title: TRUST-tPA trial: Telemedicine for remote collaboration with urgentists for stroke-tPA treatment.
abstract: Background Previous observational studies have shown that telemedicine is feasible and safe to deliver intravenous (IV) recombinant tissue plasminogen activator (rt-PA). However, implementation of telemedicine may be challenging. To illustrate this fact, we report a study showing that telemedicine failed to improve clinical outcome and analyze the reasons for this shortcoming. Methods We established a tele-stroke network of 10 emergency rooms (ERs) of community hospitals connected to a stroke center to perform a randomized, open-label clinical trial with blinded outcome evaluation. Eligible patients were randomly assigned to either a usual care arm (i.e. immediate transfer to the stroke center and administration of IV rt-PA if indication was confirmed upon stroke arrival) or tele-thrombolysis arm (i.e. immediate administration of IV rt-PA in ER and transfer to the stroke center). The primary efficacy outcome was an excellent outcome (modified Rankin scale (mRS) 0-1 at 90 days). Secondary endpoints included favorable outcome (90-day mRS 0-2) and early neurological improvement (NIHSS score 0-1 at 24 hours or a decrease of ≥ 4 points within 24 hours). Safety outcomes included symptomatic intracerebral hemorrhage (ICH) per ECASS II definition, any ICH and all-cause mortality. Results During an accrual time of 48 months, because of a slow enrollment rate, only 49 of 270 patients initially planned for inclusion were randomized into usual care ( n = 23) and tele-thrombolysis ( n = 26). Despite random assignment, patients allocated to tele-thrombolysis were older and had more severe stroke than patients allocated to usual care. The median duration of video-conference was 23 minutes in the usual care arm and 73 minutes in the tele-thrombolysis arm. Eighty-four percent of patients in the tele-thrombolysis arm were treated by IV rt-PA in comparison to 18% in the usual care arm. In univariate analysis but not after adjustment for age and baseline NIHSS, patients allocated in the usual care arm had a higher rate of excellent or favorable outcome. There were no differences in safety outcomes, with only one symptomatic ICH occurring in the tele-thrombolysis arm. Conclusions Stroke patients included in the telemedicine arm of the TRUST-tPA trial increased their rt-PA eligibility five-fold. However, the efficacy and safety remains to be determined (ClinicalTrials.org, NCT00279149).
authors.affiliation: 1 Department of Neurology and Stroke Centre, Bichat University Hospital, France.|2 INSERM LVTS-1148 and Paris-Diderot University, France.
authors.forename: Mikael
authors.initials: M
authors.lastname: Mazighi
authors.affiliation: 1 Department of Neurology and Stroke Centre, Bichat University Hospital, France.|2 INSERM LVTS-1148 and Paris-Diderot University, France.
authors.forename: Elena
authors.initials: E
authors.lastname: Meseguer
authors.affiliation: 1 Department of Neurology and Stroke Centre, Bichat University Hospital, France.|2 INSERM LVTS-1148 and Paris-Diderot University, France.
authors.forename: Julien
authors.initials: J
authors.lastname: Labreuche
authors.affiliation: 3 Emergency Department, Compiègne Hospital, France.
authors.forename: Patrick
authors.initials: P
authors.lastname: Miroux
authors.affiliation: 4 Emergency Department, Argenteuil Hospital, France.
authors.forename: Catherine
authors.initials: C
authors.lastname: Le Gall
authors.affiliation: 5 Emergency Department, Provins Hospital, Provins, France.
authors.forename: Patricia
authors.initials: P
authors.lastname: Roy
authors.affiliation: 6 APHP, Département D'Epidémiologie et Recherche Clinique, Hôpital Bichat, France; Univ Paris Diderot, Sorbonne Paris Cité, UMR 1123, France; INSERM, CIC-EC 1425, UMR 1123, France.
authors.forename: Florence
authors.initials: F
authors.lastname: Tubach
authors.affiliation: 1 Department of Neurology and Stroke Centre, Bichat University Hospital, France.|2 INSERM LVTS-1148 and Paris-Diderot University, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Amarenco
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003299:Cooperative Behavior; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009422:Nervous System Diseases / Q000175:diagnosis; D017063:Outcome Assessment, Health Care; D020521:Stroke / Q000175:diagnosis / Q000188:drug therapy*; D017216:Telemedicine / Q000379:methods* / Q000458:organization & administration; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D055815:Young Adult
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Telemedicine; teleneurology