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Objective  The aim of this article was to assess the role of emergent magnetic resonance imaging (MRI) for stroke mimics during a stoke alert (within 45 minutes) in reducing direct cost of management and duration of inpatient stay. Methods  We did a retrospective chart review of all the patients who received emergent MRI brain during a stroke alert to help make decision about intravenous tissue-type plasminogen activator (IV tPA) administration from January 2013 to December 2015. Using the patient financial resource data and with the help of billing department, we calculated the approximate money saved in taking care of the patients who may have received IV tPA if emergent MRI brain was not available to diagnose stroke mimics as they presented with acute neurologic deficit within IV tPA time window. Results  Ninety seven out of 1,104 stroke alert patients received emergent MRI. Of these only 17 (17.5%) were diagnosed with acute ischemic stroke (AIS), and 80 (82.5%) as stroke mimics. By doing emergent MRI for suspected stroke mimics, our study showed an approximate total saving of $1,005,720 to $1,384,560, that is, $12,571 to $17,307 per patient in medical expenditure. Discussion  We suggest modification of stroke pathway from current algorithm "CT+CTA≥IV-tPA/neurointervention≥MRI" to "MRI+MRA≥IV-tPA/neurointervention" for possible stroke mimics, which can reduce the cost, radiation exposure, and duration of hospital stay for stroke mimics. Conclusion  Emergent MRI is a cost-effective tool to evaluate IV-tPA eligibility for suspected stroke mimics during a stroke alert., Competing Interests: Conflict of Interest None declared., (Association for Helping Neurosurgical Sick People. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background  There are still marked disparities in stroke care between rural and urban communities including difference in stroke-related mortality. We analyzed the efficiency of tissue plasminogen activator (tPA) delivery in the spoke sites in our telestroke network to assess impact of telecare in bridging these disparities. Methods  We analyzed critical time targets in our telestroke network. These included door-to-needle (DTN) time, door-to-CT (D2CT) time, door-to-call center, door-to-neurocall, and total consult time. We compared these time targets between the larger and smaller spoke hospitals. Results  Across all the 52 spokes sites, a total of 825 stroke consults received intravenous tPA. When compared with larger hospitals (>200 beds), the smaller hospital groups with 0 to 25 and 51 to 100 beds had significantly lower D2CT time ( p -value 0.01 and 0.005, respectively) and the ones with 26 to 50 and 151 to 200 beds had significantly lower consult time ( p -value 0.009 and 0.001, respectively). There was no significant difference in the overall DTN time when all the smaller hospital groups were compared with larger hospitals. Conclusion  In our telestroke network, DTN times were not significantly affected by the hospital bed size. This shows that a protocol-driven telestroke network with frequent mock codes can ensure timely administration of tPA even in rural communities regardless of the hospital size and availability of local neurologists., Competing Interests: Conflict of Interest None declared.