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Background: Acute stroke treatment is time-critical. To provide qualified stroke care in areas without 24/7 availability of a stroke neurologist, the concept of teleneurology was established, which is based on remote video communication through telemedicine organized by telestroke networks. Data on the effectiveness and efficiency of stroke treatment via teleneurology is very scarce and is therefore partly questioned in the healthcare sector. The aim was to evaluate stroke care in hospitals with and without teleneurology in Northern Germany. Methods: We conducted a retrospective case–control data analysis using health insurance claims data for the years 2018 to 2021. Based on pre-defined criteria, two models were defined and clinical as well as health economic parameters were compared. In model 1, we compared patients from hospitals with and without support by a telestroke network, while in model 2, we compared patients from hospitals with and without support by a telestroke network, including only districts without a certified stroke unit. Assessed parameters were age, length of stay, patients' comorbidities, inpatient costs, reasons for discharge, qualified stroke care treatment according to operation and procedure codes (OPS) and intravenous thrombolysis (IVT) rates. Results: Hospitals supported by a telestroke network improved their rate of stroke care according to OPS and increased more than three-fold their IVT rate (p = 0.042). In comparison, patients from hospitals with support by a telestroke network had a higher number and rate of qualified stroke care according to OPS (model 1: 73.6% vs 2.2%, p < 0.001 and model 2: 57.0% vs 3.8%, p < 0.001), higher rate of IVT (model 1: 9.5% vs. 0.0%, p = 0.027 and model 2: 10.3% vs 0.0%, p = 0.056) and a lower rate of secondary transfers to another hospital (model 1: 5.9% vs. 28.9%, p < 0.001 and model 2: 5.6% vs 30.1%, p < 0.001). Inpatient costs were lower in cases treated in hospitals with support by a telestroke network (model 1: 4,476€ vs. 5,549€, p = 0.03 and model 2: 4,374€ vs. 5,309€, p = 0.02). In multivariate analysis costs were independently associated with length of stay and patient transfer to another hospital but not with support by a telestroke network. Conclusion: Hospitals with support by a telestroke network are associated with improved qualified stroke care resulting in higher rates of IVT and stroke care according to OPS codes as well as lower rates of onward transfers. Costs per patient were independently associated with transfer rates and length of hospital stay. [ABSTRACT FROM AUTHOR]

Abstract Background Acute stroke treatment is time-critical. To provide qualified stroke care in areas without 24/7 availability of a stroke neurologist, the concept of teleneurology was established, which is based on remote video communication through telemedicine organized by telestroke networks. Data on the effectiveness and efficiency of stroke treatment via teleneurology is very scarce and is therefore partly questioned in the healthcare sector. The aim was to evaluate stroke care in hospitals with and without teleneurology in Northern Germany. Methods We conducted a retrospective case–control data analysis using health insurance claims data for the years 2018 to 2021. Based on pre-defined criteria, two models were defined and clinical as well as health economic parameters were compared. In model 1, we compared patients from hospitals with and without support by a telestroke network, while in model 2, we compared patients from hospitals with and without support by a telestroke network, including only districts without a certified stroke unit. Assessed parameters were age, length of stay, patients’ comorbidities, inpatient costs, reasons for discharge, qualified stroke care treatment according to operation and procedure codes (OPS) and intravenous thrombolysis (IVT) rates. Results Hospitals supported by a telestroke network improved their rate of stroke care according to OPS and increased more than three-fold their IVT rate (p = 0.042). In comparison, patients from hospitals with support by a telestroke network had a higher number and rate of qualified stroke care according to OPS (model 1: 73.6% vs 2.2%, p

Background: The impact of teleneurology on healthcare utilization (HCU) in MS is unknown. Objective: Evaluate the association between teleneurology and HCU. Methods: A retrospective longitudinal analysis of HCU among adult MS and clinically isolated syndrome (CIS) patients residing in the Cleveland/Akron area from July 2020 to July 2022. Negative binomial regression models evaluated the association between number of laboratory and MRI orders per visit and number of emergency visits per patient across patient groups with variable proportions of teleneurology visits. Results: A total of 3208 patients completed 15,795 visits. Patients using teleneurology had more visits (rate ratio (RR) 1.707–1.719, p < 0.001). Teleneurology visits had fewer laboratory (RR 0.571) and MRI orders (RR 0.693, p < 0.001). There was no difference in emergency care utilization for teleneurology patients (p ⩾ 0.05). More emergency visits were observed in Black (RR 1.414) and Medicaid (RR 1.893) patients, regardless of visit type (p < 0.001). Conclusion: Teleneurology visits were associated with fewer orders, suggesting teleneurology may be incorporated into healthcare models without increasing utilization related to the visit. Teleneurology was also associated with increased visit volumes but no difference in emergency HCU. More studies are needed to clarify the ultimate impact of teleneurology on overall HCU. More emergency visits, regardless of visit type, were observed among at-risk populations, warranting further investigation. [ABSTRACT FROM AUTHOR]

Background and purpose: To simulate patient-level costs, analyze the economic potential of telemedicine-based mobile stroke units for acute prehospital stroke care, and identify major determinants of cost-effectiveness, based on two recent prospective trials from the United States and Germany. Methods: A Markov decision model was developed to simulate lifetime costs and outcomes of mobile stroke unit. The model compares diagnostic and therapeutic pathways of ischemic stroke, hemorrhagic stroke, and stroke mimic patients by conventional care or by mobile stroke units. The treatment outcomes were derived from the B_PROUD and the BEST-mobile stroke unit trials and further input parameters were derived from recent literature. Uncertainty was addressed by deterministic and probabilistic sensitivity analyses. A lifetime horizon based on the US healthcare system was adopted to evaluate different cost thresholds for mobile stroke unit and the resulting cost-effectiveness. Willingness-to-pay thresholds were set at 1x and 3x gross domestic product per capita, as recommended by the World Health Organization. Results: In the base case scenario, mobile stroke unit care yielded an incremental gain of 0.591 quality-adjusted life years per dispatch. Mobile stroke unit was highly cost-effective up to a maximum average cost of 43,067 US dollars per patient. Sensitivity analyses revealed that MSU cost-effectiveness is mainly affected by reduction of long-term disability costs. Also, among other parameters, the rate of stroke mimics patients diagnosed by MSU plays an important role. Conclusion: This study demonstrated that mobile stroke unit can possibly be operated on an excellent level of cost-effectiveness in urban areas in North America with number of stroke mimic patients and long-term stroke survivor costs as major determinants of lifetime cost-effectiveness. [ABSTRACT FROM AUTHOR]

