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Ambulance-based telestroke may be a promising solution to improving stroke care. We assessed the technical feasibility and reliability of prehospital evaluations using commercial mobile phones with fifth-generation wireless communication technology. Six standardized patients portrayed scripted stroke scenarios during ambulance transport in an urban city and were remotely evaluated by independent raters using tablets (three neurologists and three emergency physicians) in a hospital, assisted by paramedics (trained in National Institute of Health Stroke Scale [NIHSS] assessment) in the ambulance; commercial cellular networks were utilized for videoconferencing transmission. The primary outcomes were mean difference (MD) and correlation of NIHSS scores between the face-to-face and remote assessments. We also examined the Bland-Altman plot for itemized NIHSS components, and Kaplan–Meier curves were used to compare the differences in the duration of the two evaluations between neurologists and emergency physicians. We conducted 32 ambulance runs and successfully completed all NIHSS examinations. No significant difference was found between the face-to-face and remote evaluations (MD, 0.782; 95% confidence interval [CI], −0.520–0.395). The correlation of NIHSS scores between the two methods was 0.994 (95% CI, 0.945–1.026), and three items exhibited the highest frequency of runs, with score differences between the two methods. There were no significant differences between neurologists and emergency physicians in the mean evaluation duration and NIHSS scores for the two methods. Prehospital evaluation using commercial mobile phones with fifth-generation wireless communication technology is feasible and reliable during ambulance transport in urban areas. Emergency physicians and neurologists performed similarly in stroke evaluations. [ABSTRACT FROM AUTHOR]

Introduction: Telemedicine has been shown to be a safe and effective modality to assess and treat patients with acute stroke who present to a community hospital. There are no previous reports on using telemedicine to treat patients with acute stroke who present to a comprehensive stroke center. We report here the outcomes of patients with acute stroke treated in 2021 at our comprehensive stroke center using telemedicine versus an in-person assessment. Methods: Patients with acute ischemic stroke who were treated after either a telemedicine or in-person assessment at our hospital in 2021 were identified by a retrospective chart review. The primary outcomes collected were door-to-needle (DTN) time for alteplase (tPA) administration, door-to-puncture (DTP) time for endovascular thrombectomy, symptomatic intracranial hemorrhage (sICH) rates and 3-month mortality. Results: There were 302 patients with acute stroke treated at our hospital in 2021. Of these, 18.2% (n = 55/302) were treated using telemedicine. There were no differences in any of the outcomes between patients treated using telemedicine versus an in-person assessment: DTN (35.5 min (n = 42) vs 33 min (n = 182), p < 0.76), DTP (86.5 min (n = 30) vs 85 min (n = 134), p < 0.97), sICH (0% (n = 0/55) vs 1.6% (n = 4/245, p < 0.59) or 3-month mortality (20.6% (n = 7/34) vs 22.1% (n = 40/181), p < 0.29). Discussion: To the best of our knowledge, this is the first study to report on outcomes for acute stroke patients treated using telemedicine at a comprehensive stroke center. In this study, there were no differences in outcomes between patients treated using telemedicine versus an in-person assessment. [ABSTRACT FROM AUTHOR]

Background: Predicting the frequency of calls for telestroke and emergency teleneurology consultation is essential to prepare staffing for the immediate management of time-sensitive strokes. In this study, we evaluate Poisson distribution count data using a generalized linear model that predicts the volume of hourly telestroke calls over a 24-h period. Methods: We performed an Institutional Review Board approved retrospective cohort review of patients (January 2019–December 2022) from an institutional telestroke database at a large nonprofit multihospital system in the United States. All patients ≥18 years with a telestroke activation were included. Telestroke calls were quantified in frequency per day and analyzed by multiple time and date intervals. Poisson probability mass function (PMF) and cumulative distribution function (CDF) were used to predict call probabilities. A univariable Poisson regression model was fit to predict call volumes. Results: A total of 8,499 patients at 21 hospitals met inclusion criteria, the mean calls/day were 5.82 ± 2.54, and mean calls/day within each hour increment ranged from a minimum of 0.07 from 5 a.m. to 6 a.m. to a maximum of 0.45 from 7 p.m. to 8 p.m. The Poisson distribution was the most appropriate parametric probability model for these data, confirmed by the fit of the data to the expected distributions corresponding to the calculated means. The predicted probabilities of call frequencies by hour were calculated using the Poisson PMF and CDF; the probability of two or fewer calls/day by hour ranged from 98.9% to 99.9%. Univariable Poisson regression modeled an increase of future calls/day from 6.7 calls/day in July 2023 to 7.6 calls/day in October 2025. Conclusion: Poisson modeling closely fits telestroke call volumes, predicts the future volumes, and can be applied to any health system in which the mean call volume is known, which may inform the number of physicians needed to cover calls in real-time. [ABSTRACT FROM AUTHOR]

Background: Patients with a large vessel occlusion require a transfer from a primary stroke centre to access thrombectomy, often over significant distances in regional areas. We sought to optimise stroke care access in the regional South Australian Tele-Strokeservice (SATS) to improve patient access to thrombectomy. Methods: We undertook a 24-month interventional historically controlled cohort study comparing acute stroke care metrics in the SATS. This consisted of a 12-month control period and a 12-month intervention monitoring period. The study intervention considered of an education package provided to the regional hospitals, a stroke neurologist roster to receive consultations and the intervention of a centralised tele-stroke system to provide treatment advice and organise patient transfers where needed. The SATS services 61 rural hospitals in South Australia, and Alice Springs in the Northern Territory. Suspected acute stroke patients presenting to the participating regional hospitals in SATS network where a telehealth consultation took place. Results: Over the study period, there were 919 patient referrals, with 449 consultations in the pre-intervention phase and 470 in the post-intervention phase. Demographic features in both epochs were similar. The post-intervention phase was associated with shorter door-to-scan time (35 min, IQR: 18,70; vs. 49 min, IQR:25,102, p < 0.0001), faster door-to-thrombolysis time (58 min, IQR: 39,91, vs.83 min, IQR: 55,100, p = 0.0324) and a higher portion of patients treated with thrombectomy (54, 11.5% vs. 26, 5.8%, p = 0.002). Conclusion: An optimised implementation of a streamlined telehealth platform with ongoing education and feedback to referring sites was associated with improved stroke workflow metrics and higher thrombectomy rates. [ABSTRACT FROM AUTHOR]

Background: Telestroke systems operate through remote communication, providing distant stroke evaluation through expert healthcare providers. The aim of this study was to assess whether the implementation of a telestroke system influenced stroke treatment outcomes in acute ischemic stroke (AIS) patients compared with conventional in-person treatment. Aims: The study group evaluated multiple studies from electronic databases, comparing telemedicine (TM) and non-telemedicine (NTM) AIS patients between 1999 and 2022. We aimed to evaluate baseline characteristics, critical treatment times, and clinical outcomes. Summary of review: A total of 12,540 AIS patients were included in our study with 7936 (63.9%) thrombolyzed patients. Of the thrombolyzed patients, 4150 (51.7%) were treated with TM, while 3873 (48.3%) were not. The mean age of TM and NTM cohorts was 70.45 ± 4.68 and 70.42 ± 4.63, respectively (p > 0.05). Mean National Institute of Health Stroke Scale scores were comparable, with the TM group reporting a non-significantly higher mean (11.89 ± 3.29.6 vs. 11.13 ± 3.65, p > 0.05). No significant difference in outcomes was found for symptoms onset-to-intravenous tissue plasminogen activator (ivtPA) times (144.09 ± 18.87 vs. 147.18 ± 25.97, p = 0.632) and door-to-needle times (73.03 ± 20.04 vs. 65.91 ± 25.96, p = 0.321). Modified Rankin scale scores (0–2) were evaluated, and no significant difference was detected between cohorts (odds ratio (OR): 1.06, 95% confidence interval (CI): 0.89–1.29, p = 0.500). Outcomes did not indicate any significance between both cohorts for 90-day mortality (OR: 1.16, 95% CI: 0.94–1.43, p = 0.17) or symptomatic intracranial hemorrhage (OR: 0.99, 95% CI: 0.73–1.34, p = 0.93). Results between groups were also non-significant when analyzing the rate of thrombolysis with ivtPA (30.86%± 30.7 vs. 20.5%± 18.6, p = 0.372) and endovascular mechanical thrombectomy (11.8%± 11.7 vs. 18.7%± 18.9, p = 0.508). Conclusion: The use of telestroke in the treatment of AIS patients is safe with minimal non-significant differences in long-term outcomes and rates of thrombolysis compared with face-to-face treatment. Further studies comparing the different methods of TM are needed to assess the efficacy of TM in stroke treatment. [ABSTRACT FROM AUTHOR]

