Smartphone App Extends Stroke Expertise to Hospitals Without Stroke Neurologists

Daniel M. Keller, PhD

November 25, 2016

HYDERABAD, India — A smartphone system allows a stroke team to remotely evaluate high-quality images within or outside the hospital and safely and effectively aid young neurologists or neurologists without stroke expertise to make decisions about treating acute stroke, a study shows.

"We can see the images — CT scan or MRI — with very good quality, and we can discuss the case and chat with residents, neurologists without experience, or clinicians to discuss the treatment of the acute phase of stroke, for example, the decision to thrombolyse or not thrombolyse the patient," Sheila Martins, MD, PhD, of the Hospital de Clínicas de Porto Alegre, Brazil, told Medscape Medical News during the World Stroke Congress (WSC) 2016.

The Join App, available for iPhone or Android devices, can display images using the Digital Imaging and Communications in Medicine (DICOM) standard. In addition to images, the app can transmit other clinical patient data useful for decision making.

Investigators evaluated the system for 1 year beginning in December 2014 to prospectively assist in the treatment of acute stroke patients at their public university hospital in Brazil.

Of 637 patients (mean age 63 years; 50% women), 533 had an ischemic stroke (IS) and 45 had a transient ischemic attack (TIA). Neurology residents attending the patients transmitted images and patient history to stroke neurologists.

Of 575 evaluable IS/TIA patients (average baseline National Institutes of Health Stroke Scale score of 16), 86 received thrombolytic therapy. Reasons for withholding thrombolysis included exceeding the time window of 4 hours, hypodensity greater than one-third of the middle cerebral artery territory on baseline CT, TIA, or mild stroke.

Decisions to thrombolyse the patients or not based on images transmitted using the app were validated by comparing them with opinions of stroke experts reviewing the images on workstations the next day.

"The smartphone was not different in comparison to the work station in the hospital by a stroke neurologist and neuroradiologist," Dr Martins said. "We can use this system to help young neurologists and neurologists without experience in deciding [on] thrombolysis in a country where we don't have enough specialized neurologists to do this."

Outcomes were good. Dr Martins said there were low rates of intracranial hemorrhage, low mortality, and 51% of patients had outcomes with no or minimal disability.

Her stroke team is now using the system to connect a network of hospitals without neurologists to stroke centers that can, when indicated, transfer patients to hospitals with thrombectomy capabilities.

The smartphone app is a much less expensive way to do telemedicine than using a dedicated commercial system, Dr Martins said.

Vivek Sabharwal, MD, chairman of the department of neuro critical care at the Ochsner Medical Center, New Orleans, Louisiana, has published on the telestroke program his institution.

"We have telemedicine in 52 hospitals. To get [the equipment] cart and sign a contract, they have to agree to a certain number of calls, so it's very expensive," he commented to Medscape Medical News. "I think this [app] is going to be many magnitudes higher than what we have."

He said he is trying to create a similar app for neuro-critical care to be in touch with all the intensive care and ER physicians throughout Louisiana and Mississippi, so if "they need any help with anything, they can just hit an app and call me and my team, and we will help them diagnose the problem. If they can't handle it, we will move the patient to our ER," which he calls "drip and ship."

One impediment in the US to use of this approach is the Health Insurance Portability and Accountability Act, he said. "I think this is the future if you can come up with a secure network," he said. Dr Martins said no such restrictions exist in Brazil.

The Ochsner system is secure because the medical center already has contracts and systems for telestroke medicine. Having an app "would take it to the next level," he said, with the app applying not just to stroke but to all acute neurological issues, such as meningitis, status epilepticus, or spinal fracture.

There was no commercial funding for the study. Dr Martins and Dr Sabharwal had no financial conflicts.

World Stroke Congress (WSC) 2016. Abstract 087. Presented October 27, 2016.

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