Objective: Telehealth in epilepsy care is not new. During the COVID-19 public health emergency, telehealth became more readily used to deliver epilepsy care. However, a summarized guidance of use in caring for people with epilepsy utilizing telehealth is needed. Methods: Existing literature was reviewed to provide guidance on various aspects of telehealth. Billing aspects are reviewed. Recommendations and considerations along with benefits and barriers to telehealth are provided. Results: Telehealth can be a preferred delivery route of care for people with epilepsy in specific situations. Examples include psychiatric complaints, medication management, and follow-up visits for noncomplicated epilepsy care. In addition, telehealth is useful for patients who need postoperative visits, are not able to travel, or live in residential facilities. In-person care may be more suitable for patients who are medically complex, have language barriers or difficulty with resource access, hearing impaired, or have neurostimulation devices where remote monitoring or programming options are infeasible. Discussion: Telehealth care for people with epilepsy can be a useful and important method of care delivery. It should remain an option for providers to use in epilepsy clinical care. It is important for the neurology provider to understand the benefits, billing, and barriers to providing telehealth. [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]

Patients with movement disorders such as Parkinson's disease (PD) living in remote and underserved areas often have limited access to specialized healthcare, while the feasibility and reliability of the video-based examination remains unclear. The aim of this narrative review is to examine which parts of remote neurological assessment are feasible and reliable in movement disorders. Clinical studies have demonstrated that most parts of the video-based neurological examination are feasible, even in the absence of a third party, including stance and gait—if an assistive device is not required—bradykinesia, tremor, dystonia, some ocular mobility parts, coordination, and gross muscle power and sensation assessment. Technical issues (video quality, internet connection, camera placement) might affect bradykinesia and tremor evaluation, especially in mild cases, possibly due to their rhythmic nature. Rigidity, postural instability and deep tendon reflexes cannot be remotely performed unless a trained healthcare professional is present. A modified version of incomplete Unified Parkinson's Disease Rating Scale (UPDRS)-III and a related equation lacking rigidity and pull testing items can reliably predict total UPDRS-III. UPDRS-II, -IV, Timed "Up and Go", and non-motor and quality of life scales can be administered remotely, while the remote Movement Disorder Society (MDS)-UPDRS-III requires further investigation. In conclusion, most parts of neurological examination can be performed virtually in PD, except for rigidity and postural instability, while technical issues might affect the assessment of mild bradykinesia and tremor. The combined use of wearable devices may at least partially compensate for these challenges in the future. [ABSTRACT FROM AUTHOR]

Introduction: Patient acceptability with outpatient teleneurology has been reported within specific conditions, but less is known about acceptability across neurologic conditions. The study objective was to compare the acceptability of teleneurology between patients with various neurological conditions and determine what other factors influence acceptability. Methods: This was a prospective study of Veterans who completed new outpatient teleneurology visits with the Department of Veterans Affairs National Teleneurology Program. Visits were conducted via video to home or video to the outpatient clinic. Patient acceptability was assessed via telephone interview two weeks post-visit. Acceptability was a summed score (3–21) of three 7-point Likert questions (higher = more acceptable). Clinical diagnosis categories were based on the neurologists' ICD10 diagnosis code. Acceptability score was modeled using a censored Tobit model controlling for demographics, type of tele-visit, medical comorbidity, and ICD10 category. Results: In FY 2021, 277 of 637 (43.5%) patients completed an interview with analyzable acceptability data. Of these 277, 70 (25.3%) had codes indicating headache, 46 (16.6%) movement disorder, 45 (16.2%) general symptoms, and 116 (41.9%) for all other categories. Mean patient acceptability was 18.3 (SD 3.2). There was no significant difference in scores between these groups. The only factor independently related to acceptability was medical comorbidity, with higher comorbidity associated with higher acceptability scores. Discussion: Patients find their outpatient teleneurology experience highly acceptable independent of neurologic condition. Those with more comorbidity report higher acceptability. Use of teleneurology may be useful and acceptable across many outpatient neurologic conditions including for more medically complex patients. [ABSTRACT FROM AUTHOR]

Introduction:During the COVID-19 pandemic, care shifted from exclusively telemedicine to hybrid models with in-person, video, and telephone visits. We explored how patient satisfaction and visit preferences have changed by comparing in-person versus virtual visits (telephone and video) in an ambulatory neurology practice across three time points. Methods:Patients who completed a virtual visit in March 2020 (early-pandemic), May 2020 (mid-pandemic), and March 2021 (later-pandemic) were contacted. Patients were assessed for visit satisfaction and desire for future telemedicine. Univariate and multivariable logistic regression analysis was conducted to determine factors independently associated with video visit completion. Results:Four thousand seven hundred seventy-eight the number of ambulatory visits (n = 4,778) were performed (1,004 early; 1,265 mid; and 2,509 later); 1,724 patients (36%) assented to postvisit feedback; mean age 45.8 ± 24.4 years, 58% female, 79% white, and 56% with Medicare/Medicaid insurance. Patient satisfaction significantly increased (73% early, 79% mid, 81% later-pandemic, p = 0.008). Interest in telemedicine also increased for patients completing telephone visits (40% early, 50% mid, 59% later, p = 0.027) and video visits (52% early, 59% mid, 62% later, p = 0.035). Patients satisfied with telemedicine visits were younger (p < 0.001). White patients were more interested in future telemedicine (p = 0.037). Multivariable analysis showed that older patients (for each 1 year older), Black patients, and patients with Medicare/Medicaid were 2%, 45%, and 54% less likely to complete a video visit than telephone, respectively. Discussion:Patients, especially younger ones, have become more satisfied and more interested in hybrid care models during the COVID-19 pandemic. Barriers to conducting video visits persist for older, Black patients with Medicare or Medicaid insurance. [ABSTRACT FROM AUTHOR]

Background and Objectives:To better understand patients' and neurologists' assessments of their experiences regarding effectiveness of teleneurology encounters. Methods:Following an audio–video telehealth visit, neurologists asked patients to participate in a survey-based research study about the encounter, and then, the neurologists also recorded their own evaluations. Data were analyzed using standard quantitative and qualitative techniques for dichotomous and ordered-category survey responses in this cross-sectional analysis. Results:The study included unique encounters between 187 patients and 11 general neurologists. The mean patient age was 49 ± 17.5 years. Two thirds of the patients (66.8%, 125/187) were female. One third (33.2%; 62) were patients new to the NYU Langone Health neurology practices. The most common patient chief complaints were headache (69/187, 36.9%), focal and generalized numbness or tingling (21, 11.2%), memory difficulty (15, 8%), spine-related symptoms (12, 6.4%), and vertigo (11, 5.9%). Most patients (94.7%, 177/187) reported that the teleneurology encounter satisfied their needs. Patients and their neurologists agreed that the experience was effective in 91% (162/178) of encounters, regardless of whether the visit was for a new or established patient visit. Discussion:More than 90% of new and established patients and their neurologists agreed that teleneurology encounters were effective despite some limitations of the examination, the occasional need for patient assistance, and technical difficulties. Our results provide further evidence to justify and to expand the clinical use of teleneurology. [ABSTRACT FROM AUTHOR]

