Intravenous tissue plasminogen activator (tPA) is the only approved treatment for acute ischemic stroke Citation[1]. However, tPA must be administered within 3 h of onset of stroke. Patients often do not seek medical attention in this initial short period and at times there is a delay in the transport of patients to an appropriate hospital specializing in stroke care. There are also in-hospital delays because institutions lack the personnel and technical resources of a specialized stroke team to take care of acute stroke patients. This problem is accentuated in rural hospitals. Thus, tPA is under-utilized; overall utilization rates are estimated to be in the 1–2% range for all patients with acute ischemic stroke Citation[2]. Even at centers with specialized stroke capability, only 7–9% of all acute stroke patients receive tPA Citation[3].
Telemedicine for stroke (Telestroke) is a technology-driven method of providing rapid acute stroke expertize to local hospitals with CT scanning available Citation[4]. Telemedicine allows stroke patients to consult with remote stroke specialists from virtually any hospital. This technology includes assistance via either telephone or audio/video conferencing using an internet connection. Teleconsultation methods can range from basic telephone consultation to advanced hardware and imaging systems. High-bandwidth data transmission allows real-time video consultation to support truly interactive patient management and can be performed with commercially available systems that utilize integrated services, digital network lines or digital subscriber lines with internet/intranet protocols for data transfer.
Telemedicine works on a hub (usually a neurologist with stroke expertize) and spoke (patient in an outlying hospital) model. In most cases, the emergency room physicians touch base with a remote neurologist with stroke expertize, and an online connection involves the patients, physicians at both ends and, in certain cases, family members of patients. The CT scan is reviewed online and a treatment decision is made regarding tPA, following the National Institute of Neurological Disorders and Stroke (NINDS) tPA study protocol. In most cases, patients are transferred to the tertiary care hospital where the expert stroke physician is based.
Telemedicine can thus significantly improve the usage of tPA for acute ischemic stroke, and thereby reduce neurological morbidity and mortality with an added advantage of cost saving in the medical health system. Telemedicine also improves diagnostic accuracy and enhances referring physician education on acute stroke management. In addition, telemedicine can allow remote follow-up and monitoring for secondary stroke prevention. It also has the potential to identify patients for enrollment into acute stroke treatment trial protocols.
Telemedicine is an emerging field. Benefits of extending stroke expertize from a comprehensive stroke center to community hospitals have been shown in both rural and urban hospitals in both the USA and Europe using telephone and video-conference networks. LaMonte et al. have shown that telemedicine for acute stroke is an efficient means for evaluating and treating patients in a network hospital where stroke care specialists are not available Citation[5]. Similar experiences have been reported in rural areas by the The Sisters of the Third Order of St. Francis (OSF) Stroke Network. The OSF Stroke Network, consisting of 20 hospitals located in the central Illinois counties, showed that tPA could be given in a network of community hospitals (spoke) as safely as at a tertiary care center that functioned as their hub Citation[6]. Similar results have been seen on a much larger scale as part of a telemedical pilot project for integrative stroke care in a network of two stroke centers and 12 community hospitals in south Germany Citation[7]. Different institutions have used telemedicine involving telephonic consultation, and there is no evidence to suggest that one approach is better than the other. The advantage of telephone consultation is that less time is wasted and cost is minimal, whereas the advantage of video-conferencing is that stroke physicians can assess the patient visually and talk to the patient and family members.
Telemedicine, with all its advantages, has a few barriers that limit its use. Cost is a major issue. The relevant telecommunications infrastructure must be available, with personnel training and technical support. Hospital administration support is also required so that teleconsultation is incorporated into the evaluation of the acute stroke system. Above all, reimbursement by insurers is needed. Most third-party payers have been slow to recognize teleconsultation activities for reimbursement. There has been no detailed analysis of the cost–effectiveness of telemedicine in stroke, which is a barrier to making a case for a uniform system of reimbursement for teleconsultation. Clear rules of interaction and standardization of technology have not yet been achieved.
Telemedicine for stroke has a great potential to be part of routine acute stroke care. It has been proven safe in both urban and rural hospitals, following the principal of a hub-and-spoke model in a network of hospitals. In our own institution, which acts as a tertiary care center, we have shown that administrating tPA in peripheral hospitals (drip) and transporting (ship) is safe with symptomatic hemorrhages. The mortality rate using this protocol is comparable to the NINDS tPA study Citation[8]. Our experience was based on telephonic consultation with rural out-of-network hospitals.
With national healthboard funding studies, progress is being made in setting up clear rules of interaction and standardization of technology. The pharmacoeconomics of telemedicine for stroke need to be analyzed, and reimbursement for telemedicine should follow. This reimbursement should automatically increase the use of telemedicine for stroke.
Telemedicine for stroke is safe. Telemedicine delivers. A start has been made and, in this author’s opinion, it is only a matter of time until there is widespread use of telemedicine in the evaluation and treatment of stroke, especially acute thrombolysis. We, as healthcare providers, need to not only provide appropriate healthcare but to educate our hospital administrators and local politicians to move towards standardized stroke care (patients being treated in designated primary stroke centers) with incorporation of telemedicine in routine stroke care specifically for rural and small community hospitals lacking in stroke expertize.
Financial disclosure
The author has no relevant financial interests, including employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties related to this manuscript.
Acknowledgement
Anand Vaishnav was supported by K30 Career Training in Therapeutics and Translational Research Program, University of Kentucky and Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Training Grant (NIH, K-12 DA 14040-06). The author appreciates editorial assistance from Sherry Chandler Williams.
Related Research Data
References
- National Institute of Neurological Diseases and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N. Engl. J. Med.333, 1581–1587 (1995).
- Alberts MJ, Hademenos G, Latchaw RE et al. For the Brain Attack Coalition. Recommendations for the establishment of primary stroke centers. JAMA283, 3102–3109 (2000).
- Grotta JC, Burgin WS, El-Mitwalli A et al. Intravenous tissue-type plasminogen activator therapy for ischemic stroke: Houston experience 1996 to 2000. Arch. Neurol.58, 2009–2013 (2001).
- Levine SR, Gorman M. Telestroke: the application of telemedicine for stroke. Stroke30, 464–469 (1999).
- LaMonte MP, Bahouth MN, Hu P et al. Telemedicine for acute stroke: triumphs and pitfalls. Stroke34, 725–728 (2003).
- Wang DZ, Rose JA, Honings DS, Garwacki DJ, Milbrandt JC. Treating acute stroke patients with intravenous tPA: the OSF stroke network experience. Stroke31, 77–81 (2000).
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