but sometimes the most appropriate means of evaluation. When compared with other methods, it is important to weigh the risks and benefits of MRI. In addition, in many hospitals, the MR can only be used during working hours, which makes it difficult to obtain emergency MRI. An ED doctor must decide whether the patient can be admitted or discharged. With an appropriately planned MRI, an ED doctor can make this decision with more confidence. A range of MRI scans can be decided upon with a radiologist's advice to help ensure that referring doctors order the most appropriate MRI exam. After the MRI scan, preliminary reports are made available in the emergency radiology unit, resulting in rapid patient turnaround. MRI is highly sensitive to abnormality, so when compared to CT, a negative MRI far exceeds the value of a negative CT. A negative MRI can allow doctors to be more confident about making decisions. CT of the spine is the more appropriate examination of suspected vertebral fractures. Especially in Turkey, osteoporosis has become a socioeconomic challenge. For this reason, older people are examined for suspected osteoporotic compression fractures after trauma [1,2]. While CT scans are evaluated for osteoporotic fractures, the reduced mineral content of the bone often causes problems, and the fracture is usually partly masked. In these cases, additional examination with MRI is helpful. Fat-suppressed T2-weighted MRI should be preferred for differentiating between acute and old fractures because it can depict bone marrow edema [3,4]. It is essential to establish the diagnosis quickly, especially in cases of planned vertebroplasty or dorsal stabilization [5]. Associated bone injuries are best evaluated with CT but it does not assess the cord itself. Besides routine axial and sagittal T1 and T2 imaging, additional sequences of MRI depending on the clinical concern should be considered. T2* sequences (e.g. gradient echo, SWI) are more sensitive to hemorrhage, while STIR sequences are more sensitive to associated ligamentous injury [6]. Some conditions require rapid MR examination since the outcomes can be changed with an emergency. For example, if a doctor suspects spinal cord compression, an emergency MRI evaluation is necessary, because the patient can lose the ability to walk and the chances that patient will walk again after therapy are small. Emergency MRI evaluation may be required in many conditions. Most pathologies in patients can be detected using non-invasive, extremely safe MRI. Emergency MRI is recommended in the assessment of suspected arterial dissections of brain blood vessels and even for alleged acute clotting of major veins that drain the brain. Moreover, MRI is used to detect some infections and non-infectious inflammatory processes of the brain like meningoencephalitis, lupus vasculitis, or SLE. Patient outcomes can be affected with timely diagnosis and subsequent initiation of appropriate therapy of these disorders. Patients with a suspected stroke can be acutely evaluated with an emergency MRI. MRI can determine which patients should be  In the past year, we have used MRI for cranial, cervical, dorsal, lumbar, abdominal, and orbital regions. Two patients admitted to abdominal MRI were pregnant and they were suspicious of appendicitis which could not be verified by ultrasonography. The need for cervical, dorsal, and lumbar MRI arose after suspicious CT findings. Particularly in older patients, chronic vertebral osteopenic and osteodegenerative changes could be confused easily with fractures. Also, in some younger patients, the clinical outcomes made clinicians suspicious of pathology but tomographies were normal. The most common causes were falls, severe pain, and traffic accidents. Cranial and diffusion MRI was applied because of the clinical findings of a cerebrovascular disease after a normal CT. One orbital MRI was performed to evaluate the optic disc in the past one year. In all groups in our study, there was no significant difference between the number of males and females, except for lumbar MRI. It was interesting that the number of lumbar MRIs in men was about twice that in women. Usually, osteopenia after menopause leads to lumbar fractures in women, but in our series of men, lumbar MRI rates were nearly two times higher than in women. This is because the men faced more hard work, trauma, and traffic accidents than women, which leads to higher MRI rates. In our ED, the emergency doctor with a radiologist ordered targeted scans for a specific issue, so exams were performed in about 10 minutes or less. In particular, the doctors in the ED and physicians did not order extra scans, and they understood the means of shortened protocols that might extend the exam times. However, there are some contraindications to MRI. Patients with a heart pacemaker and a metallic foreign body cannot undergo an MRI scan, because the magnetic field may dislodge the metal. Patients with severe claustrophobia may not be able to tolerate an MRI scan. In these patients, medical sedation is possible to make the imaging easier to tolerate. Limitations Firstly, this was a retrospective cohort study and did not evaluate the decision to perform ED MRI prospectively. Limitations are inherent to retrospective studies based on patient data automatically queried. Data were abstracted using an automated query, and, therefore, it is possible that a small number of patients were not inadvertently included in the study sample.

Conclusion
With appropriate MRI sequences and fast reporting, ED and consultant doctors make a more definitive decision. Using MRI in the ED has resulted in efficient patient management and substantial reductions in radiation dose.

Scientific Responsibility Statement
The authors declare that they are responsible for the article's scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.