Introduction: : One recent development in telemedicine is the remote management of implanted brain stimulation technologies. Deep brain stimulation (DBS) is widely used to treat Parkinson's disease and other movement disorders. Treatment requires optimal post-surgical programming of the device through numerous in-person visits. Remote programming is increasingly being used to address the risks and inconveniences of in-person programming adjustment. This review presents an overview of the legal issues that are associated with this telemedical innovation. Methods: An authorship team comprised of health law experts from Canada and Germany and a clinician experienced in caring for patients with Parkinson's disease was assembled for this review. The team identified the key areas of law applicable to remote management of DBS, and then used standard legal research methods to identify relevant legal issues, primarily using the jurisdiction of Ontario, Canada, as an example, with additional references to the laws applicable in the European Union and United States. Results: Technological and clinical evolution toward the use of remote programming of DBS and adaptive or "closed loop" DBS raises important questions related to (1) privacy and data protection law, (2) cybersecurity and medical device regulation, (3) medical negligence and physician liability and (4) cross-border issues related to licensing, malpractice insurance and physician payment. Conclusions: Remote programming of DBS offers many important advantages in improving access to care, reducing travel risks, and improving efficiency for patients, caregivers and clinicians. At the same time, this will involve modification of implanted devices influencing patient physiology as well as the exchange of significant amounts of information that bear upon patients' physiological states. As a result, important ethical and legal questions should be considered in the development and deployment of remote DBS programming platforms. [ABSTRACT FROM AUTHOR]

Background: Telemedicine may increase access to clinical care, particularly for mobility-limited communities such as the spinal muscular atrophy (SMA) community. However, much of the information on exposure to and attitudes toward telemedicine in neuromuscular diseases generally and SMA specifically is anecdotal or from focus groups. Gaining greater insight into patient perspectives is important, given telemedicine's potential for expanding access to care and growing use of telemedicine as a result of technology advances and the COVID-19 pandemic. Methods: Cure SMA collected information on the SMA community's exposure to, comfort with, and perceived effectiveness of telemedicine through its 2021 Community Update Survey. The final analytic sample represented 463 SMA-affected individuals, resident in the United States. Descriptive analyses, correlations, and ordered logit regression models were used to characterize the sample and identify predictors of exposure, comfort, and perceived effectiveness. Data were analyzed on weighted and unweighted bases to account for differences between the survey sample and the SMA community. Stratified analyses were used to compare self-completed surveys with caregiver-completed surveys. Results: 463 individuals answered questions about telemedicine. Approximately four-fifths of these respondents had used telemedicine previously. Factors predicting greater likelihood of prior telemedicine use included male gender, increasing income, having received drug treatment for SMA, history of mental illness, and having non-neutral views regarding comfort and perceived effectiveness of telemedicine. Several factors were also significant predictors of comfort with and perceived effectiveness of telemedicine. Stratified analyses indicated differences between self-completed and caregiver-completed surveys. Conclusion: These results can provide insight into patient experiences with telemedicine and can inform approaches to its use by health care professionals and clinical trial sponsors. [ABSTRACT FROM AUTHOR]

BackgroundThe reliability of the Progressive Supranuclear Palsy Rating Scale (PSPRS) using teleneurology has not been assessed.ObjectivesTo test whether removing items inadequately assessed by video would impact measurement of PSP severity and progression.MethodsWe performed secondary analyses of two data sets: the phase 2/3 trial of Davunetide in PSP and a large single-center cohort. We examined two modifications of the PSPRS: (1) removing neck rigidity, limb rigidity, and postural stability (25 items; mPSPRS-25) and (2) also removing three ocular motor items and limb dystonia (21 items; mPSPRS-21). Proportional agreement relative to the possible total scores was measured using the intraclass correlation coefficient, compared to the original PSPRS baseline values and change over 6 and 12 months. We examined the ability of both scales to predict survival in the single-center cohort using proportional hazards models.ResultsThe mPSPRS-25 showed excellent agreement (0.99; P

A patient presented with acute onset of double vision during the start of the COVID-19 pandemic when elective medical care was restricted. Initially declining an in-person evaluation, she was examined using a telehealth video visit, incorporating multiple technological modalities to ascertain ophthalmic examination elements. Her findings prompted emergent neuroimaging, revealing a giant internal carotid artery aneurysm, which was successfully embolized to prevent debilitating and possibly fatal intracranial haemorrhage. This case report illustrates the successful use of telemedicine and remote patient data acquisition to make a life-saving diagnosis.

Resumen: Introducción: La pandemia COVID-19 ha provocado un inusitado impulso a la telemedicina (TM). Analizamos el impacto de la pandemia en la TM aplicada en las consultas de cefaleas españolas, revisamos la literatura y lanzamos unas recomendaciones para implantar la TM en las consultas. Método: Tres fases: 1) Revisión de la base Medline desde el año 1958 (primera experiencia de TM); 2) Formulario Google Forms enviado a todos los neurólogos del Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología (GECSEN), y 3) Consenso on-line de expertos GECSEN para emitir recomendaciones para implantar la TM en España. Resultados: La pandemia por COVID-19 ha empeorado los tiempos de espera presenciales, incrementando el uso de todas las modalidades de TM antes y después de abril de 2020: teléfono fijo (del 75% al 97%), teléfono móvil (del 9% al 27%), correo electrónico (del 30% al 36%) y videoconsulta (del 3% al 21%). Los neurólogos son conscientes de la necesidad de ampliar la oferta con videoconsultas, claramente in crescendo, y otras herramientas de e-health y m-health. Conclusiones: Desde el GECSEN recomendamos y animamos a todos los neurólogos que asisten a pacientes con cefaleas a implantar recursos de TM, teniendo como objetivo óptimo la videoconsulta en menores de 60-65 años y la llamada telefónica en mayores, si bien cada caso debe individualizarse. Se deberá contar previamente con la aprobación y asesoramiento de los servicios jurídicos e informáticos y de la dirección del centro. La mayoría de los pacientes con cefalea y/o neuralgia estable son candidatos a seguimiento mediante TM, tras una primera visita que tiene que ser siempre presencial. Abstract: Introduction: The COVID-19 pandemic has caused an unexpected boost to telemedicine. We analyse the impact of the pandemic on telemedicine applied in Spanish headache consultations, review the literature, and issue recommendations for the implementation of telemedicine in consultations. Method: The study comprised 3 phases: 1) review of the MEDLINE database since 1958 (first reported experience with telemedicine); 2) Google Forms survey sent to all members of the Spanish Society of Neurology's Headache Study Group (GECSEN); and 3) online consensus of GECSEN experts to issue recommendations for the implementation of telemedicine in Spain. Results: COVID-19 has increased waiting times for face-to-face consultations, increasing the use of all telemedicine modalities: landline telephone (from 75% before April 2020 to 97% after), mobile telephone (from 9% to 27%), e-mail (from 30% to 36%), and video consultation (from 3% to 21%). Neurologists are aware of the need to expand the availability of video consultations, which are clearly growing, and other e-health and m-health tools. Conclusions: The GECSEN recommends and encourages all neurologists who assist patients with headaches to implement telemedicine resources, with the optimal objective of offering video consultation to patients under 60-65 years of age and telephone calls to older patients, although each case must be considered on an individual basis. Prior approval and advice must be sought from legal and IT services and the centre's management. Most patients with stable headache and/or neuralgia are eligible for telemedicine follow-up, after a first consultation that must always be held in person.

