Editorial

10.1586/14737175.7.8.913 © 2007 Future Drugs Ltd ISSN 1473-7175 913

Telemedicine in acute ischemic stroke‘Telemedicine can … reduce neurological morbidity and mortality with an added advantage of cost saving in the medical health system.’

Anand VaishnavStroke Unit, Sanders-Brown Center on Aging, University of Kentucky Medical Center, KY, USATel.: +1 859 257 5560Fax: +1 859 257 8990agvais2@uky.edu

Expert Rev. Neurotherapeutics 7(8), 913–914 (2007)

Intravenous tissue plasminogen activator (tPA)is the only approved treatment for acuteischemic stroke [1]. However, tPA must beadministered within 3 h of onset of stroke.Patients often do not seek medical attention inthis initial short period and at times there is adelay in the transport of patients to an appro-priate hospital specializing in stroke care.There are also in-hospital delays because insti-tutions lack the personnel and technicalresources of a specialized stroke team to takecare of acute strokepatients. This problemis accentuated in ruralhospitals. Thus, tPA isunder-utilized; overallutilization rates are esti-mated to be in the 1–2% range for all patientswith acute ischemic stroke [2]. Even at centerswith specialized stroke capability, only 7–9%of all acute stroke patients receive tPA [3].

Telemedicine for stroke (Telestroke) is atechnology-driven method of providing rapidacute stroke expertize to local hospitals withCT scanning available [4]. Telemedicineallows stroke patients to consult with remotestroke specialists from virtually any hospital.This technology includes assistance via eithertelephone or audio/video conferencing usingan internet connection. Teleconsultationmethods can range from basic telephoneconsultation to advanced hardware andimaging systems. High-bandwidth datatransmission allows real-time video consulta-tion to support truly interactive patient man-agement and can be performed withcommercially available systems that utilize

integrated services, digital network lines ordigital subscriber lines with internet/intranetprotocols for data transfer.

Telemedicine works on a hub (usually aneurologist with stroke expertize) and spoke(patient in an outlying hospital) model. In mostcases, the emergency room physicians touchbase with a remote neurologist with strokeexpertize, and an online connection involvesthe patients, physicians at both ends and, incertain cases, family members of patients. The

CT scan is reviewedonline and a treatmentdecision is made regard-ing tPA, following theNational Institute ofNeurological Disorders

and Stroke (NINDS) tPA study protocol. Inmost cases, patients are transferred to the tertiarycare hospital where the expert stroke physicianis based.

Telemedicine can thus significantly improvethe usage of tPA for acute ischemic stroke, andthereby reduce neurological morbidity andmortality with an added advantage of cost sav-ing in the medical health system. Telemedicinealso improves diagnostic accuracy and enhancesreferring physician education on acute strokemanagement. In addition, telemedicine canallow remote follow-up and monitoring for sec-ondary stroke prevention. It also has the poten-tial to identify patients for enrollment intoacute stroke treatment trial protocols.

Telemedicine is an emerging field. Benefits ofextending stroke expertize from a comprehen-sive stroke center to community hospitals havebeen shown in both rural and urban hospitals

‘…tPA is under-utilized. Even at centers with specialized stroke

capability, only 7–9% of all acute stroke patients receive tPA.’

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Vaishnav

914 Expert Rev. Neurotherapeutics 7(8), (2007)

in both the USA and Europe using telephone and video-confer-ence networks. LaMonte et al. have shown that telemedicine foracute stroke is an efficient means for evaluating and treatingpatients in a network hospital where stroke care specialists arenot available [5]. Similar experiences have been reported in ruralareas by the The Sisters of the Third Order of St. Francis (OSF)Stroke Network. The OSF Stroke Network, consisting of 20hospitals located in the central Illinois counties, showed thattPA could be given in a network of community hospitals(spoke) as safely as at a tertiary care center that functioned astheir hub [6]. Similar results have beenseen on a much larger scale as part of atelemedical pilot project for integrativestroke care in a network of two strokecenters and 12 community hospitals insouth Germany [7]. Different institutions have used telemedi-cine involving telephonic consultation, and there is no evidenceto suggest that one approach is better than the other. Theadvantage of telephone consultation is that less time is wastedand cost is minimal, whereas the advantage of video-conferenc-ing is that stroke physicians can assess the patient visually andtalk to the patient and family members.