BackgroundPatients with a large vessel occlusion require a transfer from a primary stroke centre to access thrombectomy, often over significant distances in regional areas. We sought to optimise stroke care access in the regional South Australian Tele-Strokeservice (SATS) to improve patient access to thrombectomy.MethodsWe undertook a 24-month interventional historically controlled cohort study comparing acute stroke care metrics in the SATS. This consisted of a 12-month control period and a 12-month intervention monitoring period. The study intervention considered of an education package provided to the regional hospitals, a stroke neurologist roster to receive consultations and the intervention of a centralised tele-stroke system to provide treatment advice and organise patient transfers where needed. The SATS services 61 rural hospitals in South Australia, and Alice Springs in the Northern Territory. Suspected acute stroke patients presenting to the participating regional hospitals in SATS network where a telehealth consultation took place.ResultsOver the study period, there were 919 patient referrals, with 449 consultations in the pre-intervention phase and 470 in the post-intervention phase. Demographic features in both epochs were similar. The post-intervention phase was associated with shorter door-to-scan time (35 min, IQR: 18,70; vs. 49 min, IQR:25,102, p

Abstract Background Black and Latinx populations are disproportionately affected by stroke and are likely to experience gaps in health care. Within fragmented care systems, remote digital solutions hold promise in reversing this pattern. However, there is a digital divide that follows historical disparities in health. Without deliberate attempts to address this digital divide, rapid advances in digital health will only perpetuate systemic biases. This study aimed to characterize the range of digital health interventions for stroke care, summarize their efficacy, and examine the inclusion of Black and Latinx populations in the evidence base. Methods We searched PubMed, the Web of Science, and EMBASE for publications between 2015 and 2021. Inclusion criteria include peer-reviewed systematic reviews or meta-analyses of experimental studies focusing on the impact of digital health interventions on stroke risk factors and outcomes in adults. Detailed information was extracted on intervention modality and functionality, clinical/behavioral outcome, study location, sample demographics, and intervention results. Results Thirty-eight systematic reviews met inclusion criteria and yielded 519 individual studies. We identified six functional categories and eight digital health modalities. Case management (63%) and health monitoring (50%) were the most common intervention functionalities. Mobile apps and web-based interventions were the two most commonly studied modalities. Evidence of efficacy was strongest for web-based, text-messaging, and phone-based approaches. Although mobile applications have been widely studied, the evidence on efficacy is mixed. Blood pressure and medication adherence were the most commonly studied outcomes. However, evidence on the efficacy of the various intervention modalities on these outcomes was variable. Among all individual studies, only 38.0% were conducted in the United States (n = 197). Of these U.S. studies, 54.8% adequately reported racial or ethnic group distribution. On average, samples were 27.0% Black, 17.1% Latinx, and 63.4% White. Conclusion While evidence of the efficacy of selected digital health interventions, particularly those designed to improve blood pressure management and medication adherence, show promise, evidence of how these interventions can be generalized to historically underrepresented groups is insufficient. Including these underrepresented populations in both digital health experimental and feasibility studies is critical to advancing digital health science and achieving health equity.

Introduction: Telemedicine can alleviate the problems faced in rural settings in providing access to specialist stroke care. The evidence of the cost-effectiveness of this model of care outside high-income countries is limited. This study aimed to conduct: (a) a systematic review of economic evaluations of telestroke and (b) a cost–utility analysis of telestroke, using China as a case study. Methods: We systematically searched Embase, Medline Complete and Cochrane databases. Inclusion criteria: full economic evaluations of telemedicine/telestroke networks examining the use of thrombolysis in patients with acute ischaemic stroke, published in English. A cost–utility analysis was undertaken using a Markov model incorporating a decision tree to simulate the delivery of telestroke for acute ischaemic stroke in rural China, compared to no telestroke from a societal and healthcare perspective. One-way deterministic sensitivity analyses and probabilistic sensitivity analyses were performed to test the robustness of results. Results: Of 559 publications found, eight met the eligibility criteria and were included in the systematic review (two cost-effectiveness analyses and six cost–utility analyses, all performed in high-income countries). Telestroke was a cost-saving/cost-effective intervention in five out of the eight studies. In our modelled analysis for rural China, telestroke was the dominant strategy, with estimated cost savings of Chinese yuan 4,328 (US$627) and additional 0.0925 quality-adjusted life years per patient. Sensitivity analyses confirmed the base case results. Discussion: Consistent with published economic evaluations of telestroke in other jurisdictions, telestroke represents a cost-effective solution to enhance stroke care in rural China. [ABSTRACT FROM AUTHOR]

Background: Black and Latinx populations are disproportionately affected by stroke and are likely to experience gaps in health care. Within fragmented care systems, remote digital solutions hold promise in reversing this pattern. However, there is a digital divide that follows historical disparities in health. Without deliberate attempts to address this digital divide, rapid advances in digital health will only perpetuate systemic biases. This study aimed to characterize the range of digital health interventions for stroke care, summarize their efficacy, and examine the inclusion of Black and Latinx populations in the evidence base. Methods: We searched PubMed, the Web of Science, and EMBASE for publications between 2015 and 2021. Inclusion criteria include peer-reviewed systematic reviews or meta-analyses of experimental studies focusing on the impact of digital health interventions on stroke risk factors and outcomes in adults. Detailed information was extracted on intervention modality and functionality, clinical/behavioral outcome, study location, sample demographics, and intervention results. Results: Thirty-eight systematic reviews met inclusion criteria and yielded 519 individual studies. We identified six functional categories and eight digital health modalities. Case management (63%) and health monitoring (50%) were the most common intervention functionalities. Mobile apps and web-based interventions were the two most commonly studied modalities. Evidence of efficacy was strongest for web-based, text-messaging, and phone-based approaches. Although mobile applications have been widely studied, the evidence on efficacy is mixed. Blood pressure and medication adherence were the most commonly studied outcomes. However, evidence on the efficacy of the various intervention modalities on these outcomes was variable. Among all individual studies, only 38.0% were conducted in the United States (n = 197). Of these U.S. studies, 54.8% adequately reported racial or ethnic group distribution. On average, samples were 27.0% Black, 17.1% Latinx, and 63.4% White. Conclusion: While evidence of the efficacy of selected digital health interventions, particularly those designed to improve blood pressure management and medication adherence, show promise, evidence of how these interventions can be generalized to historically underrepresented groups is insufficient. Including these underrepresented populations in both digital health experimental and feasibility studies is critical to advancing digital health science and achieving health equity. [ABSTRACT FROM AUTHOR]

Introduction:Telestroke is an effective strategy to increase appropriate stroke treatments among patients in resource-limited environments. Despite the well-documented benefits of telestroke, there is limited literature regarding its utilization. The purposes of this study are: (1) determine the percentage of potential stroke patients who generate a telestroke consult in rural critical access hospitals (CAHs) and (2) validate an electronic medical record (EMR)-derived report as a stroke screen. Methods:This retrospective chart review analyzed patients presenting between September 1, 2020 and February 1, 2021 to three CAHs. Visits with triage complaints suggesting acute ischemic stroke (AIS)/transient ischemic attack (TIA) were pooled for analysis using an EMR-derived report. Patients with confirmed AIS/TIA at discharge over this period were used to validate the EMR tool. Results:The EMR report pooled 252 possible AIS/TIA visits out of 12,685 emergency department visits for analysis. It had a specificity of 98.78% and sensitivity of 58.06%. Of the 252 visits, 12.7% met telestroke criteria and 38.89% received telestroke evaluation. Among these, a definite diagnosis of AIS/TIA was made in 92.86%. Of the remaining population who met criteria but didn't undergo consultation, 61.11% were diagnosed with AIS/TIA at discharge. Conclusion:This study provides novel characterization of stroke presentations and telestroke in rural CAHs. The EMR-derived report is a reasonable tool to concentrate potential AIS/TIA cases for review and resource allocation but is not sensitive enough to detect stroke as a stand-alone tool. The majority (56%) of eligible patients did not undergo telestroke consultation. Future studies are critical to further understand reasons contributing to this. [ABSTRACT FROM AUTHOR]

StrokeLine is a specialised telephone helpline led by health professionals in Australia. (i) To describe the profile of StrokeLine callers; (ii) to understand the reasons people engage with the service and (iii) how StrokeLine responded to the caller's needs. Routine call data were obtained from the StrokeLine between November 2019 and November 2020. Data were extracted and descriptive analyses performed. De-identified free-text data were obtained separately for November 2019 and June 2020 and analysed using qualitative content analysis. Of the 1429 calls most were from carers, family and friends (38%) or the stroke survivor themselves (34%). Most calls were made by women (64%) and the average age of the stroke survivor was ≥65 years (33%) with the time since the stroke occurred <1 year. The main reason for calling was to manage stroke-related impairments (40%). Providing information, support and advice was the most common action provided by StrokeLine staff (25%). Content analysis of 225 calls revealed most stroke survivors called for emotional support, while carers sought more practical guidance. StrokeLine provided information for referral to relevant services and guidance on what to do next. Most calls were received from family and carers, as well as stroke survivors. They contacted StrokeLine for information and advice, practical solutions, emotional support, and referral advice to other services. [ABSTRACT FROM AUTHOR]