Teleneurology is a specialist field within the realm of telemedicine, which is dedicated to delivering neurological care and consultations through virtual encounters. Teleneurology has been successfully used in acute care (e.g., stroke) and outpatient evaluation for chronic neurological conditions such as epilepsy and headaches. However, for some neurologic entities like Parkinson's disease, in which an in-depth physical examination by palpating muscles and performing neurologic maneuvers is the mainstay of monitoring the effects of medication, the yield and feasibility of a virtual encounter are low. Therefore, in this prospective review, we discuss two promising teleneurology approaches and propose adjustments to enhance the value of virtual encounters by improving the validity of neurological examination: 'hybrid teleneurology', which involves revising the workflow of virtual encounters; and 'artificial intelligence (AI)-assisted teleneurology', namely the use of biosensors and wearables and data processing using AI. [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]

Background: In stroke networks, hospitals that do not provide thrombectomy (referring hospitals) refer patients to specialized hospitals (receiving hospitals) for this specific intervention. In order to improve the access and management of thrombectomy, the focus of research needs to be not only on the receiving hospitals but also on the prior stroke care pathways in referring hospitals. Objective: The purpose of this study was to investigate the stroke care pathways in different referring hospitals as well as the advantages and disadvantages associated with these pathways. Methods: A qualitative multicenter study was carried out in three referring hospitals of a stroke network. Stroke care was assessed and analyzed by using non-participant observations and 15 semi-structured interviews with employees in various health professions. Results: The following aspects were reported as advantageous within the stroke care pathways: (1) a structured and personal prenotification of the patient by the emergency medical service (EMS) members; (2) a more efficiently organized teleneurology workflow; (3) the provision of the secondary referral to thrombectomy by the same EMS members of the primary referral and (4) the integration of external neurologists into in-house structures. Conclusion: The study provides insights into different stroke care pathways of three different referring hospitals of a stroke network. The results can be used to derive potentials for improvement of other referring hospitals; however, this study is too small to provide reliable information about their potential effectiveness. Future studies should investigate whether implementation of these recommendations actually leads to improvements and under which conditions they are successful. To ensure patient-centeredness, the perspectives of patients and relatives should also be included. [ABSTRACT FROM AUTHOR]

A patient presented with acute onset of double vision during the start of the COVID-19 pandemic when elective medical care was restricted. Initially declining an in-person evaluation, she was examined using a telehealth video visit, incorporating multiple technological modalities to ascertain ophthalmic examination elements. Her findings prompted emergent neuroimaging, revealing a giant internal carotid artery aneurysm, which was successfully embolized to prevent debilitating and possibly fatal intracranial haemorrhage. This case report illustrates the successful use of telemedicine and remote patient data acquisition to make a life-saving diagnosis.

Patients with movement disorders such as Parkinson’s disease (PD) living in remote and underserved areas often have limited access to specialized healthcare, while the feasibility and reliability of the video-based examination remains unclear. The aim of this narrative review is to examine which parts of remote neurological assessment are feasible and reliable in movement disorders. Clinical studies have demonstrated that most parts of the video-based neurological examination are feasible, even in the absence of a third party, including stance and gait—if an assistive device is not required—bradykinesia, tremor, dystonia, some ocular mobility parts, coordination, and gross muscle power and sensation assessment. Technical issues (video quality, internet connection, camera placement) might affect bradykinesia and tremor evaluation, especially in mild cases, possibly due to their rhythmic nature. Rigidity, postural instability and deep tendon reflexes cannot be remotely performed unless a trained healthcare professional is present. A modified version of incomplete Unified Parkinson’s Disease Rating Scale (UPDRS)-III and a related equation lacking rigidity and pull testing items can reliably predict total UPDRS-III. UPDRS-II, -IV, Timed “Up and Go”, and non-motor and quality of life scales can be administered remotely, while the remote Movement Disorder Society (MDS)-UPDRS-III requires further investigation. In conclusion, most parts of neurological examination can be performed virtually in PD, except for rigidity and postural instability, while technical issues might affect the assessment of mild bradykinesia and tremor. The combined use of wearable devices may at least partially compensate for these challenges in the future.

Background: Video recordings of neurological examinations are often used in clinical trials. The Scale for Assessment and Rating of Ataxia (SARA) is a widely used clinical scale for ataxic patients. Despite several advantages of video ratings, correlation between live ratings and remote video‐ratings has not been systematically investigated. Objective: To compare live and remote video assessment of SARA. Methods: Full SARA examinations of 69 patients with cerebellar ataxia were recorded on video. Live rating from site investigators were compared with remote video rating of three experienced ataxia clinicians using Bland–Altman analysis. Results: Live and remote video ratings showed a high level of agreement for the complete score (bias = 0.09, with standard deviation = 2.00) and all single SARA items (bias <0.20 for all items). Conclusion: Remote video ratings of SARA are a reliable means to assess severity of ataxia. [ABSTRACT FROM AUTHOR]

