At the Turning Point in Effective and Equitable Stroke Care

Joseph L. Schindler, MD


August 24, 2009

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Stroke is the third leading cause of death and the leading cause of adult disability in the United States. We know that intravenous tissue plasminogen activator [tPA] is the only FDA [US Food and Drug Administration]-approved treatment for ischemic stroke that has been shown to reduce disability. However, despite its widespread availability, it is only given to a small percentage of patients who may benefit from treatment. Why is that?

The medication is only safe and effective when administered in select patients and only up to 4.5 hours after the onset of symptoms. With many physicians who first see acute stroke patients reluctant to make the call to administer the medication, a primary barrier to treatment remains the inaccessibility of emergent neurologic expertise in stroke. One solution is the use of telemedicine for a neurologic consultation.

In fact, "telestroke" services provide swift access to neurologic expertise and empowers institutions without access to an acute stroke specialist to be able to provide optimal acute stroke care. The recommendation involves a remote consultation among practitioners and patients using high-quality videoconferencing, or HQ-VTC. Both an NIHSS [NIH Stroke Scale] assessment and a review of the head CT [computed tomography] scan are performed remotely using this protocol. This ultimately leads to an order by the stroke specialist to provide a lytic treatment decision.

Although not in widespread use yet, over 20 networks have been implemented and described. And, in an acknowledgement of gaining acceptance, in May, the American Heart Association and American Stroke Association published an evidence-based review of the scientific evidence supporting telecommunications in the delivery of acute stroke care.

So where do we go from here? Two steps need to take place. First, the concept of telestroke may provide a culture shock to many neurologists who, in being exposed to the technology, will need reassurance that it is only an interface to [the] continuing traditional values of excellent history taking and the physical exam, critical elements of neurologic diagnosis and treatment.

Second, regionalization of acute stroke care should be developed with stroke centers and nonstroke centers in close proximity defining their resources and needs and [with] telemedicine actively promoted when poor accessibility to expertise interferes with providing the standard of care. If we are serious about bridging the disparities related to acute stroke treatment, telemedicine is the next step.

That's my opinion. I'm Dr. Joseph Schindler, Director of Stroke Services at Yale-New Haven Hospital and Assistant Professor of Neurology and Neurosurgery at the Yale University School of Medicine.