BackgroundTelestroke networks aim to address variability in both quality and access to stroke care in rural areas, by providing remote access to expert stroke neurologists. Implementation of telestroke requires adaptation of workflow processes and education. We previously developed virtual reality (VR) workflow training and documented acceptability, utility and feasibility. The effects on acute stroke treatment metrics have not been previously described.AimsThe overall aim was to improve hyperacute stroke metrics and shorten the time-to-reperfusion therapy administration in rural settings.MethodsThis study applies a natural experiment approach, collecting stroke metric data during transition from a pre-existing pilot to a statewide telestroke service at five rural hospitals. Pre- and post-intervention data included baseline patient demographics and assessment, diagnosis, and treatment delivery metrics. The primary study outcome was door-to-decision time (thrombolysis and endovascular thrombectomy). Secondary outcomes included door-to-computerized tomography time, door-to-thrombolysis time and proportion of patients receiving thrombolysis or thrombectomy treatment. Usage data relating to the VR stroke workflow training of interprofessional healthcare professionals was automatically captured via Wi-Fi. Statistical comparisons of clinical metrics between the pre- and post-intervention time periods, defined as the timeframes before and after VR deployment, were performed.ResultsA total of 2,683 patients were included (April 2013–December 2022); 1910 pre- and 773 post-intervention. All acute stroke time metrics significantly improved post-intervention. The primary outcome, door-to-decision time, decreased from 80 min [56–118] to 54 min [40–76; P < 0.001]. Secondary outcomes also improved, including door-to-thrombolysis time (90 min [68–114] vs. 68.5 min [54–90]; P < 0.001) and proportion of patients thrombolysed (11 vs. 16%; P < 0.001). The proportion of patients transferred for thrombectomy was unchanged (6 vs. 7%; P = 0.69). Seventy VR sessions totaling 15 h 39 min of training time were logged. VR training usage varied across sites (3–31 sessions per site).ConclusionsDelivery of a multi-factorial intervention including infrastructure, funding, education and training (with VR workflow training) as part of a state-wide telestroke rollout was associated with improved acute stroke treatment metrics. Additional work is required to identify the contribution of each intervention component on clinical outcomes and to increase training uptake and sustainment.

Background The optimal strategy for transferring patients to specialized acute stroke care remains controversial. This substudy of the Effect of Direct Transportation to Thrombectomy‐Capable Center vs Local Stroke Center on Neurological Outcomes in Patients with suspected Large‐Vessel Occlusion Stroke in Nonurban Areas (RACECAT) trial aims to investigate the impact of local hospital characteristics and performance on the optimal transport strategy and stroke outcomes. Methods This was a secondary post hoc analysis of the RACECAT trial, evaluating factors potentially associated with functional outcomes among patients initially evaluated at a local stroke center (Local‐SC) versus a thrombectomy‐capable center. The primary outcome was the shift in the 90‐day modified Rankin Scale score in the target population of the RACECAT trial. Door‐to‐needle time, level of care of the Local‐SC (telestroke versus primary stroke center), the specialty of the physician involved with therapeutic decisions, and Local‐SC case volume were assessed for subgroup analyses. Results Of the 1367 patients included in the analysis, 903 had acute ischemic strokes (modified intention to treat). The 90‐day modified Rankin Scale score was associated with door‐to‐needle time in the entire modified intention‐to‐treat cohort (P = 0.026) and in patients initially evaluated in a Local‐SC (P = 0.063), and with local hospital level of care (telestroke versus primary stroke center; P = 0.10). There was a trend favoring direct transport to thrombectomy‐capable center for patients whose assigned Local‐SC was a telestroke center (adjusted odds ratio [OR], 1.47 [95% CI, 0.93–2.33] versus 0.94 [95% CI, 0.71–1.24]; Pinteraction = 0.08) or had door‐to‐needle time over the global median (adjusted OR, 1.52 [95% CI, 0.97–2.40] versus 0.94 [95% CI, 0.71–1.25]; Pinteraction = 0.06). In patients with confirmed large‐vessel occlusion, the benefit of direct transport to thrombectomy‐capable centers when the Local‐SC was a telestroke center (Pinteraction = 0.04) or had longer door‐to‐needle time (Pinteraction = 0.07) was more evident. Conclusions Direct transport to thrombectomy‐capable centers may be preferable in areas primarily covered by telestroke or Local‐SCs with poorer performance, especially in patients with large‐vessel occlusion. These findings can contribute to refining prehospital triage strategies and optimizing stroke systems of care.

BackgroundAmbulance-based telemedicine is an innovative strategy through which transport time can be used to rapidly and accurately triage stroke patients (i.e., mobile telestroke). The acute phase of stroke is a time-sensitive emergency, and delays in care during this phase worsen outcomes. In this literature review, we analyzed studies that investigated the feasibility and reliability of ambulance based telestroke.MethodsWe followed PRISMA guidelines to perform a keyword-based search of PubMed, Web of Science, CINHAL, and Academic Search Complete databases. We reviewed references of search-identified articles to screen for additional articles. Articles for inclusion were selected according to author consensus in consideration of the studies' investigation of feasibility, reliability, or validity of ambulance-based telestroke.ResultsWe identified 67 articles for secondary screening from which 19 articles were selected for full text review. The selected studies reported diverse methods of development, implementation, and assessment of ambulance-based telestroke systems. Although the methods and results varied among these studies, most concluded that the implementation of ambulance based telestroke is feasible.ConclusionThis topical review suggests that ambulance based telestroke is a feasible method for enhanced prehospital stroke care in a variety of settings. Further prospective research is needed to assess the real-world challenges and to identify additional strategies that bolster rapid and accurate prehospital assessment of acute stroke patients.

IntroductionTelestroke care is likely not inferior to face-to-face care in acute stroke management while it also provides rural sites with access to specialist expertise. However, little is known about the distribution and activity of telestroke networks across Europe. Consequently, the European Stroke Organization (ESO) Telestroke Committee aimed to address this through an online questionnaire.MethodsThe questionnaire was developed through an unstructured consensus process, ratified by the ESO Executive Committee, and emailed to ESO members.ResultsOf 2,147 ESO members contacted, complete data sets were submitted on 25 networks from 10 countries. Among the 25 networks, the mean number of hubs per network was 1.6 (SD 1.2), and the mean number of spokes was 9 (SD 6.7), with considerable variability observed (range 2–24 spokes/network). All sites used audiovisual communication. The mean telemedicine consultations per year per site was 197 (SD 164). The primary reason for consultation was “diagnostic and triage purposes” in all but one network. The median number of strokes per site was 175 (interquartile range 192), and the mean intervention rate was 12.3% (SD 10; thrombolysis or thrombectomy).ConclusionAt 25 networks, this survey probably underrepresents telestroke activity across Europe, yet it is still the first study to provide a continent-wide geographical footprint and report on activity within the networks. There was considerable variability in network size and activity. Spoke sites reported an acceptable intervention rate of 12.3%. This percentage compares favorably with national data from European countries and suggests telestroke care supports reasonable intervention rates.

Hyper-acute stroke treatments are time sensitive, and decision-making is complex. Telemedicine has been highly effective in breaking down regional access barriers by providing front line rural hospital clinicians with remote telemedicine decision support by remote stroke experts. With the advent of mechanical thrombectomy, hyper-acute stroke care has grown even more complex from both a decision-making and logistical perspective. Mobile Stroke Units (MSU) have been deployed in a few urban settings globally but are unlikely to address all global access issues due to geographical and logistical factors. This paper reviews the feasibility and benefit of extending telestroke into the pre-hospital setting as an adjunct or alternative to MSUs. It will discuss how this service model can fit into existing stroke networks and potential deployment strategies. Finally, the paper also considers potential scalability of pre- and in-hospital telestroke support across regional and international boundaries to further reduce global hyper-acute access inequities.