Introduction: Telestroke (TS) networks are standard in many areas of the US. Despite TS systems having approximately 33% mimic rates, it is unknown if TS can accurately diagnose patients with acute ischemic stroke (AIS) versus stroke mimics. Methods: We performed a retrospective review of consecutive TS consults to 27 TS sites in six states during 2018. Clinical information and diagnosis were extracted from discharge records and compared to those from the TS consult. Discharge diagnoses were verified and coded into 12 categories. Cases without a clear discharge diagnosis and intracerebral haemorrhage were excluded. We report agreement and a Cohen's kappa between TS and discharge diagnoses for the category of AIS/transient ischemic attack (TIA) versus stroke mimic. Results: We included 404 cases in the analysis (mean age 66 years; 54% women). Of these, 225 had a TS diagnosis of AIS/TIA; 102 (45%) received intravenous tissue plasminogen activator. Our study demonstrated a high diagnostic agreement for AIS/TIA (88%) with a kappa of 0.75 for stroke and mimics. Of the 179 patients diagnosed with a stroke mimic on TS, 27 (15%) were diagnosed with AIS/TA by discharge. TS mimic diagnosis had a positive predictive value (PPV) of 85% and a negative predictive value (NPV) of 90%; TS diagnosis of stroke/TIA had PPV 90%, NPV 85%. Discussion: We found excellent correlation between TS and discharge diagnoses for patients with both stroke and stroke mimics. This suggests that TS systems can accurately assess a wider variety of patients with acute neurologic syndromes other than AIS. [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]

Teleneurology is an adaption of telemedicine used in neurological practices. Due to the widespread availability of the Internet and the development of information and communication technology (ICT), the use of teleneurology has increased in healthcare systems. This study aimed to determine how the Covid-19 pandemic has affected neurologists' attitudes towards teleneurology as well as their experiences of remote health care before and after the pandemic. The study was conducted as a web-based questionnaire sent to all Finnish neurologists. Two identical surveys were sent via e-mail from the National Neurology Society. The first survey was conducted in spring 2021 and second in spring 2023. The results show that the pandemic moderately increased the use of teleneurology, which enhanced neurologists' technical skills. Neurologists estimated that the use of teleneurology will continue to increase in the future. [ABSTRACT FROM AUTHOR]

INTRODUCTION:Polyneuropathy (PN) is a common condition with significant morbidity. We developed tele-polyneuropathy (tele-PN) clinics to improve access to neurology and increase guideline-concordant PN care. This article describes the mixed-methods evaluation of pilot tele-PN clinics at three community sites within the Greater Los Angeles VA Healthcare System. METHODS:For the first 25 patients (48 scheduled visits), we recorded the duration of the tele-PN visit and exam; the performance on three guideline-concordant care indicators (PN screening labs, opiate reduction, physical therapy for falls); and patient-satisfaction scores. We elicited comments about the tele-PN clinic from patients and the clinical team. We combined descriptive statistics with qualitative themes to determine the feasibility and acceptability of the tele-PN clinics. RESULTS:The average tele-PN encounter and exam times were 28.5 and 9.1 min, respectively. PN screening lab completion increased from 80 to 100%. Opiate freedom improved from 68 to 88%. Physical therapy for patients with recent falls increased from 58 to 100%. The tele-PN clinic was preferred for follow-up over in-person clinics in 86% of cases. Convenience was paramount to the clinic's success, saving an average of 231 min per patient in round-trip travel. The medical team's caring and collaborative spirit received high praise. While the clinic's efficiency was equal or superior to in-person care, the limited treatment options for PN and the small clinical exam space are areas for improvement. CONCLUSION:In this pilot, we were able to efficiently see and examine patients remotely, promote guideline-concordant PN care, and provide a high-satisfaction encounter.

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 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]

Background: The COVID-19 pandemic and subsequent acceleration of telemedicine usage allowed many neurologists to trial telemedicine for neurological care. The purpose of this study is to explore neurology providers' experiences with delivering telemedicine care during the COVID-19 pandemic. Methods: Semistructured video interviews were conducted with 27 neurology providers who practice at a single, urban academic center. Interviews were transcribed and analyzed for content and themes. Results: Five major themes were identified: virtual examination subspecialty differences, tips and tricks for the virtual examination, improved infrastructure needs, future technologies that could support the virtual examination, and preferences for the postpandemic telemedicine protocol. Subspecialists who described their visits as more focused on behavioral examination and obtaining patient history reported fewer limitations with delivering neurological care through telemedicine platforms. Conclusions: The implementation of a telemedicine system should reflect the needs of each neurology subspecialty. Funding is needed to improve logistical infrastructure for health providers' telemedicine visits, such as technical and administrative assistance, as well as creation and testing of technologies to support physical examination in the virtual environment. [ABSTRACT FROM AUTHOR]

This ambispective, observational study evaluated the impact of the COVID-19 pandemic on managing children with Infantile epileptic spasms syndrome (IESS) and the feasibility of telemedicine-based management for IESS. Caregivers of children with IESS were telephonically interviewed using a structured questionnaire and various relevant indices were compared between the study population and a pre-pandemic cohort from the same center. There was a significant increase in diagnostic lag during the pandemic (p = 0.04). Adrenocorticotropic hormone was the first-line antiseizure medication of choice in both cohorts and the response to treatment was also similar. Telemedicine was utilized by around 80% of caregivers and satisfaction rates with telemedicine were high. However, caregivers continued to rate physical consultations higher in preference. [ABSTRACT FROM AUTHOR]

Telemedicine is an emerging field of medicine that has become more important during the coronavirus disease 2019 (COVID-19) pandemic era and is being studied actively in various medical fields. In neurology, the introduction of telemedicine is accelerating worldwide under the label of teleneurology. So far, few studies have been conducted on telemedicine for patients with epilepsy. In nonmetropolitan areas, video-based clinics have been demonstrated to be effective for seizure control, and smartphone-based diagnosis has also been confirmed to be accurate. Indeed, after the onset of the COVID-19 pandemic, telemedicine has been used to treat patients with epilepsy around the world. Few studies have examined the use of telemedicine for patients with autoimmune encephalitis. One showed that telephone-based evaluation is sufficient to assess the cognitive reserve of leucine-rich glioma inactivated-1-antibody encephalitis patients, thereby diagnosing their dementia. Telephone-based outpatient clinics are temporarily permitted under Korean medical law, and telemedicine can be attempted for clinically stable patients with epilepsy in Korea. In addition, patients with autoimmune encephalitis in stable or improving status may also be candidates for treatment with telemedicine. This review presents evidence for the safety and efficacy of telemedicine to treat epilepsy and encephalitis patients and discusses indication guidelines. Based on our literature review and current Korean medical law, we suggest tentative guidelines for telemedicine in the fields of epilepsy and autoimmune encephalitis.

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.

