Starting bring the hospital to patients: Accessibility and outcomes of therapy in acute ischemic stroke in southern Spain by telestroke

Dear editor,

Stroke is the leading cause of disability, the second cause of dementia and one of the most prevalent causes of death in high- to middle-income countries. ¹ Nevertheless, geographical barriers and limited resources impose differing levels of access to health services and prevent adequate care for acute stroke patients. ² In two decades, telemedicine applied to cerebrovascular disease has facilitated the administration of thrombolytic therapy successfully to a larger number of patients with ischemic stroke and increased the efficacy of stroke units. ³ The rapid expansion and practice of telemedicine networks has allowed the development of evidences for use and the implementation of guidelines. ⁴

Our hub stroke research center partnered with two stroke community hospitals, and a five-year prospective cohort study of stroke patients was conducted. Consultations were held to make shared decisions on treatment with recombinant tissue plasminogen activator (rtPA). A total of 1189 patients with acute ischemic stroke were diagnosed by the referring centers, 81 (6.81%) were evaluated using telestroke and 56.8% were treated with intravenous rtPA. Mean baseline National Institutes of Health Stroke Scale score was 14.3 (vs. 13.7 in tertiary center, p = 0.48). Door-to-needle time was 15 min longer in telestroke patients than in the tertiary center (p < 0.001), due to teleconsultation (p < 0.001 in CT-needle time). However, there were similar rates of symptomatic cerebral hemorrhage (2.2% vs. 3.6%, p = 0.8) and long-term mortality (17% vs. 21%, p = 0.72) with a trend towards higher disability (39.6% had a modified Rankin scale score of ≤2 vs. 55.6%, p = 0.07) (Table 1).

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Table 1.

Baseline characteristics, clinical outcomes at day 90 and hemorrhagic complications

	Overall results
		Local referring centers	Tertiary center	p
Total number of ischemic stroke patients admitted (TIA and hemorrhagic patients excluded)	1189 (2009–2013)	1640 (2010–2013)
Total thrombolysis and consultation	- Thrombolysis N = 46 (56.8%) - Non-thrombolysis N = 35 (Telestroke)	Thrombolysis N = 260 (15.9%)
Sex (men)	- Thrombolysis 20 (43.5%) - Non-thrombolysis 14 (40%)	Thrombolysis 121 (46.5%)	0.701
Age (years) (mean ± SD)	65.3 (±10.2)	67.6 (±14.9)	0.190
Symptom onset-to-door (min) (median (P25–P75))	64.5 (32.75–95.25)	75.0 (51–114.75)	0.048
Symptom-to-needle (min) (median (P25–P75)	160 (130–191.5)	150 (120–200)	0.705
Door-to-needle (min) (median (P25–P75))	82.5 (71.5–108)	67 (48–94.75)	0.001
Door-to-CT (min) (median (P25–P75))	25 (14.5–34.5)	30 (22–45)	0.006
CT-to-needle (min) (median (P25–P75))	62 (47–77)	35.5 (20–55)	<0.001
%Thrombolysis <180	71.7%	46.8%	0.0045
%Thrombolysis 180–270 (from October 2009)	28.26%	53.16%	<0.05
Baseline NIHSS (mean ± SD)	14.3 (±5.7)	13.7 (±6.2)	0.479
NIHSS at hospital discharge (mean ± SD)	10.0 (±6.3)	9.8 (±8.3)	0.893
mRS < 3 at 3 months	39.6% (17/43)	55.6% (119/214)	0.078
In-hospital mortality (%)	3/46 (6.5%)	41/258 (15.9%)	0.151
Cumulative mortality at 3 Months (%)	8/46 (17.4%)	45/214 (21.0%)	0.723
Cerebral hemorrhage (%)	4/46 (8.7%)	17.6%	0.197
Symptomatic cerebral hemorrhage (%) a	1/46 (2.2%)	9/250 (3.6%)	0.850

Telestroke safely select a large number of patients requiring intravenous rtPA. The results are similar in terms of efficacy and safety in experienced centers, and unnecessary transfers of patients are avoided. Telestroke is now considered key to clinical practice in academic and community environments. So, it has been demonstrated that high-quality telestroke consultations can be performed with mobile enhancing the portability of the service and to progress in the prehospital setting. ⁵ This field appears to be advancing via creative postimplementation studies.