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Telemedicine for Stroke: An Idea Whose Time Has Come
Abstract & Commentary
By Dana Leifer, MD, Associate Professor, Neurology, Weill Medical College, Cornell University. Dr. Leifer reports no financial relationship relevant to this field of study.
Synopsis: Outcomes for treatment of stroke with intravenous tissue plasminogen activator (tPA) were similar at community hospitals supported by telemedicine consultation with stroke experts compared to academic stroke centers.
Source: Schwab, S et al. on behalf of the TEMPiS Group. Long-Term Outcome After Thrombolysis in Telemedical Stroke Care. Neurology 2007;69:898.
Although intravenous recombinant tissue plasminogen activator (tPA) is the only FDA approved treatment for acute ischemic stroke, it is still given to only 1 to 6% of stroke patients. Many patients are not eligible for IV tPA because they arrive at a hospital after the 3-hour window, but there are many small hospitals where tPA is not routinely given because there is insufficient expertise in the use of this beneficial medicine, which also has a significant risk of catastrophic bleeding.
Several studies have suggested that it is feasible to safely administer tPA when stroke experts at a remote center consult through the use of high-speed data transmission that permits experts to view imaging studies and to examine patients by live audiovisual conferencing. In a previous study, the TEMPiS investigators demonstrated that in the first year of their stroke telemedicine project, the number of tPA patients treated in the 12 participating community hospitals increased from a total of 10 patients annually to 110 patients (4.4% of the total number of ischemic strokes). These investigators have now directly compared patients treated with telemedical consultation to patients treated at the academic stroke centers where the experts work.
The investigators established a network of 12 community hospitals in Germany, supported by experts from 2 regional stroke centers. The stroke centers provided teleconferencing starting within 3 minutes of a request. Images were transferred and reviewed; a videoconference link was then established so that the expert could examine the patient with the help of a local physician.
During the first 22 months of the project, 170 patients received IV tPA at the community hospitals after telemedical consultation, and 132 were treated at the stroke centers. The baseline characteristics of the patients were similar with a median admission NIH stroke score of 12 in the telemedical group and 11 in the stroke center group. The authors found no statistically significant differences in outcome between the two groups. 39.5% of the telemedicine group had a modified Rankin score (mRS) of 0 or 1 (no symptoms or minimal disability) compared to 30.9% of the stroke center patients at 6 months. Mortality at 6 months was 14.2% in the telemedicine group and 13.0% in the stroke center group. The results in both groups compare favorably to the mortality rate of 21% at 6 months in the NIH trial that led to the approval of tPA.
In making plans to establish other telemedicine networks for stroke care, one other important point should be noted about the TEMPiS project. It not only provided initial telemedicine consultations to the community hospitals, but also established local stroke units and stroke teams and guaranteed availability of CT scanning 24 hours per day, along with neurovascular ultrasound. All of these measures may have contributed to the results seen in the community hospitals. Telemedicine, in conjunction with appropriate care after the first three hours, appears to be a safe and effective way of making the benefits of tPA available to more patients.