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]

Background and Objectives: To better understand neurologists' assessments of the experiences and effectiveness of teleneurology encounters. Methods: After completing an audio–video telehealth visit with verbally consenting patients, neurologists recorded their evaluations of the encounter. Data were analyzed using standard quantitative and qualitative techniques. Results: The study included unique encounters between 187 patients and 11 neurologists. The mean patient age was 49 ± 17.5 years. Two thirds of patients (66.8%, 125/187) were female. One third of patients (33.2%; 62) were new patients. The most common patient complaints were headache (69/187, 36.9%), focal and generalized numbness or tingling (21, 11.2%), memory difficulty (15, 8%), spine-related symptoms (12, 6.4%), and vertigo (11, 5.9%). Neurologists reported that they completed a virtual examination that provided enough information for medical decision-making in 94.9% of encounters (169/178, 9 missing responses). Fourteen of 25 examination elements important for medical decision-making could be performed sufficiently during virtual encounters. Examination assistance was needed for 16.4% (30/183) of patients, who were, on average, 17.3 years older than those who did not require assistance (62.9 years vs. 45.6 years, p = 0.0002). In 19.1% (34/178) of encounters, neurologists learned clinically relevant information from seeing patients in their homes. Neurologists' assessments of the effectiveness of encounters were not related to the presence (97.2%, 35/36 effective) or absence (95%, 134/141 effective) of technical difficulties (p = 0.5729) in 177 encounters (10 missing responses). Discussion: Neurologists reported that nearly 95% of teleneurology encounters were effective despite limitations of the virtual examination, occasional need for patient assistance, and technical difficulties. [ABSTRACT FROM AUTHOR]

• Telemedicine can reduce the treatment gap for patients with epilepsy. • Telemedicine can also be used for EEG diagnostics, neuropsychology assessment, and counselling patients and caregivers. • The Telemedicine Task Force of the ILAE recommends the technical requirements and the specificities of first or follow-up consultations. Worldwide, People with Epilepsy (PWE) are confronted with several barriers to face-to-face consultations. These obstacles hamper appropriate clinical follow-up and also increase the treatment gap for Epilepsy. Telemedicine holds the potential to enhance management as follow-up visits for PWE are focused on more on clinical history and counselling rather than physical examination. Besides consultation, telemedicine can also be used for remote EEG diagnostics and tele-neuropsychology assessments. In this article, the Telemedicine Task Force of the International League Against Epilepsy (ILAE) outlines recommendations regarding optimal practice in utilizing in the management of individuals with epilepsy. We formulated recommendations for minimum technical requirements, preparing for the first tele-consultation and the specificities for follow-up consultations. Special considerations are necessary for specific populations, including paediatric patients, patients who are not conversant with tele-medicine and those with intellectual disability. Telemedicine for individuals with epilepsy should be vigorously promoted with the aim of improving the quality of care and ultimately reduce the wide clinician access related treatment gap across several regions of the globe. [ABSTRACT FROM AUTHOR]

Background: The use of telemedicine has quickly increased during of the COVID-19 pandemic. Given that unmet needs and barriers to multiple sclerosis (MS) care have been reported, telemedicine has become an interesting option to the care of these patients. The objective of these consensus recommendations was to elaborate a guideline for the management of people with MS using telemedicine in order to contribute to an effective and high-quality healthcare. Methods: A panel of Argentinean neurologist's experts in neuroimmunological diseases and dedicated to the diagnosis, management,and care of MS patients gathered virtually during 2021 and 2022 to conduct a consensus recommendation on the use of telemedicine in clinical practice in adult people with MS. To reach consensus, the methodology of "formal consensus RAND/UCLA Appropriateness method" was used. Results: Recommendations were established based on relevant published evidence and expert opinion focusing on definitions, general characteristics and ethical standards, diagnosis of MS, follow-up (evaluation of disability and relapses of MS), identification and treatment of relapses, and finally disease-modifying treatments using telemedicine. Conclusion: The recommendations of this consensus would provide a useful guide for the proper use of telemedicine for the assessment, follow-up, management, and treatment of people with MS. We suggest the use of these guidelines to all the Argentine neurologists committed to the care of people with MS. [ABSTRACT FROM AUTHOR]

Background and purpose: The aim was to systematically review the effectiveness and safety of telemedicine combined with usual care (in‐person visits) compared to usual care for the therapeutic management and follow‐up assessment of neurological diseases. Methods: The electronic databases MEDLINE, Embase, Web of Science and Cochrane Central Register of Controlled Trials were searched (June 2021). Randomized controlled trials (RCTs) on patients of any age with neurological diseases were considered. Two reviewers screened and abstracted data in duplicate and independently and assessed risk of bias using the Cochrane risk‐of‐bias tool for randomized trials (RoB 2). When possible, pooled effect estimates were calculated. Results: Of a total of 3018 records initially retrieved, 25 RCTs (n = 2335) were included: 11 (n = 804) on stroke, four (n = 520) on Parkinson's disease, three (n = 110) on multiple sclerosis, two (n = 320) on epilepsy, one (n = 63) on dementia, one (n = 23) on spina bifida, one (n = 40) on migraine, one (n = 22) on cerebral palsy and one (n = 433) on brain damage. Types of telemedicine assessed were online visits (11 studies), tele‐rehabilitation (seven studies), telephone calls (three), smartphone apps (two) and online computer software (two). The evidence was quite limited except for stroke. Compared to usual care alone, telemedicine plus usual care was found to improve depressive symptoms, functional status, motor function, executive function, generic quality of life, healthcare utilization and healthy lifestyle in patients in post‐stroke follow‐up. Conclusions: Well‐designed and executed RCTs are needed to confirm our findings on stroke and to have more scientific evidence available for the other neurological diseases. [ABSTRACT FROM AUTHOR]

Background: Genetic testing is essential to identify research participants for clinical trials enrolling people with Parkinson disease (PD) carrying a variant in the glucocerebrosidase (GBA) or leucine-rich repeat kinase 2 (LRRK2) genes. The limited availability of professionals trained in neurogenetics or genetic counseling is a major barrier to increased testing. Telehealth solutions to increase access to genetics education can help address issues around counselor availability and offer options to patients and family members. Objective: As an alternative to pretest genetic counseling, we developed a web-based genetics education tool focused on GBA and LRRK2 testing for PD called the Interactive Multimedia Approach to Genetic Counseling to Inform and Educate in Parkinson's Disease (IMAGINE-PD) and conducted user testing and usability testing. The objective was to conduct user and usability testing to obtain stakeholder feedback to improve IMAGINE-PD. Methods: Genetic counselors and PD and neurogenetics subject matter experts developed content for IMAGINE-PD specifically focused on GBA and LRRK2 genetic testing. Structured interviews were conducted with 11 movement disorder specialists and 13 patients with PD to evaluate the content of IMAGINE-PD in user testing and with 12 patients with PD to evaluate the usability of a high-fidelity prototype according to the US Department of Health and Human Services Research-Based Web Design & Usability Guidelines. Qualitative data analysis informed changes to create a final version of IMAGINE-PD. Results: Qualitative data were reviewed by 3 evaluators. Themes were identified from feedback data of movement disorder specialists and patients with PD in user testing in 3 areas: content such as the topics covered, function such as website navigation, and appearance such as pictures and colors. Similarly, qualitative analysis of usability testing feedback identified additional themes in these 3 areas. Key points of feedback were determined by consensus among reviewers considering the importance of the comment and the frequency of similar comments. Refinements were made to IMAGINE-PD based on consensus recommendations by evaluators within each theme at both user testing and usability testing phases to create a final version of IMAGINE-PD. Conclusions: User testing for content review and usability testing have informed refinements to IMAGINE-PD to develop this focused, genetics education tool for GBA and LRRK2 testing. Comparison of this stakeholder-informed intervention to standard telegenetic counseling approaches is ongoing. [ABSTRACT FROM AUTHOR]