Background and aim: Loss of time is a major obstacle to effcient stroke treatment. Our telestroke path intends to optimize prehospital triage using a video link connecting ambulance personnel and a stroke physician. The objectives were as follows: (1) To identify patients suering a stroke and (2) in particular large vessel occlusion (LVO) strokes as candidates for endovascular treatment. We have chosen the Rapid Arterial Occlusion Evaluation (RACE) scale for this purpose. Methods: This analysis aimed to verify the feasibility of prehospital stroke identification by video assessment. In this prospective telestroke cohort study, we included 97 subjects, in which the RACE score (items: facial palsy, arm and leg motor function, head and gaze deviation, and aphasia or agnosia) was applied, and the assessment videotaped by a trained member of the Emergency Medical Services (EMS) in the field using a mobile device. Each recorded patient video was independently assessed by three experienced stroke physicians from a certified stroke center and compared to the neuroimaging gold standard. Within this feasibility study, the stroke code was not altered by the outcome of the RACE assessment, and all patients underwent the standard procedures within the emergency unit. Results: We analyzed 97 patients (median age 78 years, 53% women), of whom 51 (52.6%) suered an acute stroke, 12 (23.5%) of which were due to an LVO and 46 patients had symptoms mimicking a stroke. The sensitivity of stroke identification was 77.8%, and specificity was 53.6%. In regard to the identification of an LVO, sensitivity was 69.4% and specificity was 84.3%. The inter-rater agreement in the RACE-score assessment was ICC = 0.82 (intraclass-correlation coeffcient) Conclusion: These results confirm our hypothesis that the local telestroke concept is feasible. It allows correct (i) stroke and (ii) LVO identification in the majority of the cases and thus has the potential to assist in effcient prehospital triage. [ABSTRACT FROM AUTHOR]

Introduction:Central retinal artery occlusion (CRAO) is an under-recognized stroke subtype that may benefit from hyperacute reperfusion therapies. We aimed to evaluate the ability of telestroke activations to provide CRAO diagnosis and thrombolysis. Methods:This retrospective observational study investigates all encounters conducted for acute visual loss between 2010 and 2021 in our multicentric Mayo Clinic Telestroke Network. Demographics, time from visual loss to telestroke evaluation, ocular examination, diagnostic, and therapeutic recommendations were collected for CRAO subjects. Results:Out of 9,511, 49 encounters (0.51%) were conducted for an acute ocular complaint. Five patients had possible CRAO, and 4 presented within 4.5 h from symptom onset (range 1.5–5 h). None received thrombolytic therapy. All telestroke physicians recommended ophthalmology consultation. Conclusion:Current telestroke assessment of acute visual loss is suboptimal and patients eligible for acute reperfusion therapies may not be offered treatment. Teleophthalmologic evaluations and advanced ophthalmic diagnostic tools should complement telestroke systems. [ABSTRACT FROM AUTHOR]

Introduction: Stroke in Regional Australia may have worse outcomes due to difficulties accessing optimal care. The South Australian Regional Telestroke service aimed to improve telestroke neurologist access, supported by improved ambulance triage. Objective: To assess stroke care quality and patient mortality pre‐ and postimplementation of a vascular neurologist‐led Telestroke service. Design: Historically controlled mixed methods cohort study comparing key quality indicators and patient mortality (6 months pre‐ vs. 18 months postimplementation date [4 June 2018]) at the three major South Australian regional stroke centres. The primary outcome was 13 care quality indicators as a combined composite risk‐adjusted score, and the secondary outcome was risk‐adjusted mortality at 12‐month postadmission. Findings: On an annualised basis, of 189 patients with stroke, more were admitted postintervention to the regional stroke centres than in the control period (158 [annualised rate 105.3, 95% CI 86.2–127.4] vs. 31 [annualised rate 62.0, 95% CI 47.5–79.5]) Baseline patient characteristics were similar in both periods. Post‐implementation, median last‐known‐well time to presentation (3.5 h [IQR 1.6–17] vs. 2.0 [IQR 1–14]; p = 0.46) and door to needle times (121 min [IQR 97–144] vs. 90 [IQR 75–138]; p = 0.65) were not significantly lower but an improvement in the combined composite quality score was observed (0.069 [95% CI 0.004–0.134; p = 0.04]), reflecting individual improvements in some quality indicators. Mortality at 12‐month postimplementation was substantially lower postimplementation (prechange 23% vs. postchange 13% [hazard ratio 0.58 (95% CI 0.44–0.76; p < 0.001)]). Conclusion: Implementation of a South Australian Regional Telestroke service was associated with improved care metrics and lower mortality. [ABSTRACT FROM AUTHOR]

Abstract Background Endovascular therapy (EVT) offers a highly effective therapy for patients with acute ischemic stroke due to large vessel occlusion. Comprehensive stroke centers (CSC) are required to provide permanent accessibility to EVT. However, when affected patients are not located in the immediate catchment area of a CSC, i.e. in rural or structurally weaker areas, access to EVT is not always ensured. Main body Telestroke networks play a crucial role in closing this healthcare coverage gap and thereby support specialized stroke treatment. The aim of this narrative review is to elaborate the concepts for the indication and transfer of EVT candidates via telestroke networks in acute stroke care. The targeted readership includes both comprehensive stroke centers and peripheral hospitals. The review is intended to identify ways to design care beyond those areas with narrow access to stroke unit care to provide the indicated highly effective acute therapies on a region-wide basis. Here, the two different models of care: "mothership" and "drip-and-ship" concerning rates of EVT and its complications as well as outcomes are compared. Decisively, forward-looking new model approaches such as a third model the “flying/driving interentionalists” are introduced and discussed, as far as few clinical trials have investigated these approaches. Diagnostic criteria used by the telestroke networks to enable appropriate patient selection for secondary intrahospital emergency transfers are displayed, which need to meet the criteria in terms of speed, quality and safety. Conclusion The few findings from the studies with telestroke networks are neutral for comparison in the drip-and-ship and mothership models. Supporting spoke centres through telestroke networks currently seems to be the best option for offering EVT to a population in structurally weaker regions without direct access to a CSC. Here, it is essential to map the individual reality of care depending on the regional circumstances.

Background and aimLoss of time is a major obstacle to efficient stroke treatment. Our telestroke path intends to optimize prehospital triage using a video link connecting ambulance personnel and a stroke physician. The objectives were as follows: (1) To identify patients suffering a stroke and (2) in particular large vessel occlusion (LVO) strokes as candidates for endovascular treatment. We have chosen the Rapid Arterial Occlusion Evaluation (RACE) scale for this purpose.MethodsThis analysis aimed to verify the feasibility of prehospital stroke identification by video assessment. In this prospective telestroke cohort study, we included 97 subjects, in which the RACE score (items: facial palsy, arm and leg motor function, head and gaze deviation, and aphasia or agnosia) was applied, and the assessment videotaped by a trained member of the Emergency Medical Services (EMS) in the field using a mobile device. Each recorded patient video was independently assessed by three experienced stroke physicians from a certified stroke center and compared to the neuroimaging gold standard. Within this feasibility study, the stroke code was not altered by the outcome of the RACE assessment, and all patients underwent the standard procedures within the emergency unit.ResultsWe analyzed 97 patients (median age 78 years, 53% women), of whom 51 (52.6%) suffered an acute stroke, 12 (23.5%) of which were due to an LVO and 46 patients had symptoms mimicking a stroke. The sensitivity of stroke identification was 77.8%, and specificity was 53.6%. In regard to the identification of an LVO, sensitivity was 69.4% and specificity was 84.3%. The inter-rater agreement in the RACE-score assessment was ICC = 0.82 (intraclass-correlation coefficient).ConclusionThese results confirm our hypothesis that the local telestroke concept is feasible. It allows correct (i) stroke and (ii) LVO identification in the majority of the cases and thus has the potential to assist in efficient prehospital triage.

Background: Previous studies have shown sex differences in stroke care. Female patients have both lower thrombolytic treatment rates with OR reported as low as 0.57 and worse outcomes. With updated standards of care and improved access to care through telestroke, there is potential to reduce or alleviate these disparities. Methods: Acute stroke consultations seen by TeleSpecialists, LLC physicians in the emergency department in 203 facilities (23 states) from January 1, 2021 to April 30, 2021 were extracted from the Telecare by TeleSpecialists™ database. The encounters were reviewed for demographics, stroke time metrics, thrombolytics candidate, premorbid modified Rankin Score, NIHSS score, stroke risk factors, antithrombotic use, admitting diagnosis of suspected stroke, and reason not treated with thrombolytic. The treatment rates, door to needle (DTN) times, stroke metric times, and variables of treatment were compared for females and males. Results: There were 18,783 (10,073 female and 8,710 male) total patients included. Of the total, 6.9% of females received thrombolytics compared to 7.9% of males (OR 0.86, 95% CI 0.75-0.97, p = 0.006). Median DTN times were shorter for males than females (38 vs. 41 min, p < 0.001). Male patients were more likely to have an admitting diagnosis of suspected stroke, p < 0.001. Analysis by age showed the only decade with significant difference in thrombolytics treatment rate was 50--59 with increased treatment of males, p = 0.047. When multivariant logistic regression analysis was performed with stroke risk factors, NIHSS score, age, and admitting diagnosis of suspected stroke, the adjusted odds ratio for females was 0.9 (95% CI 0.8, 1.01), p = 0.064. Conclusion: While treatment differences between sexes existed in the data and were apparent in univariate analysis, no significant difference was seen in multivariate analysis once stroke risk factors, age, NIHSS score and admitting diagnosis were taken into consideration in the telestroke setting. Differences in rates of thrombolysis between sexes may therefore be reflective of differences in risk factors and symptomatology rather than a healthcare disparity. [ABSTRACT FROM AUTHOR]

