Amid the current modernisation of ischaemic stroke treatment, Michael Chen discusses how telemedicine not only has tremendous value, but should become a more standard part of any future stroke network.
Modern treatment of acute ischaemic stroke is characterised by a number of unique access challenges. The initial diagnosis is primarily based on clearly visible clinical findings that rely on a specialist who understands how to administer and interpret the neurologic exam. Current treatments including pharmacologic or mechanical thrombolysis are not only proven, but time sensitive. However, the specialists who can provide accurate diagnoses as well as the therapies are limited.
In fact, there are thought to be just over 1100 neurologists who specialise in stroke in the USA, while half of the hospitals have no neurologists on staff. Only 55% of Americans live within 60 miles of a primary stroke centre. As a result, the diagnosis and management of a patient with an acute ischaemic stroke is often led by the local emergency room physician. Furthermore, access for patients with large vessel occlusions to thrombectomy is limited because of the entrenched design of stroke care over the last 20 years being focused exclusively on delivering intravenous lytics. The accreditation priorities of the 1100 primary stroke centres in the USA—with only 10% of them being able to delivery thrombectomy—have focused exclusively on shortening door to needle times, with the early and accurate diagnosis of a large vessel occlusion (LVO) often considered an afterthought.
One classic example of how complicated the access challenges to appropriate stroke care are is in the determination of a patient with a LVO at the spoke hospital; what may seem intuitive is challenging to implement. Non-neurological physicians may have difficulty reliably discerning cortical symptoms such as aphasia and neglect. Using National Institutes of Health Stroke Scale (NIHSS) cutoffs may not be reliable when the person administering the NIHSS does not regularly perform the exam. Erring on the side of taking any patient with the suspicion of a large vessel occlusion, over time, may incur certain costs that may be hidden, but remain significant. In particular, if the patient does not have an actual large vessel occlusion, then unnecessary transfers would lead to wasted transportation costs, sometimes including the use of a helicopter, as well as family transportation costs and opportunity costs for future patients with higher acuity.
With these concerns in mind, it becomes increasingly obvious why telestroke not only has tremendous value, but should become a more standard part of any future stroke network. At its essence, it allows a specialist, who understands not only how to perform, but also interpret a neurologic exam, to make the clinical diagnosis of a stroke and determine if there are cortical signs to suggest a large vessel occlusion. This is much more powerful than a NIHSS threshold which has its inherent imperfections and is administered by someone not familiar with it. Telemedicine has the potential to reduce unnecessary transfers, and gives confidence to the spoke hospital to admit the patient for further management. It might also be an opportunity, particularly if a LVO is suspected and transfer is planned, to obtain informed consent ahead of time, which is preferable that obtaining consent over the phone.
Busy stroke centres can now have up to 15 telestroke hospitals in their network, seeing over 100 consultations per month. The large majority of these consultations lead to the patient remaining at the spoke hospitals, and the rates of alteplase treatment are closer to where they should be. The best long-term value that telestroke creates is responsive, improved diagnostic accuracy in helping spoke hospitals manage their patients, while maintaining a relationship whereby patients who might benefit from thrombectomy can have rapid access to higher levels of care.
There are still significant challenges in the implementation of any telestroke network, and significant resources and time are certainly needed to build it. There are potentially medicolegal ambiguity and financial sustainability concerns—particular in lower volume spoke hospitals—as well as adequate technological infrastructure concerns including support when there are technical difficulties as well as issues of reimbursement to those who are available 24/7 to answer the calls.
Multiple technologies that are current being evaluated range from mobile stroke units and artificial intelligence, to interpret imaging studies and helmet devices; aiming to provide information similar to what the portable electrocardiogram provides, all to front-load the ability to determine stroke severity. Since such an essential component of the diagnosis of an acute ischaemic stroke lies in the clinical exam, the live video that is the basis for telestroke will likely remain an essential component of future stroke networks.
Michael Chen is an associate professor in the department of Neurological Surgery at Rush University Medical