Background: Patients with neurodegenerative diseases who live in remote areas often have limited access to specialized healthcare, and telemedicine represents a useful solution. The aim of this study was to investigate the perceptions toward the use of a specialized-tertiary telemedicine service of patients with cognitive and movement disorders, caregivers, and local healthcare professionals (HPs) in the Aegean Islands. Methods: Data were derived from the “Specialized Outpatient Clinic of Memory, Dementia and Parkinson’s disease through the National Telemedicine Network”, March 2021–March 2023. The survey included 10 questions (5-point Likert scale). Results: We received 64 questionnaires (25 patients, 18 caregivers, 21 HPs). Most participants positively perceived all aspects of telemedicine, including comfort (mean ± standard deviation: patients 4.5 ± 0.9, caregivers: 4.8 ± 0.5, HPs: 4.6 ± 0.7), access to specialized care (4.7 ± 0.6, 4.7 ± 0.5, 4.9 ± 0.4), number of transportations (4.6 ± 0.8, 4.6 ± 0.9, 4.8 ± 0.5), adequacy of follow-up (4.6 ± 0.7, 4.4 ± 0.8, 4.2 ± 0.7), future telemedicine selection (4.8 ± 0.4, 4.8 ± 0.4, 4.6 ± 0.6), perceived reliable medical assessment (4.7 ± 0.5, 4.6 ± 0.6, 4.3 ± 0.6), information delivery (4.7 ± 0.6, 4.6 ± 0.5, 4.4 ± 0.9), health status improvement (4.6 ± 0.7, 4.6 ± 0.6, 4.0 ± 0.7), cost (4.6 ± 1, 4.6 ± 1, 5.0 ± 0.2), and general satisfaction (4.8 ± 0.4, 4.7 ± 0.5, 4.5 ± 0.6). The commonest recommendations were more frequent visits, medical specialties, and dissemination of information. Conclusions: The positive perception of participants highlights the value of telemedicine for specialized healthcare for neurodegenerative disorders, especially in remote areas.

Background and Purpose—Systemic thrombolysis represents the main proven therapy for acute ischemic stroke, but safe treatment is reported only in well-established stroke units. To extend the use of tissue plasminogen activator (tPA) treatment in primary care hospitals on isolated areas through telemedic was the purpose of specific initiatives in southern Umbria, Italy. Methods—The stroke center of Foligno established a telestroke network to provide consultations for three local hospitals in southern Umbria. The telemedic system consists of a digital network that includes a two-way video conference system and imaging sharing. The main network hospital established specialized stroke wards/teams in which qualified teams treat acute stroke patients. Physicians in these hospitals are able to contact the stroke centers 24 h per day. Quality data are available to support the safe implementation of the stroke procedures. Those available from governmental authorities and local datasets are volume of hospitalization, in-hospital mortality, 30-days mortality, and discharge setting. Objective of the study was to assess the annual hospitalization volume in both the hub and spoke hospitals for ischemic stroke and appraise the performance of the network after the introduction of the telestroke system. Results—A total of 225 systemic thrombolyses were performed in time period indicated above all hospitals. In the main spoke hospital, 41 procedures were performed after teleconsultations were made available. The thrombolysis rate in the hub hospital ranged between 10% in 2016 and 20% in 2019, while in the spoke hospital was below 5% in 2016 and raised to 15% in 2019. The statistically significant difference, in the number of procedures, between hub and spoke in the beginning of the observation time disappeared after introduction of the telestroke network. No increase of the mortality was found. Conclusions—The present data suggest that systemic thrombolysis indicated via stroke experts in the setting of teleconsultation shows similar complication rates to those reported in the National Institute of Neurological Disorders and Stroke trial. Therefore, tPA treatment is also safe in this context and can be extended to primary hospitals.

Background: Governments have imposed lockdowns in the wake of the COVID-19 pandemic. Hospitals have restricted outpatient clinics and elective services meant for non-COVID illnesses. This has led to patients facing unprecedented challenges and uncertainties. This study was carried out to assess patients' concerns and apprehensions about the effect of the lockdown on their treatments. Materials and Methods: An ambispective, observational cross-sectional single centre study was conducted. Patients were contacted telephonically and requested to answer a structured questionnaire. Their responses were documented and summarized as frequency and proportions. Results: A total of 727 patients were interviewed. Epilepsy (32%) was the most common neurological illness in our cohort followed by stroke (18%). About half the patients and/or their caregivers reported health-related concerns during the lockdown. The primary concern was how to connect with their treating neurologist if need arose. Forty-seven patients (6.4%) had drug default. Among patients on immunomodulatory treatments, only eight patients had drug default. High compliance rates were also observed in the stroke and epilepsy cohorts. Of the 71 patients who required emergency care during the lockdown, 24 could reach our hospital emergency. Fourteen patients either had a delay or could not seek emergency care. Two-thirds of our patients found the telemedicine experience satisfactory. Conclusion: The ongoing pandemic will continue to pose challenges to both physicians and patients. Patients in follow-up may need to be contacted regularly and counselled regarding the importance of maintaining drug compliance. Telemedicine can be used to strengthen the healthcare delivery to patients with non-COVID illnesses.