An updated stroke process was designed and implemented at an Acute Stroke Ready community hospital that relies on telestroke services. The objectives of the current quality improvement project were to describe the updates to the stroke process and compare pre- and postintervention data on nurse-driven elements of the process, namely telestroke notification and neurologist assessment. Our multidisciplinary team reviewed quality data over several months to identify areas of improvement in the stroke process. Delays in door to telestroke notification and neurologist assessment were identified. A new process was developed and implemented, including e-alert notification and storing the telestroke cart in the computed tomography suite. The study period was 14 months, with nonrandomized, convenience sample data collected for 7 months before and after intervention. There was a significant reduction in door to telestroke notification and neurologist assessment after implementing the new process. Door to telestroke notification and neurologist assessment were also strongly correlated. This project led to significant improvements in nurse-driven elements of the stroke process. It demonstrates effective implementation of e-alert and collaboration with telestroke services at an Acute Stroke Ready Hospital serving rural communities. [ABSTRACT FROM AUTHOR]

Background and purpose: Telestroke has grown significantly since its implementation. Despite growing utilization, there is a paucity of data regarding the diagnostic accuracy of telestroke to distinguish between stroke and its mimics. We aimed to evaluate diagnostic accuracy of telestroke consultations and explore the characteristics of misdiagnosed patients with a focus on stroke mimics. Methods: We conducted a retrospective study of all the consultations in our Ochsner Health's TeleStroke program seen between April 2015 and April 2016. Consultations were classified into one of three diagnostic categories: stroke/ transient ischemic attack, mimic, and uncertain. Initial telestroke diagnosis was compared with the final diagnosis post review of all emergency department and hospital data. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR) for diagnosis of stroke/TIA versus mimic were calculated. Area under receiveroperating characteristic curve (AUC) analysis to predict true stroke was performed. Bivariate analysis based on the diagnostic categories examined association with sex, age, NIHSS, stroke risk factors, tPA given, bleeding after tPA, symptom onset to last known normal, symptom onset to consult, timing in the day, and consult duration. Logistic regression was performed as indicated by bivariate analysis. Results: Eight hundred and seventy-four telestroke evaluations were included in our analysis. Accurate diagnosis through teleneurological consultation was seen in 85% of which 532 were strokes (true positives) and 170 were mimics (true negatives). Sensitivity, specificity, PPV, NPV were 97.8, 82.5, 93.7 and 93.4%, respectively. LR+ and LR were 5.6 and 0.03. AUC (95% CI) was 0.9016 (0.8749-- 0.9283). Stroke mimics were more common with younger age and female gender and in those with less vascular risk factors. LR revealed OR (95% CI) of misdiagnosis for female gender of 1.9 (1.3--2.9). Lower age and lower NIHSS score were other predictors of misdiagnosis. Conclusion: We report high diagnostic accuracy of the Ochsner Telestroke Program in discriminating stroke/TIA and stroke mimics, with slight tendency towards over diagnosis of stroke. Female gender, younger age and lower NIHSS score were associated with misdiagnosis. [ABSTRACT FROM AUTHOR]

Emergency Medicine core clinical privileges include administration of thrombolytic therapy for myocardial infarction and stroke. However, emergency medicine providers have created their own paradigm to rely on neurology specialty consultation to treat acute stroke patients. A 2013 study supported by the American Academy of Neurology showed an 11% shortage of neurologists at that time and projected a 19% shortage by 2025. The lack of neurologists is a worldwide problem. To help ease the shortage, teleneurology and telestroke care has been implemented by neurologists, most notably for acute ischemic stroke (AIS) patients. We present a model in which an Emergency Medicine (EM) Stroke Champion (SC); an EM physician within our Neurologic Emergency Department, directs care for acute stroke patients at our comprehensive hub and primary stroke center spoke hospitals. The SCs independently treat patients with fibrinolytic therapy and provide teleneurology to fellow emergency physicians caring for acute stroke patients at spoke hospitals. Over nineteen months the SCs received 457 phone calls for patients meeting stroke alert criteria. Sixteen patients were deemed eligible for IV alteplase with one hemorrhagic conversion (6.25%). Sixty-four patients required transfer, and this was facilitated by the SCs. The concept of emergency physician SCs providing teleneurology consultation to other fellow emergency physicians was found to be feasible and safe. This model has the potential to be generalized not to just stroke champions, but to all emergency physicians to feel both confident and comfortable treating acute stroke patients. [ABSTRACT FROM AUTHOR]

Introduction: Clinical trials have proven the efficacy of mechanical thrombectomy in stroke patients with large-vessel occlusion presenting within 24 hours of symptom onset. Extending the thrombectomy window to 24 hours resulted in a higher number of thrombectomies being performed. However, little is known about the impact of the extended thrombectomy window on the telestroke call burden. Methods: We used the prospectively maintained database of a telestroke network covering a large geographic area in the Southeast USA. We included patients presenting between January 2015 and December 2019. We compared the characteristics and outcomes between patients who presented before and after the publication of the extended window thrombectomy trials. Results: A total of 9041 patients presented with stroke-like symptoms during the study period. Of these, 4995 presented after February 2018. There was no difference in the patient demographics in both groups. However, patients in the post extended window group had a lower National Institute of Health Stroke Scale on presentation (3 vs. 4; p < 0.001) and longer symptom-onset-to-door time (124 vs. 85 minutes; p < 0.001). The number of consults per month nearly doubled (200 vs. 103; p < 0.001) in the extended thrombectomy window era. Similarly, the number of mechanical thrombectomies performed per month increased from four to seven since extending the thrombectomy window (p < 0.001). Discussion: The number of telestroke consults nearly doubled after the publication of the extended thrombectomy window trials, with an increase in the number of thrombectomies performed. These findings have important operational implications for hospitals implementing telestroke call coverage. [ABSTRACT FROM AUTHOR]

Background: Endovascular therapy (EVT) offers a highly effective therapy for patients with acute ischemic stroke due to large vessel occlusion. Comprehensive stroke centers (CSC) are required to provide permanent accessibility to EVT. However, when affected patients are not located in the immediate catchment area of a CSC, i.e. in rural or structurally weaker areas, access to EVT is not always ensured. Main body: Telestroke networks play a crucial role in closing this healthcare coverage gap and thereby support specialized stroke treatment. The aim of this narrative review is to elaborate the concepts for the indication and transfer of EVT candidates via telestroke networks in acute stroke care. The targeted readership includes both comprehensive stroke centers and peripheral hospitals. The review is intended to identify ways to design care beyond those areas with narrow access to stroke unit care to provide the indicated highly effective acute therapies on a region-wide basis. Here, the two different models of care: "mothership" and "drip-and-ship" concerning rates of EVT and its complications as well as outcomes are compared. Decisively, forward-looking new model approaches such as a third model the "flying/driving interentionalists" are introduced and discussed, as far as few clinical trials have investigated these approaches. Diagnostic criteria used by the telestroke networks to enable appropriate patient selection for secondary intrahospital emergency transfers are displayed, which need to meet the criteria in terms of speed, quality and safety. Conclusion: The few findings from the studies with telestroke networks are neutral for comparison in the drip-and-ship and mothership models. Supporting spoke centres through telestroke networks currently seems to be the best option for offering EVT to a population in structurally weaker regions without direct access to a CSC. Here, it is essential to map the individual reality of care depending on the regional circumstances. [ABSTRACT FROM AUTHOR]

BackgroundPrevious studies have shown sex differences in stroke care. Female patients have both lower thrombolytic treatment rates with OR reported as low as 0.57 and worse outcomes. With updated standards of care and improved access to care through telestroke, there is potential to reduce or alleviate these disparities.MethodsAcute stroke consultations seen by TeleSpecialists, LLC physicians in the emergency department in 203 facilities (23 states) from January 1, 2021 to April 30, 2021 were extracted from the Telecare by TeleSpecialists™ database. The encounters were reviewed for demographics, stroke time metrics, thrombolytics candidate, premorbid modified Rankin Score, NIHSS score, stroke risk factors, antithrombotic use, admitting diagnosis of suspected stroke, and reason not treated with thrombolytic. The treatment rates, door to needle (DTN) times, stroke metric times, and variables of treatment were compared for females and males.ResultsThere were 18,783 (10,073 female and 8,710 male) total patients included. Of the total, 6.9% of females received thrombolytics compared to 7.9% of males (OR 0.86, 95% CI 0.75–0.97, p = 0.006). Median DTN times were shorter for males than females (38 vs. 41 min, p