Telemedicine, with all its advantages, has a few barriers thatlimit its use. Cost is a major issue. The relevant telecommunica-tions infrastructure must be available, with personnel trainingand technical support. Hospital administration support is alsorequired so that teleconsultation is incorporated into the evalua-tion of the acute stroke system. Above all, reimbursement byinsurers is needed. Most third-party payers have been slow to rec-ognize teleconsultation activities for reimbursement. There hasbeen no detailed analysis of the cost–effectiveness of telemedicinein stroke, which is a barrier to making a case for a uniform systemof reimbursement for teleconsultation. Clear rules of interactionand standardization of technology have not yet been achieved.

Telemedicine for stroke has a great potential to be part of rou-tine acute stroke care. It has been proven safe in both urban andrural hospitals, following the principal of a hub-and-spoke modelin a network of hospitals. In our own institution, which acts as a

tertiary care center, we have shown that administrating tPA inperipheral hospitals (drip) and transporting (ship) is safe withsymptomatic hemorrhages. The mortality rate using this proto-col is comparable to the NINDS tPA study [8]. Our experiencewas based on telephonic consultation with rural out-of-networkhospitals.

With national healthboard funding studies, progress is beingmade in setting up clear rules of interaction and standardiza-tion of technology. The pharmacoeconomics of telemedicinefor stroke need to be analyzed, and reimbursement for tele-

medicine should follow. This reimburse-ment should automatically increase theuse of telemedicine for stroke.

Telemedicine for stroke is safe. Tele-medicine delivers. A start has been made

and, in this author’s opinion, it is only a matter of time untilthere is widespread use of telemedicine in the evaluation andtreatment of stroke, especially acute thrombolysis. We, as health-care providers, need to not only provide appropriate healthcarebut to educate our hospital administrators and local politiciansto move towards standardized stroke care (patients being treatedin designated primary stroke centers) with incorporation of tele-medicine in routine stroke care specifically for rural and smallcommunity hospitals lacking in stroke expertize.

Financial disclosureThe author has no relevant financial interests, includingemployment, consultancies, honoraria, stock ownership oroptions, expert testimony, grants or patents received or pending,or royalties related to this manuscript.

AcknowledgementAnand Vaishnav was supported by K30 Career Training inTherapeutics and Translational Research Program, Universityof Kentucky and Building Interdisciplinary Research Careersin Women’s Health (BIRCWH) Training Grant (NIH, K-12DA 14040-06). The author appreciates editorial assistancefrom Sherry Chandler Williams.

References

1 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).

2 Alberts MJ, Hademenos G, Latchaw RE et al. For the Brain Attack Coalition. Recommendations for the establishment of primary stroke centers. JAMA 283, 3102–3109 (2000).

3 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).

4 Levine SR, Gorman M. Telestroke: the application of telemedicine for stroke. Stroke 30, 464–469 (1999).

5 LaMonte MP, Bahouth MN, Hu P et al. Telemedicine for acute stroke: triumphs and pitfalls. Stroke 34, 725–728 (2003).

6 Wang DZ, Rose JA, Honings DS, Garwacki DJ, Milbrandt JC. Treating acute stroke patients with intravenous tPA: the OSF stroke network experience. Stroke 31, 77–81 (2000).

7 Audebert HJ, Kukla C, von Claranau SC et al. Telemedicine for safe and extended use of thrombolysis is stroke: the Telemedic Pilot Project for Integrative Stroke Care (TEMPIS) in Bavaria. Stroke 36, 287–291 (2005).

8 Vaishnav AG, Pettigrew LC, Ryan S. Telephonic expert guidance of systemic thrombolysis in acute ischemic stroke: safety outcome in rural community hospitals. Presented at: American Academy of Neurology 59th Annual Meeting. Boston, MA, USA, 28 April–5 May 2007 (Abstract).

Affiliation

• Anand Vaishnav, MD

Medical Director, Stroke Unit, Assistant Professor of Neurology & the Sanders-Brown Center on Aging, University of Kentucky Medical Center, KY, USATel.: +1 859 257 5560Fax: +1 859 257 8990agvais2@uky.edu

‘Telemedicine for stroke has a great potential to be part of routine acute stroke care.’