Stroke Thrombolysis in a Centralized and a Decentralized System (Helsinki and Telemedical Project for Integrative Stroke Care Network).
Intravenous thrombolysis with tissue-type plasminogen activator (tPA) for acute ischemic stroke is more effective when delivered early. Timely delivery is challenging particularly in rural areas with long distances. We compared delays and treatment rates of a large, decentralized telemedicine-based system and a well-organized, large, centralized single-hospital system.



We analyzed the centralized system of the Helsinki University Central Hospital (Helsinki and Province of Uusimaa, Finland, 1.56 million inhabitants, 9096 km2) and the decentralized TeleStroke Unit network in a predominantly rural area (Telemedical Project for Integrative Stroke Care [TEMPiS], South-East Bavaria, Germany, 1.94 million inhabitants, 14 992 km2). All consecutive tPA treatments were prospectively registered. We compared tPA rates per total ischemic stroke admissions in the Helsinki and TEMPiS catchment areas. For delay comparisons, we excluded patients with basilar artery occlusions, in-hospital strokes, and those being treated after 270 minutes.



From January 1, 2011, to December 31, 2013, 912 patients received tPA in Helsinki University Central Hospital and 1779 in TEMPiS hospitals. Area-based tPA rates were equal (13.0% of 7017 ischemic strokes in the Helsinki University Central Hospital area versus 13.3% of 14 637 ischemic strokes in the TEMPiS area; P=0.078). Median prehospital delays were longer (88; interquartile range, 60-135 versus 65; 48-101 minutes; P<0.001) but in-hospital delays were shorter (18; interquartile range, 13-30 versus 39; 26-56 minutes; P<0.001) in Helsinki University Central Hospital compared with TEMPiS with no difference in overall delays (117; interquartile range, 81-168 versus 115; 87-155 minutes; P=0.45).



A decentralized telestroke thrombolysis service can achieve similar treatment rates and time delays for a rural population as a centralized system can achieve for an urban population.
From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.). gordian.hubert@klinikum-muenchen.de.
Gordian J
GJ
Hubert
From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.).
Atte
A
Meretoja
From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.).
Heinrich J
HJ
Audebert
From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.).
Turgut
T
Tatlisumak
From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.).
Florian
F
Zeman
From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.).
Sandra
S
Boy
From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.).
Roman L
RL
Haberl
From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.).
Markku
M
Kaste
From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.).
Peter
P
Müller-Barna
D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000188:drug therapy*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005387:Finland; D005858:Germany; D006760:Hospitalization / Q000706:statistics & numerical data*; D006785:Hospitals, University / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012042:Registries / Q000706:statistics & numerical data*; D012424:Rural Population; D020521:Stroke / Q000188:drug therapy*; D017216:Telemedicine / Q000706:statistics & numerical data*; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
delivery of health care; stroke; telemedicine; telestroke; thrombolysis; time delays