Background and purposeTelestroke has grown significantly since its implementation. Despite growing utilization, there is a paucity of data regarding the diagnostic accuracy of telestroke to distinguish between stroke and its mimics. We aimed to evaluate diagnostic accuracy of telestroke consultations and explore the characteristics of misdiagnosed patients with a focus on stroke mimics.MethodsWe conducted a retrospective study of all the consultations in our Ochsner Health’s TeleStroke program seen between April 2015 and April 2016. Consultations were classified into one of three diagnostic categories: stroke/transient ischemic attack, mimic, and uncertain. Initial telestroke diagnosis was compared with the final diagnosis post review of all emergency department and hospital data. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR−) for diagnosis of stroke/TIA versus mimic were calculated. Area under receiver-operating characteristic curve (AUC) analysis to predict true stroke was performed. Bivariate analysis based on the diagnostic categories examined association with sex, age, NIHSS, stroke risk factors, tPA given, bleeding after tPA, symptom onset to last known normal, symptom onset to consult, timing in the day, and consult duration. Logistic regression was performed as indicated by bivariate analysis.ResultsEight hundred and seventy-four telestroke evaluations were included in our analysis. Accurate diagnosis through teleneurological consultation was seen in 85% of which 532 were strokes (true positives) and 170 were mimics (true negatives). Sensitivity, specificity, PPV, NPV were 97.8, 82.5, 93.7 and 93.4%, respectively. LR+ and LR− were 5.6 and 0.03. AUC (95% CI) was 0.9016 (0.8749–0.9283). Stroke mimics were more common with younger age and female gender and in those with less vascular risk factors. LR revealed OR (95% CI) of misdiagnosis for female gender of 1.9 (1.3–2.9). Lower age and lower NIHSS score were other predictors of misdiagnosis.ConclusionWe report high diagnostic accuracy of the Ochsner Telestroke Program in discriminating stroke/TIA and stroke mimics, with slight tendency towards over diagnosis of stroke. Female gender, younger age and lower NIHSS score were associated with misdiagnosis.

Objectives: Emergency Medicine (EM) provider experiences consulting telestroke (TS) are poorly studied. In this qualitative study, we aimed to determine how TS changes patient management and to measure TS effects on EM provider confidence with acute ischemic stroke (AIS) treatment. Materials and methods: We designed a survey for EM providers querying perceptions of TS value, confidence with treating AIS, and counterfactuals regarding what EM providers would have done without TS. Eligible EM providers participated in an audio-visual TS consult within a 6-state TS network between 11/2016–11/2017. Results: We received 48 surveys (response rate 43%). The most common reason (71%) for using TS was tPA eligibility expert opinion. Most EM providers (94%) thought the patient/family were satisfied with TS and none felt their medical knowledge was doubted because of using TS. EM providers had high confidence in diagnosing AIS (95%) and tPA decision-making (86%), but not in determining thrombectomy eligibility (10%). Among EM providers who administered tPA, 85% said tPA would not have been given without TS consultation. TS consultation changed patient diagnosis in 60% of all patients and treatment plans in 56% of non-stroke patients. Most EM providers (86%) had increased confidence in their knowledge of future stroke patient management. Nearly all TS consults (93%) resulted in EM providers being more likely to use TS again. Conclusions: TS consult frequently results in both patient management change and increased EM knowledge of stroke management with increased likelihood of repeat usage. Discomfort in determining eligibility for thrombectomy points to educational opportunities.

Background. Age is one of the most important risk factors for stroke, and an estimated 75% of strokes occur in people 65 years old and above. Adults > 75 years of age experience more hospitalizations and higher mortality. In this study, we aimed to investigate how age and various clinical risk factors affect acute ischemic stroke (AIS) severity in two age categories. Methods. This retrospective data analysis study was conducted using data collected from the PRISMA Health Stroke Registry between June 2010 and July 2016. Baseline clinical and demographic data were analyzed for 65–74-year-old patients and those ≥ 75 years of age. This study aimed to investigate risk factors associated with stroke severity in these two age categories of AIS patients treated in telestroke settings. Results. An adjusted multivariate analysis showed that the acute ischemic stroke (AIS) population of 65–74-year-old patients experiencing heart failure (odds ratio (OR) = 4.398, 95% CI = 3.912–494.613, p = 0.002) and elevated high-density lipoprotein (HDL) levels (OR = 1.066, 95% CI = 1.009–1.126, p = 0.024) trended towards worsening neurological function, while patients experiencing obesity (OR = 0.177, 95% CI = 0.041–0.760, p = 0.020) exhibited improved neurological functions. For the patients ≥ 75 years of age, direct admission (OR = 0.270, 95% CI = 0.085–0.856, p = 0.026) was associated with improved functions. Conclusions. Heart failure and elevated HDL levels were significantly associated with worsening neurologic functions in patients aged 65–74. Obese patients and individuals ≥ 75 years of age who were directly admitted were most likely to exhibit improving neurological functions. [ABSTRACT FROM AUTHOR]

Introduction: Telestroke has been shown to be a cost-effective approach to promoting use and timeliness of evidence-based treatment. However, adoption of telestroke has been relatively low. Several barriers to telestroke implementation have been previously identified in the literature. These barriers, and the strategies needed to overcome them, may vary across hospitals. Our study aimed to examine telestroke programs to identify opportunities for future research and efforts to promote effective implementation and sustainment of telestroke services. Methods: We surveyed hospitals in five states to capture information about the current status of the hospital's telestroke program; the model(s) of delivery being used (e.g., hub-and-spoke and third-party vendor); and telestroke infrastructure, processes, and implementation strategies. The survey included both closed-ended and open-ended response options. Descriptive results are presented, complemented with illustrative examples of open-ended responses. Results: We received 89 responses, each representing a different hospital. Approximately one-third of telestroke programs in our sample began between 2018 and 2020. More than two-thirds reported participating in a collaboration with other organizations to improve telestroke services. The most commonly reported, high-priority topics for additional guidance involved monitoring process measures, using performance indicators for improvement, and sharing data from measures with physicians. Discussion: Results complement prior studies, specifically about impacts of COVID-19 on telestroke programs and capabilities that hospitals most need assistance with. Challenges faced and guidance needed differ across hospitals, suggesting a need for a tailored support. The results also suggest more work is needed to understand factors that threaten sustainability of telestroke programs. [ABSTRACT FROM AUTHOR]

Background: Efficacy of telemedicine for stroke was first established by the Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) trials in California and Arizona. Following these randomized controlled trials, the Stroke Telemedicine for Arizona Rural Residents (STARR) network was the first telestroke network to be established in Arizona. It consisted of a 7 spoke 1 hub telestroke system, and it was designed to serve rural, remote, or neurologically underserved communities. Objective: The objective of STARR was to establish a multicenter state-wide telestroke research network to determine the feasibility of prospective collection, recording, and regularly analysis of telestroke patient consultations and care data for the purposes of establishing quality measures, improvement, and benchmarking against other national and international telestroke programs. Methods: The STARR trial was open to enrollment for 29 months from 2008 to 2011. Mayo Clinic Hospital, Phoenix, Arizona served as the hub primary stroke center and its vascular neurologists provided emergency telestroke consultations to seven participating rural, remote, or underserved spoke community hospitals in Arizona. Eligibility criteria for activation of a telestroke alert and study enrollment were established. Consecutive patients exhibiting symptoms and signs of acute stroke within a 12?h window were enrolled, assessed, and treated by telemedicine. The state government sponsor, Arizona Department of Health Services' research grant covered the cost of acquisition, maintenance, and service of the selected telemedicine equipment as well as the professional telestroke services provided. The study deployed multiple telemedicine video cart systems, picture archive and communications systems software, and call management solutions. The STARR protocol was reviewed and approved by Mayo Clinic IRB, which served as the central IRB of record for all the participating hospitals, and the trial was registered at ClinicalTrials.gov. Results: The telestroke hotline was activated 537 times, and ultimately 443 subjects met criteria and consented to participate. The STARR successfully established a multicenter state-wide telestroke research network. The STARR developed a feasible and pragmatic approach to the prospective collection, storage, and analysis of telestroke patient consultations and care data for the purposes of establishing quality measures and tracking improvement. STARR benchmarked well against other national and international telestroke programs. STARR helped set the foundation for multiple regional and state telestroke networks and ultimately evolved into a national telestroke network. Conclusions: Multiple small and rurally located community hospitals and health systems can successfully collaborate with a more centrally located larger hospital center through telemedicine technologies to develop a coordinated approach to the assessment, diagnosis, and emergency treatment of patients manifesting symptoms and signs of an acute stroke syndrome. This model may serve well the needs of patients presenting with other time-sensitive medical emergencies. Clinical Trial Registration number: NCT00829361.

