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Telestroke allows for specialized stroke care in underserved areas

Telemedicine is the use of electronic communication methods, such as telephone, Internet, and videoconferencing, to exchange medical information from one geographic site to another.1

Telestroke is the use of telemedicine specifically for stroke care.1

The 2009 American Stroke Association (ASA) recommendations on telemedicine support the use of telestroke as a means of providing stroke care in rural, remote, or underserved areas:

"Telestroke networks should be deployed wherever a lack of readily available stroke expertise prevents patients in a given community from accessing a primary stroke center (or center of equivalent capability) within a reasonable distance or travel time to permit eligibility for intravenous thrombolytic therapy."2

The 2009 ASA recommendations emphasize the necessity to address the issue of adequate stroke diagnosis and care. The importance of addressing stroke care issues is evident in the following statistics:

  • 795,000 strokes occur annually in the United States3
  • 4 neurologists are available per 100,000 persons in the United States2
  • Acute ischemic stroke may be misdiagnosed by primary care and emergency physicians in up to 30% of cases2*
  • *
  • When compared with stroke team final diagnoses.

The "hub and spoke" model for a telestroke system

The hub and spoke telemedicine structure connects several smaller spoke hospitals to 1 hub hospital via formal agreements to engage in stroke consultation.4

  • Hub hospitals are typically Joint Commission–certified primary stroke centers (PSCs) with advanced capacities, including in-house neurologists and neurosurgery capabilities available 24 hours a day, 7 days a week
  • Spoke hospitals are typically smaller and do not have extensive neurology support. They may be community hospitals located in underserved rural or suburban areas and may or may not have stroke center certification

The "third-party consult" model for a telestroke system

Within the third-party consult model, the spoke hospital contracts with a third-party provider for neurologist coverage.4

  • Third-party provider employs neurologists to be on call to provide telestroke services
  • Spoke hospitals typically have sufficient ICU capabilities for treating patients who do not require surgery, but they transfer more complicated patients to a tertiary hospital when interventional procedures are required. The system allows spoke hospitals to maintain stroke certification, giving them access to a steady stream of patients

Indication
Activase (Alteplase) is indicated for the management of acute ischemic stroke in adults for improving neurological recovery and reducing the incidence of disability. Treatment should only be initiated within 3 hours after the onset of stroke symptoms, and after exclusion of intracranial hemorrhage by a cranial computerized tomography (CT) scan or other diagnostic imaging method sensitive for the presence of hemorrhage (see CONTRAINDICATIONS).

Safety Information
Activase therapy in patients with AIS is contraindicated in certain situations (eg, suspicion of subarachnoid hemorrhage on pretreatment evaluation, recent (within 3 months) intracranial or intraspinal surgery, history of intracranial hemorrhage, uncontrolled hypertension at time of treatment, active internal bleeding, known bleeding diathesis (eg, current use of oral anticoagulants, administration of heparin within 48 hours of onset of stroke, platelet count <100,000) (see CONTRAINDICATIONS for full list).

The most common complication during Activase therapy is bleeding. Should serious bleeding in a critical location (intracranial, gastrointestinal, retroperitoneal, pericardial) occur, Activase therapy should be discontinued immediately. Death and permanent disability are not uncommonly reported in patients who have experienced stroke (including intracranial bleeding) and other serious bleeding episodes.

The risks of Activase therapy may be increased and should be weighed against the anticipated benefits in certain conditions. [See WARNINGS in full prescribing information].

  • Patients with severe neurological deficit (eg, NIHSS >22) at presentation. There is an increased risk of intracranial hemorrhage in these patients.
  • Patients with major early infarct signs on a computerized cranial tomography (CT) scan (eg, substantial edema, mass effect, or midline shift).

Treatment of patients with minor neurological deficit or with rapidly improving symptoms is not recommended.

Orolingual angioedema has been observed in postmarketing experience in patients treated with Activase for AIS. Patients should be monitored during and for several hours after infusion for signs of orolingual angioedema.

Please click here for full prescribing information.
References:
1.
Demaerschalk BM, Miley ML, Kiernan T-E J, et al; for STARR Coinvestigators. Stroke telemedicine. Mayo Clin Proc. 2009;84(1):53-64.
2.
Schwamm LH, Audebert HJ, Amarenco P, et al. Recommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the American Heart Association. Stroke. 2009;40. http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.109.192361v1. Accessed May 7, 2009.
3.
Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics — 2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119(3):480-486.
4.
Demaerschalk B, Kiernan T. Stroke telemedicine in Arizona. Paper presented at: Mayo Clinic College of Medicine; 2008; Phoenix, AZ. http://www.azcvd.gov/pdf/Stroke%20Telemedicine%20Presentation.pdf. Accessed May 8, 2009.