Telestroke In Clinical Practice Networks of Care

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TeleStroke networks (e.g., Fig. 10.3) are now well established in Germany and Ontario, as well as in Georgia, Massachusetts, Texas, California, and Maryland in the United States.

One of the first large series of TeleStroke consultations was described in southern Germany, where seven rural hospitals were linked to a stroke unit in

FIGURE 10.3 Regional maps depicting TeleStroke Networks. Two hospitals in the TEMPiS network in Bavaria (Germany) provide acute stroke expertise to 12 community hospitals.56

Gunzburg as part of the Telemedicine in Stroke in Swabia (TESS) Project.33 Of 153 patients examined, 87 were determined to have had an ischemic stroke, but importantly, 40 patients had a diagnosis other than stroke, confirming that teleme-dicine is also helpful in identifying other emergency neurological conditions that may mimic stroke. The duration of teleconsultation was 15 minutes on average. Thirty-seven percent of the 94 patients with ischemic stroke or TIA reached the hospital within 3 hours, and two received thrombolysis. In the opinion of the referring physicians, relevant contributions were made in over 75% of all cases concerning the diagnostic workup, CT assessment, and therapeutic recommendations.

More recently, thrombolytic therapy was reported in 106 patients as part of the TEMPiS system in Bavaria, Germany. The network consists of two comprehensive and 12 regional centers connected by around-the-clock telemedicine support for stroke care. In the first year following intervention, the number of patients treated with rt-PA increased to 86 patients (2% of all patients admitted with stroke), compared to 10 patients treated in the year preceding intervention. The rate of symptomatic hemorrhage was 8.5%, similar to the NINDS trial.34

In the REACH study involving the Medical College of Georgia and five rural hospitals in Georgia,35 12 of 75 (16%) patients evaluated received rt-PA, all without intracranial hemorrhagic complications.

We described our own initial experience at the Partners TeleStroke Center in Massachusetts,30 before expanding this service from 2 to 14 participating community hospitals. In our pilot experience with two community hospitals, six patients were treated with IV rt-PA in the first 27 months. Among the six patients receiving rt-PA, two patients had persistent deficits (one of whom had care withdrawn), two patients had moderate recovery, and two had good recovery (one of whom had initial worsening deficits). There were no violations of NINDS protocol2 and re-review of the initial CT by a neuroradiologist with stroke expertise did not alter the diagnosis in any case. All patients had follow-up imaging and only one patient developed symptomatic ICH within 36 hours; another developed a small delayed asymptomatic intracerebral hemorrhage.

University of Maryland investigators reported 23 telemedicine consultations and 27 telephone consultations preceding transfer among patients with suspected acute stroke.36 Of the 23 telemedicine consultations, 2 were aborted because of technical difficulties, but 5 of the 21 patients receiving successful TeleStroke consultation received IV rt-PA. No patient experienced complications. Diagnoses included sub-arachnoid hemorrhage, intracerebral hemorrhage, seizure, hypoglycemia, and transient ischemic attack as well as acute ischemic stroke (both anterior and posterior circulations).

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