Objective This study aimed to evaluate the effect of telestroke practices on patient prognosis and mortality by comparing the data of patients that presented before and during a period when tele-stroke application was in use. Method Stroke patients presenting from October, 2018 to October, 2019 for whom WhatsApp was used for telestroke purposes, were evaluated as the telestroke group. The previous year it was a pre-telestroke group. The two groups were compared in terms of factors affecting prognosis and mortality. All statistical analyses were performed using SPSS version 16.0 for Windows. Results A total of 727 patients clinically and radiologically confirmed to have ischemic stroke were included in the study. There were 252(34.6%) patients in the pre-telestroke group and 475(65,4%) patients in the telestroke group. Both rtPA and thrombectomy treatment were significantly higher in the telestroke group(p lt;0.001). In the first 24-hour evaluation, the rate of discharge increased and hospital admission and mortality decreased in the telestroke group(p lt;0.001). There was no statistically significant difference between the groups in terms of poor prognosis and 30-day mortality(p=0.470 and p=0.625, respectively). Conclusion Telestroke practices not only provide access to the relevant clinical branch for early consultation but also facilitate timely treatment thus leading to improvement in prognosis.

Background: Telemedicine helps to provide the safe management of stroke patients in the emergency department (ED) and has been used worldwide. However, we had limited experience of telestroke in Taiwan. We aimed to identify the quality of telestroke and compare it with the original face-to-face consultation model. Methods: Among 178 consecutive acute ischemic stroke patients treated with intravenous tissue plasminogen activator (IVtPA) from January 1, 2018, to December 31, 2019, we compared two different consultation methods: face-to-face consultation and telestroke consultation. We collected data on demographics, the National Institutes of Health Stroke Scale (NIHSS) scores, Modified Rankin Scale (mRS) scores, time measurements (onset-to-arrival time, onset-to-telestroke activation time, and time of IVtPA administration (Door-to-Needle; DTN)). Results: The mean age to receive a telestroke consultation was 66.6 years, 36% were female, and the median NIHSS score was 9. The median time from patient arrival to telestroke consult activation was 40 min, and the median DTN time was 11 min longer than for face-to-face consults (62 min versus 51 min, p = .01). Telestroke consultation, similar to a face-to-face consultation, resulted in safe IVtPA eligibility assessments and administration with post-thrombolysis ICH in 4% overall (4% telestroke, 3% face-to-face consultation; p = .851). The 90-day outcomes were not different for mRS score, dichotomized 0–2 (60% telestroke 59% face-to-face consultation; p = .961), or for mortality (16% telestroke, 9% face-to-face consultation; p = .292). Conclusion: In the ED, consultation via the telestroke program provides equal quality to the original face-to-face consultation model to manage ischemic stroke.

Purpose of review: The goal of this paper is to discuss the role and utilization of telestroke services through the COVID-19 pandemic and to suggest future directions to sustain and increase patients' access to stroke expertise. Recent findings: Telestroke is an innovative and effective tool that has been shown to improve access, quality of care, and outcomes of patients with acute stroke syndromes in resource-limited areas for the last two decades. The COVID-19 pandemic posed a significant challenge and strained healthcare systems worldwide, but it created novel and unique opportunities to expand and increase the utilization of telehealth and telestroke services to deliver personalized healthcare across the continuum of stroke care outside of traditional settings. This rapid and widespread increase in telestroke use was facilitated by the removal of many legislative and regulatory barriers which have limited patients' access to stroke expertise for many years. Summary: As the public health emergency ends, there exists a unique opportunity to optimize and expand upon the pandemic-related rapid growth of telestroke care. Optimal utilization of telehealth and telestroke services will depend on maintaining and improving required infrastructure, laws, and regulations, particularly those governing reimbursement and licensing. [ABSTRACT FROM AUTHOR]

Background and Purpose: Telemedicine for stroke patients' care (telestroke [TS]) has grown notably in recent decades and may offer advantages during health crisis. Hospital admissions related to stroke have decreased globally during the COVID-19 pandemic, but scarce information is available regarding the effect of COVID-19 in TS. Using a population-based TS registry, we investigated the impact of the first year of the COVID-19 pandemic throughout our TS network in Santiago, Chile. Methods: Stroke codes evaluated after the onset of COVID-19 restrictions in Chile (defined as March 15, 2020) were compared with those evaluated in 2019. We analyzed differences between number of stroke codes, thrombolysis rate, stroke severity, and time from the stroke onset to hospital admission. Results: We observed that the number of stroke codes and the number of patients undergoing reperfusion therapy did not change significantly (p = 0.669 and 0.415, respectively). No differences were found with respect to the median time from the stroke onset to admission (p = 0.581) or in National Institutes of Health Stroke Scale (NIHSS) scores (p = 0.055). The decision-making-to-needle time was significantly shorter in the COVID-19 period (median 5 min [IQR 3–8], p < 0.016), but no significant changes were found at the other times. Conclusions: This study demonstrates the potential of adapting TS to extreme situations such as the COVID-19 pandemic, as well as the importance of establishing networks that facilitate patient access to quality treatments. [ABSTRACT FROM AUTHOR]

Introduction: In a telestroke network, patients at a referring hospital (RH) with large-vessel occlusion (LVO) are transferred to a comprehensive stroke centre (CSC) for endovascular thrombectomy (EVT). However, a significant number of patients do not ultimately undergo thrombectomy after CSC arrival.Methods: Within a 17-hospital telestroke network, we retrospectively analysed patients with suspected or confirmed LVO transferred to a CSC, and characterized the reasons why these patients did not undergo EVT based on the 2019 American Heart Association guidelines.Results: Of 400 patients transferred to our hub, 68 (17%) were based on vascular imaging at RH. Time from RH arrival to neuroimaging was significantly longer in patients that underwent both computed tomography (CT) and CT angiography of the brain and neck compared to only CT of the brain (53 vs 13 minutes, p < 0.05). Accuracy of anterior circulation LVO (ACLVO) detection based on clinical suspicion was 62% (205 of 332 patients). Among 234 ACLVO patients, overall, 175 (74%) (early window group: 123 (73%) patients and late window group: 52 (80%) patients) met at least one EVT ineligibility criterion. The reasons for EVT ineligibility varied from large core infarct (aspects <6 or core volume >70 cc on perfusion imaging in late window), low National Institutes of Health Stroke Scale (<6), distal occlusion, and poor baseline modified Rankin Scale score (>1).Discussion: Instituting rapid acquisition and interpretation of vascular imaging at RHs for LVO detection and establishing benchmarks for door to vascular imaging is urgently needed for RHs. [ABSTRACT FROM AUTHOR]

Background and Aim: Despite progress made over the last 30 years, stroke is still a leading cause of disability and mortality; likewise, its burden is expected to increase over the next decades, due to population growth and aging. The development of drugs with better safety-efficacy profiles as well as strategies able to improve ischemic stroke management from the pre-hospital setting is needed. Summary: The pathophysiology of ischemic stroke involves multiple pathways resulting in cerebral artery obstruction and brain tissue ischemia. To date, the only approved drug for acute ischemic stroke is intravenous thrombolytic alteplase. Intravenous thrombolysis (IVT) can be administered alone or in combination with endovascular treatment (EVT) with mechanical thrombectomy, in case of large vessel occlusion and generally within 6 h from symptoms onset. The risk of potential bleeding complications, especially symptomatic intracerebral hemorrhage, is one of the reasons for the reluctance to administer IVT. Tenecteplase is a promising alternative fibrinolytic agent, having a better safety profile than alteplase. Moreover, recent evidences have allowed an extension of the IVT ± EVT time window for patients with unknown onset time and for those with a known onset time thanks to the new "tissue-window" approach guided by advanced neuroimaging techniques, which also helps in collateral circulation estimation. Regarding primary-secondary prevention, researchers are focused on improving the efficacy of antithrombotic drugs with a "hemostasis-sparing" approach. Neuroprotective agents are also under development, particularly stem cells. The COVID-19 pandemic has critically stressed global healthcare systems, with collateral damage resulting in access delivery of only emergency care, such as ischemic stroke. Regarding telemedicine, it has had a minor role in acute stroke management, and with the onset of COVID-19, this role will most likely be adopted to increase access and delivery in stroke assessment, but also in the follow-up. [ABSTRACT FROM AUTHOR]

