Virtual TeleStroke support for the emergency department evaluation of acute stroke.
OBJECTIVE
Telemedicine-enabled acute stroke consultation (TeleStroke) may be useful to determine eligibility for treatment with tissue plasminogen activator (tPA) and provide support to emergency departments without on-site stroke expertise.


METHODS
Emergency physicians consulted with stroke neurologists via two-way videoconferencing in the evaluation of patients with possible acute stroke. History, neurologic examination, and computed tomography of the head were reviewed to determine eligibility for treatment with tPA. Interpretations of computed tomography were compared for inter-rater reliability between the neurologist and the neuroradiologist using a conventional workstation. Videotape and written records were analyzed to determine time intervals, patient management, and user satisfaction.


RESULTS
The authors reviewed data from 24 patients evaluated over 27 months at an island-based hospital. The mean National Institutes of Health Stroke Scale score was 5.7 (range, 0-22). Fifteen patients arrived at the emergency department less than three hours after symptom onset; 12 were presented for TeleStroke consultation within three hours after symptom onset. Eight of these 12 (75%) had acute ischemic stroke, and six of these eight potentially eligible patients (75%) received intravenous tPA. There was very good agreement among all remote readers for detecting the one case of imaging exclusion (subdural hemorrhage). There were no protocol violations, and a mean (+/- SD) consult-to-needle time of 36 (+/- 15) minutes and door-to-needle time of 106 (+/- 22) minutes was achieved. Transfer was avoided in 11 patients. Physicians believed that TeleStroke consultation improved care in >95% of the cases.


CONCLUSIONS
TeleStroke videoconferencing can support emergency department-based evaluation of acute stroke and may facilitate tPA delivery in neurologically underserved facilities. A prospective, randomized trial is needed to determine if these systems are superior to traditional telephone consultation.
Schwamm
Lee H
LH
Department of Neurology, VBK 915, Massachusetts General Hospital, Boston, MA 02114, USA. lschwamm@partners.org
Rosenthal
Eric S
ES
Hirshberg
Alan
A
Schaefer
Pamela W
PW
Little
Elizabeth A
EA
Kvedar
Joseph C
JC
Petkovska
Iva
I
Koroshetz
Walter J
WJ
Levine
Steven R
SR
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D004635:Emergency Medicine / Q000379:methods; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019114:Remote Consultation / Q000379:methods*; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis* / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000379:methods; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome; D049269:Videoconferencing
D010959:Tissue Plasminogen Activator