Published online before print September 18, 2003, doi: 10.1161/01.STR.0000095163.28915.B9
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(Stroke. 2003;34:e191.)
© 2003 American Heart Association, Inc.
Research Reports |
Editorial Comment—Remote Evaluation of Acute Ischemic Stroke: A Reliable Tool to Extend Tissue Plasminogen Activator Use to Community and Rural Stroke Patients?
Department of Neurology, University Hospital Göttingen, Göttingen, Germany
In order to apply thrombolytic therapy to patients presenting with an acute stroke in community hospitals without permanent access to consulting neurologists, Wang et al report an interesting replenishment of the classic stroke unit concept. They present an easy-to-use video evaluation tool, which allows the raising of a bedside NIHSS score remotely. According to their data, this remote NIHSS score strongly correlates with the NIHSS score evaluated by a blinded bedside investigator. Although remote evaluation of NIHSS by telemedicine has been reported before,1 the technical approach presented here may allow scoring under more real-life conditions. Nevertheless, the small number of 20 patients can only serve as a proof of principle, since an evaluation especially of patients with complex deficits like neglect, other neuropsychological deficits, or visual field defects might be challenging even under real-life conditions, which means examination in the short 3-hour time window.
Moreover, the NIHSS is only one critical step in the decision about a thrombolytic therapy, according to the NINDS criteria. It remains to be shown by the already ongoing trial that remote evaluation of NIHSS and, even more critical, of the CT scan will lead to reliable and safe decisions about intravenous rtPA administration in this setting. Another fundamental disadvantage of remote evaluation is the fact that examination of the patient is restricted to one given time point. This neglects the fact that many patients present not with stable but with fluctuating, decreasing or increasing deficits that complicate the decision about thrombolytic therapy in everyday life. The same is true in the case of relative contraindications, where a decision about thrombolytic therapy is difficult to reach remotely.
Compared with other community-based stroke networks2,3 it may be an advantage that only a few stroke experts at least virtually examine the patient on their own, which should lead to more reproducible decisions about stroke treatment as compared with settings where the NIHSS is obtained by a large number of heterogeneously trained physicians. However, the safety of rtPA application in community hospitals has been proven for small cohorts of patients,2,3 while this remains to be demonstrated for the remote concept.
Further, in community-based concepts thrombolytic therapy is performed in hospitals without facilities or expertise for the treatment of complications like bleeding or brain edema. Even for successfully treated patients, sophisticated diagnostic tools are usually not available. Other studies have already shown that secondary prevention or blood pressure treatment often does not follow the existing guidelines and recommendations for the management of acute stroke in such settings, which may influence the final outcome of the patients even more profoundly than access to thrombolysis.4,5
Therefore, we think that referral to a tertiary stroke center after thrombolytic therapy is inevitable for many patients, even in the case of remote rtPA treatment. This raises the question of why such a referral should not be performed immediately within the therapeutic time window. A recent study has already demonstrated the feasibility of a helicopter transfer in an acute stroke transport program within an acceptable time window in rural regions in northeastern Florida and southeastern Georgia.6 Such an approach is encouraged by the findings of the Southwestern Ontario Stroke Program.7 In this prospective, study patients referred from rural hospitals to the academic medical center were treated with the same success as patients who were admitted directly to the academic medical center. In accordance with our own experience as an academic tertiary stroke center, patients referred from outside hospitals had a significantly lower door-to-needle time, which compensated for most of the referral time in the Ontario study. This observation proves that no significant time is finally lost in referred patients, because laboratory routine examinations are already performed, informed consent of the patient is obtained, facts about medical history are collected, and, most importantly, the stroke team in the tertiary center and a radiologist are already in standby once the patient reaches the stroke unit.
The German concept of regional stroke units in addition to the tertiary, mainly academic medical centers, which close the gaps in between the tertiary centers, also aims in this direction. Such a network of hospitals with stroke expertise—not necessarily run by neurologists—that can be reached in an appropriate time window is currently being developed. In this concept, stroke expertise is available in a limited number of hospitals that cover also rural and remote regions, and trained staff for stroke treatment must not be kept available in other hospitals.8
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1. Shafqat S, Kvedar JC, Guanci MM, Chang Y, Schwamm LH. Role for telemedicine in acute stroke: feasibility and reliability of remote administration of the NIH stroke scale. Stroke. 1999; 30: 2141–2145.
2. Wang DZ, Rose JA, Honings DS, Garwacki DJ, Milbrandt JC. Treating acute stroke patients with intravenous tPA: the OSF stroke network experience. Stroke. 2000; 31: 77–81.
3. Davenport J, Hanson SK, Altafullah IM, Anderson DC, Brauer DJ, Brown RD, Ramirez-Lassepas M. tPA: a rural network experience. Stroke. 2000; 31: 1457–1458.
4. Handschu R, Garling A, Heuschmann PU, Kolominsky-Rabas PL, Erbguth F, Neundorfer B. Acute stroke management in the local general hospital. Stroke. 2001; 32: 866–870.
5. Burgin WS, Staub L, Chan W, Wein TH, Felberg RA, Grotta JC, Demchuk AM, Hickenbottom SL, Morgenstern LB. Acute stroke care in non-urban emergency departments. Neurology. 2001; 57: 2006–2012.
6. Silliman SL, Quinn B, Huggett V, Merino JG. Use of a field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural residents. Stroke. 2003; 34: 729–733.
7. Merino JG, Silver B, Wong E, Foell B, Demaerschalk B, Tamayo A, Poncha F, Hachinski V. Southwestern Ontario Stroke Program: extending tissue plasminogen activator use to community and rural stroke patients. Stroke. 2002; 33: 141–146.
8. Ringelstein EB. Concept of interregional and regional stroke treatment in Germany: report of the recommendation of Commission 1.06 "Stroke Units and Acute Stroke Therapy" of the German Society for Neurology. [In German.] Nervenarzt. 2000; 71: 322–324.[Medline] [Order article via Infotrieve]
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