Outcomes for Telestroke Transfers Similar to Traditional Referral Outcomes

Damian McNamara

May 15, 2018

LOS ANGELES — Outcomes in patients who receive teleconsultations for acute stroke management and are then transferred to a comprehensive stroke center (CSC) are similar to those in individuals who receive routine transfers.

A direct comparison of the two approaches showed that neurologists consulted via telemedicine diagnosed more severe strokes. The study also revealed a slightly longer time to administration of intravenous (IV) tissue plasminogen activator (tPA) via telestroke services. However, patient outcomes did not differ significantly.

"We actually captured a lot more serious strokes — the risk was much higher in people [assessed through] telestroke," study investigator Aashrai Gudlavalleti, MBBS, a neurologist at Upstate Medical University, State University of New York (SUNY) in Syracuse, told Medscape Medical News. "We were able to reach out to the community when acute strokes were happening."

"Telestroke services are up and coming to help people in rural areas who don't have access to acute stroke care. They live far away from a tertiary stroke care center that can provide acute therapies like tPA or thrombectomy," said Gudlavalleti during a poster presentation here at the American Academy of Neurology (AAN) 2018 Annual Meeting.

Once SUNY Upstate Medical Center began expanding its stroke expertise to surrounding rural communities via telestroke services, Gudlavalleti and colleagues wanted to determine "if there were any positive or negative outcomes of telestroke itself. It's a big industry, and we need to know if there are any adverse events compared to the traditional transferring of patients to a stroke center."

The retrospective study included  90 patients, including 24 patients who arrived at a CSC via telestroke triage and another 66 who came via routine transfers. They included adults with radiologically confirmed ischemic strokes entered in a prospectively collected stroke database between January 2015 and March 2017. Mean age was 70 years, and both sexes were equally represented.

Upon admission, the median admission National Institutes of Health Stroke Scale score was significantly higher among telestroke patients, at 6.5, than among the routine transfer patients, at 4.0  (P = .01).

More telestroke patients than routinely transferred patients also received intravenous tPA: 42% vs 21%, respectively (P = .05). "Although it was not [statistically] significant, a lot more patients got intravenous tPA because they had a telestroke neurologist consult, so it could be the ED [emergency department] physician was more confident giving the tPA," Gudlavalleti said.

Improving Time to tPA

Another interesting but nonsignificant finding involved time between mean symptom onset and administration of tPA. Overall, this took a mean 149 minutes, or 2 hours, 29 minutes. However, mean time was longer in the telestroke group, at 173 minutes, than in  the routine transfer group, at 127 minutes (P = .08).

Gudlavalleti theorized that the longer time to administration of tPA with telemedicine involved establishing the Skype-like connection between physicians and extra time for the consulting neurologist to review the CT scan or other patient data. "It was surprising in a way that it can take longer to give the IV  tPA [via telestroke]. That's something we need to look into more."

In addition, "we did not find any difference in the outcomes in terms of patients undergoing endovascular therapy." The study revealed 13% of the telestroke patients and 17% of the routine transfer patients had this intervention, a nonsignificant difference (P = .63).

Favorable short-term functional outcome also did not differ significantly. The proportion of patients in each group with a discharge score of 0 to 2 on the modified Rankin Scale was similar: 50% of the telestroke patients and 48% of the routine transfer patients (P = .9).

"We didn't find any adverse events associated with telestroke," he added. The investigators were concerned that administration of more IV tPA in the telestroke patients could lead to more complications. "I didn't find that here, so that was a good thing."

Going forward, Gudlavalleti said he wants to further examine any factor slowing down the time between symptom onset and tPA administration in telestroke patients and "then addressing it prospectively to see if we can improve the time to tPA."

Commenting on the findings for Medscape Medical News, Parthasarathy Thirumala, MD, associate professor of neurological surgery and director of the Center for Clinical Neurophysiology at the University of Pittsburgh Medical Center, Pennsylvania, said the study highlights the value of telemedicine in providing care for patients with acute stroke in a rural setting.

"By providing the telestroke service, physicians from a comprehensive stroke center can improve the rate of administration of tPA for stroke patients, hospitals can prevent patient transfers, [and] patients can stay in their community and receive care. More importantly, this will allow for a comprehensive stroke center to transfer patients who need intervention, thereby efficiently managing resources," he said.

Previous studies have indicated that telemedicine services can be cost-effective for treating rural stroke patients and, perhaps not surprisingly, increase access to emergency care of strokes.

Gudlavalleti and Thirumala have disclosed no relevant financial relationships.

American Academy of Neurology (AAN) 2018 Annual Meeting. Abstract P5.251. Presented April 26, 2018.

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