Telestroke

Telestroke

Telemedicine is the use of electronic communication methods, such as telephone, Internet, and videoconferencing, to exchange medical information from one geographic site to another.1

 

Figure 1: Imaging from a remote unit is transmitted to an experienced stroke physician for further management advice

Imaging from a remote unit is transmitted to an experienced stroke physician for further management advice

 

  • Telemedicine can overcome geographical barriers, may save money and improve knowledge in acute stroke care.
  • Telemedicine-guided thrombolysis is feasible, safe and efficient.2,3
  • The Telemedical Pilot Project for Integrative Stroke Care (TEMPiS) has shown a marked reduction of “death and dependency” (mRS >3).4
  • The mean length of stay in hospital was significantly reduced in TEMPiS patients compared with the control group (10.7 vs. 11.9 days; p<0.0001).4

Telestroke is the use of telemedicine specifically for stroke care.1

Geography, lack of knowledge and poor funding are the 3 main reasons for unequal access to stroke care, and the rationale behind telestroke (figure 2).

 

Figure 2: Rational for telemedicine in stroke

Rational for telemedicine in stroke

The 2009 American Stroke Association (ASA) recommendations on telemedicine support the use of telestroke as a means of providing acute stroke care in rural, remote, or underserved areas:

"Telestroke networks should be deployed wherever a lack of readily available stroke expertise prevents patients in a given community from accessing a primary stroke center (or center of equivalent capability) within a reasonable distance or travel time to permit eligibility for intravenous thrombolytic therapy."

Telestroke unit concept

  • Specialised stroke wards in community hospitals
    • 24-hour availability of diagnostics/monitoring
    • Stroke teams
    • Standardised stroke care protocols
  • Comprehensive stroke training for all staff
  • Continuous quality management
  • Telemedicine network (figure 3)

 

Figure 3: Model for a telestroke system

Model for a telestroke system

 

Telemedical pilot project for integrative stroke care (TEMPiS)

In TEMPiS, 12 community hospitals with little or no experience with thrombolysis were connected in 2003 to 2 university hospital stroke centres, which provide 24-hour telemedicine and image transmission.

22 months into the project, comparable functional outcomes and mortality rates were seen in the telemedicine-linked community hospitals and in the stroke centres, and these results were in turn comparable to results from randomised trials (figure 4).

 

Figure 4: Results from TEMPiS

Results from TEMPiS

RCT, randomised controlled trial; mRS, modified Rankin Scale

Telemedicine in acute stroke: learnings from TEMPiS3-5

  • Telemedicine-guided thrombolysis is feasible, safe and efficient.
  • Use of telemedicine not only gives patients rapid access to specialised care, but can also increase accessibility to other stroke services.
  • Telemedicine networks can improve many other aspects of acute stroke care (figure 5).

 

Figure 5: Indicators for quality of stroke care

Indicators for quality of stroke care

"Drip and ship" approach6-8

Although telestroke is important for the confirmation of an acute ischaemic stroke and guidance in the decision to administer intravenous rt-PA, it is often still beneficial to transfer the patient (if conditions allow) to a hub stroke centre for further management – commonly known as the “drip and ship” approach.

There is currently not a large amount of evidence on the benefits and safety of this approach, but smaller studies that have been performed report comparable long-term functional outcomes and safety (sICH and mortality rates) to patients treated directly in a specialised stroke centre. Further benefits of the drip-and-ship approach include:

  • Empowers emergency physicians and neurologists at outside hospitals
  • Facilitates early administration of rt-PA
  • Improves access to specialised stroke treatment and adjunctive therapeutic options
References 
  1. Demaerschalk BM. Telestrokologists: treating stroke patients here, there, and everywhere with telemedicine. Semin Neurol 2010;30(5):477-491.
  2. Schwamm LH, Audebert HJ, Amarenco P et al. Recommendations for the Implementation of Telemedicine Within Stroke Recommendations for the Implementation of Telemedicine Within Stroke. Stroke 2009;40:2635-2660.
  3. Schwab S, Vatankhah B, Kukla C et al. Long-term outcome after thrombolysis in telemedical stroke care Neurology 2007;69:898-903.
  4. Audebert HJ, Schultes K, Tietz V et al. Long-Term Effects of Specialized Stroke Care With Telemedicine Support in Community Hospitals on Behalf of the Telemedical Project for Integrative Stroke Care (TEMPiS). Stroke 2009;40:902-908.
  5. Audebert HJ, Schenkel J, Heuschmann PU et al. Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany. Lancet Neurol 2006;5:742-748.
  6. Pervez MA, Silva G, Masrur S, et al. Remote supervision of IV-tPA for acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe. Stroke 2010;41:e18-e24.
  7. Martin-Schild S, Morales MM, Khaja AM, et al. Is the drip-and-ship approach to delivering thrombolysis for acute ischemic stroke safe? J Emerg Med 2011;42:135-141.
  8. Silverman IE, Beland DK, Chhabra J, McCullough LD. The "drip-and-ship" approach: starting IV t-PA for acute ischemic stroke at outside hospitals prior to transfer to a regional stroke center. Conn Med 2005;69:613-620.
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