Background: Telehealth in the setting of patient with stroke or widely known as a telestroke has been researched and practiced in various ways in past decades, but recently with the appearance of pandemic Covid-19 the utilization of telestroke needs to synthesis of the existing literature. This has been reported that there are changes in the utilization of of technology-based health services, includes in the use of telestroke. This study aims to review the utilization of telestroke during this recent pandemic Covid-19. Subjects and Method: This study used scoping review as a method to answer the research question. The study was permormed by searching PubMed, Science Direct, BMJ, and Wiley Online Library databases from 2020 to June 2022. The studies that investigating the uses of telestroke during the period of pandemic Covid-19 were included to this scoping review. The PEOS framework and PRISMA flowchart has been utilized as a method to identifying and selecting the studies, as well as inclusion and exclusion criteria. Results: There were 8 studies that relevant to inclusion criteria and reviewed in this study. The majority of telestroke studies were observational study using retrospective method. Five studies stated that the decreased number of utilization of telestroke during pandemic. Demographic characteristics of the study shown the mean age were >60 years old (87.5%), female patients were more than male (62.5%), primary diagnosed with ischemic stroke (87.5%), severity from mild to severe (62.5%), stroke patients were received thrombolysis (75%), and two studies stated shorter duration for patient to receive treatment. Conclusion: Telestroke has been proven as an effective way in caring patient with stroke. Significant decreased number of telestroke admission was shown from most of the studies due to the Covid-19 while the explanation for this phenomena is still unclear. [ABSTRACT FROM AUTHOR]

Background: Despite the proven efficacy of telestroke in improving clinical outcomes by providing access to specialized expertise and allowing rapid expert hyperacute stroke management and decision-making, detailed operational evidence is scarce, especially for less developed or lower - income regions., Aim: We aimed to map the global telestroke landscape and characterize existing networks., Methods: We employed a four-tiered approach to comprehensively identify telestroke networks, primarily involving engagement with national stroke experts, stroke societies, and international stroke authorities. A carefully designed questionnaire was then distributed to the leaders of all identified networks to assess these networks' structures, processes, and outcomes., Results: We identified 254 telestroke networks distributed across 67 countries. High-income countries (HICs) concentrated 175 (69%) of the networks. No evidence of telestroke services was found in 58 (30%) countries. From the identified networks, 88 (34%) completed the survey, being 61 (71%) located in HICs. Network set-up was highly heterogenous, ranging from 17 (22%) networks with more than twenty affiliated hospitals, providing thousands of annual consultations using purpose-built highly specialized technology, to 11 (13%) networks with fewer than 120 consultations annually using generic videoconferencing equipment. Real-time video and image transfer was employed in 64 (75%) networks, while 62 (74%) conducting quality monitoring. Most networks established in the last three years were located in low- and middle-income countries (LMICs)., Conclusions: This comprehensive global survey of telestroke networks found significant variation in network coverage, set-up, and technology use. Most services are in HICs, and few services are in LMICs, although an emerging trend of new networks in these regions marks a pivotal moment in global telestroke care. The wide variation in quality monitoring practices across networks, with many failing to report key performance metrics, underscores the urgent need for standardized, resource-appropriate quality assurance measures that can be adapted to diverse settings.

Background: Early diagnosis and triage of patients with ischemic stroke is essential for rapid reperfusion therapy. The prehospital delay may be substantial and patients from rural districts often arrive at their local hospital too late for disability-preventing thrombolytic therapy due to prolonged transport times., Methods: Hallingdal District Medical Centre (HDMC) is located in a rural area of Norway and is equipped with a computed tomography (CT) scanner. We established emergency pathways of CT imaging and thrombolytic treatment of patients with acute ischemic stroke at HDMC. During office hours these pathways were managed by a radiographer and a general physician supported by videoconference from the Primary Stroke Centre. Outside office hours we remotely controlled the CT exam and supported telestroke guided paramedics handling and examining the patients. With a primary aim of demonstrating the feasibility of this de novo concept we enrolled patients in the period 2017-2021 into a comparative cohort observational study. We compared patients treated at HDMC (the Rural CT group) to patients from two other rural regions in Norway with similar distances to their local hospital but without access to a rural CT scanner (the Reference group)., Results: A total of 86 patients were included in the Rural CT group (mean age 74, 52% male, 43% stroke mimics), and 69 patients were included in the Reference group (mean age 70, 42% male, 28% stroke mimics). Median time from onset of symptoms to completed CT examination was 93 min in the Rural CT group as compared to 240 min in the Reference group ( p  < 0.05). In patients receiving intravenous thrombolysis time from onset of symptoms to treatment was median 124 min in the Rural CT group and 213 min in the Reference group, p  < 0.05. The frequency of thrombolysis for ischemic stroke did not significantly differ between the two groups., Conclusion: Combining prehospital rural CT examination with telestroke guided diagnosis and thrombolytic treatment by paramedics may facilitate earlier initiation of thrombolysis for patients with ischemic stroke., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

With advances in high-throughput image processing technologies and increasing availability of medical mega-data, the growing field of radiomics opened the door for quantitative analysis of medical images for prediction of clinically relevant information. One clinical area in which radiomics have proven useful is stroke neuroimaging, where rapid treatment triage is vital for patient outcomes and automated decision assistance tools have potential for significant clinical impact. Recent research, for example, has applied radiomics features extracted from CT angiography (CTA) images and a machine learning framework to facilitate risk-stratification in acute stroke. We here provide methodological guidelines and radiomics data supporting the referenced article “CT angiographic radiomics signature for risk-stratification in anterior large vessel occlusion stroke.” The data were extracted from the stroke center registry at Yale New Haven Hospital between 1/1/2014 and 10/31/2020; and Geisinger Medical Center between 1/1/2016 and 12/31/2019. It includes detailed radiomics features of the anterior circulation territories on admission CTA scans in stroke patients with large vessel occlusion stroke who underwent thrombectomy. We also provide the methodological details of the analysis framework utilized for training, optimization, validation and external testing of the machine learning and feature selection algorithms. With the goal of advancing the feasibility and quality of radiomics-based analyses to improve patient care within and beyond the field of stroke, the provided data and methodological support can serve as a baseline for future studies applying radiomics algorithms to machine-learning frameworks, and allow for analysis and utilization of radiomics features extracted in this study.

Background: During the COVID-19 pandemic emergency departments have noted a significant decrease in stroke patients. We performed a timely analysis of the Bavarian telestroke TEMPiS "working diagnosis" database.Methods: Twelve hospitals from the TEMPiS network were selected. Data collected for January through April in years 2017 through 2020 were extracted and analyzed for presumed and definite ischemic stroke (IS), amongst other disorders. In addition, recommendations for intravenous thrombolysis (rtPA) and endovascular thrombectomy (EVT) were noted and mobility data of the region analyzed. If statistically valid, group-comparison was tested with Fisher's exact test considering unpaired observations and ap-value < 0.05 was considered significant.Results: Upon lockdown in mid-March 2020, we observed a significant reduction in recommendations for rtPA compared to the preceding three years (14.7% [2017-2019] vs. 9.2% [2020], p = 0.0232). Recommendations for EVT were significantly higher in January to mid-March 2020 compared to 2017-2019 (5.4% [2017-2019] vs. 9.3% [2020], p = 0.0013) reflecting its increasing importance. Following the COVID-19 lockdown mid-March 2020 the number of EVT decreased back to levels in 2017-2019 (7.4% [2017-2019] vs. 7.6% [2020], p = 0.1719). Absolute numbers of IS decreased in parallel to mobility data.Conclusions: The reduced stroke incidence during the COVID-19 pandemic may in part be explained by patient avoidance to seek emergency stroke care and may have an association to population mobility. Increasing mobility may induce a rebound effect and may conflict with a potential second COVID-19 wave. Telemedical networks may be ideal databases to study such effects in near-real time. [ABSTRACT FROM AUTHOR]

Virtual care is here to stay. The explosive expansion of telehealth caused by the SARS-CoV-2 pandemic is more than a necessary measure of protection. The key drivers of this transition in healthcare delivery to a virtual setting are changes in patient behavior and expectations and societal attitudes, and prevailing technologies that are impossible to ignore. The younger population - Generation Z - is increasingly connected and mobile-first. We are heading to a world where we expect to see healthcare in general and neurology, in particular, delivered virtually. The medical community should prepare for this overhaul; proper implementation of virtual care from the ground up is the need of the hour. In an era of virtualization, it is up to the medical community to ensure a well-informed patient population, overcome cultural differences and build digital infrastructure with enhanced access and equity in care delivery, especially for the aging neurological patient population, which is not technologically savvy. Virtual care is a continuum of care that needs deeper integration at systematic levels. The design principles of a patient's journey need to be incorporated while simultaneously placing physician satisfaction with a better user experience at the center of implementation. In this paper, we discuss common challenges and pitfalls of virtual care implementation in neurology - logistical, technical, medicolegal, and those faced in incorporating health and medical education into virtual care - intending to provide solutions and strategies. [ABSTRACT FROM AUTHOR]