Background: As the global population grows, there is an increasing demand for neurologic consultation that prompts new ways to reach more patients. Telemedicine can provide an accessible, cost-effective, and high-quality healthcare services. Objectives: In this article, we highlight recent developments, achievements, and challenges regarding outcomes, clinical care, tele-education, teletreatment, teleresearch, and cybersecurity for telemedicine applied to Parkinson´s disease (PD) and other neurological conditions. Results: A growing body of evidence supports the feasibility and effectiveness of telemedicine tools for PD and other movement disorders. Outcome variables regarding satisfaction and efficacy in clinical care and specific issues about education, research, and treatment are reviewed. Additionally, a specific legal framework for teleconsultation has been developed in some centers worldwide. Yet, the implementation of telemedicine is conditioned by the limitations inherent to remote neurological examination, the variable computer usage literacy among patients, and the availability of a reliable internet connection. At present, telemedicine can be considered an additional tool in the clinical management of PD patients. Conclusions: There is an increasing use of remote clinical practice regarding the management of PD and other neurological conditions. Telemedicine is a new and promising tool aimed at special settings and subpopulations. [ABSTRACT FROM AUTHOR]

Aim: To assess the overall satisfaction level of movement disorder specialists using a virtual platform during the COVID-19 pandemic. Methods: This was a multicenter cross-sectional survey for a 6-month period during the beginning of the COVID-19 pandemic. Movement disorder specialists, who utilized telehealth visits from March 2020 to August 2020, were included. The study surveys, including provider's satisfaction with the care that they were able to provide and visit quality, were completed by the provider after each visit. Results: A total of 206 visits, provided by movement disorder specialists, were analyzed. Zoom was the most popular platform used for remote visits (70, 34%). A backup platform was not needed in the majority of movement disorder visits (171, 83%). The majority of physicians were very satisfied or satisfied with the care provided (72.9%) and visit quality (61%). Conclusions: The satisfaction level of specialists using telemedicine during COVID-19 was high despite having encounters with elderly patients with cognitive impairment or lacking advanced skills with technology. [ABSTRACT FROM AUTHOR]

Background: Many clinics and health systems implemented telemedicine appointment services out of necessity due to the COVID-19 pandemic., Objective: Our objective was to evaluate patient and general provider satisfaction with neurology telemedicine implementation at an urban academic medical center., Methods: Patients who had completed 1 or more teleneurology visits from April 1 to December 31, 2020, were asked to complete a survey regarding their demographic information and satisfaction with teleneurology visits. Providers of all specialties within the same hospital system were given a different survey to gather their experiences of providing telemedicine care., Results: Of the estimated 1500 patients who had completed a teleneurology visit within the given timeframe, 117 (7.8%) consented to complete the survey. Of these 117 respondents, most appointments were regarding epilepsy (n=59, 50.4%), followed by multiple sclerosis (n=33, 28.2%) and neuroimmunology (n=7, 6%). Overall, 74.4% (n=87) of patients rated their experience as 8 out of 10 or higher, with 10 being the highest satisfaction. Furthermore, 75.2% (n=88) of patients reported missing an appointment in the previous year due to transportation issues and thought telemedicine was more convenient instead. A significant relationship between racial or ethnic group and comfort sharing private information was found (P<.001), with 52% (26/50) of Black patients reporting that an office visit is better, compared to 25% (14/52) of non-Black patients. The provider survey gathered 40 responses, with 75% (n=30) of providers agreeing that virtual visits are a valuable tool for patient care and 80% (n=32) reporting few to no technical issues. The majority of provider respondents were physicians on faculty or staff (n=21, 52%), followed by residents or fellows (n=15, 38%) and nurse practitioners or physician assistants (n=4, 10%). Of the specialties represented, 15 (38%) of the providers were in neurology., Conclusions: Our study found adequate satisfaction among patients and providers regarding telemedicine implementation and its utility for patient care in a diverse urban population. Additionally, while access to technology and technology literacy are barriers to telemedical care, a substantial majority of patients who responded to the survey had access to devices (101/117, 86.3%) and were able to connect with few to no technological difficulties (84/117, 71.8%). One area identified by patients in need of improvement was comfortability in communicating via telemedicine with their providers. Furthermore, while providers agreed that telemedicine is a useful tool for patient care, it limits their ability to perform physical exams. More research and quality studies are needed to further appreciate and support the expansion of telemedical care into underserved and rural populations, especially in the area of subspecialty neurological care., (©Noah Robertson, Maryam J Syed, Bowen Song, Arshdeep Kaur, Janaki G Patel, Rohit Marawar, Maysaa Basha, Deepti Zutshi. Originally published in JMIR Formative Research (https://formative.jmir.org), 30.10.2024.)

Introduction : The use of remote patient monitoring (RPM) services for neurological disorders remains understudied, particularly in the context of newer billing codes introduced before the COVID-19 pandemic. Methods : This retrospective cohort study utilized data from commercial and Medicare employer-sponsored administrative claims between January 1, 2019, to December 31, 2021. The study population included all patients with at least one qualifying RPM-related Current Procedural Terminology (CPT) code for a neurological disorder, separated into first-generation (CPT 99091) codes and second-generation (CPT 99453, 99454, 99457, 99458) code cohorts. We compared patient and encounter characteristics between both cohorts. Results : We identified 27,756 encounters attributable to 11,326 patients who received RPM services for neurological disorders, of whom 5,785 (51.1%) received RPM via second-generation billing codes, 3,941 (34.8%) were female, 6,712 (59.3%) were between 45 and 64 years old, and 10,488 (92.6%) had a primary diagnosis of sleep-wake disorder. The second-generation cohort was significantly more likely to be female (41.5% vs. 27.8%, p < 0.001), be of age 65 or older (15.7% vs. 7.1%, p < 0.001), and reside in urban areas (93.4% vs. 87.6%, p < 0.001) than the first-generation cohort. Patients in the second-generation cohort were more likely to receive RPM in office settings (86.3% vs. 62.5%, p < 0.001), by physicians (77.0% vs. 40.3%, p < 0.001), and less likely for sleep-wake disorders (87.9% vs. 97.5%, p < 0.001) than the first-generation cohort. Patients who received RPM from physicians were most often evaluated by pulmonologists (31.4%). Discussion : In this commercially insured patient population receiving RPM for neurological disorders, we found that sleep-wake disorders and non-neurologists were over-represented.

Objective: Access to health centers was restricted during the coronavirus disease-2019 pandemic, which hit our country in March 2020. Ensuring the medical control of patients who were followed up in the neurology outpatient clinic with the tele-medicine method was an important step to decrease the viral load of patients and physicians. This study aimed to share our tele-medicine experience with patients with movement disorders. Materials and Methods: The data of 71 patients with movement disorder who communicated with our unit between March 11, 2020 and June 20, 2020 were retrospectively analyzed. Results: A total of 117 verbal and written interviews with 71 patients were mostly conducted via WhatsApp®. The evaluation of reasons for physician consultation revealed that patients most frequently communicated for worsening rigidity and prescription-drug requests. Of these interviews, 25 (21.4%) resulted in setting patient appointments for a physical examination. The tele-medicine service in 92 (78.6%) interviews solved the problem without physical contact with patients. Conclusion: Movement disorder evaluations are suitable through teleconference. Therefore, our teleneurology application, which we actively use, is effective in reducing the risk of viral transmission to both patients and healthcare workers during the pandemic. Developing telemedical applications is necessary in terms of their legal aspects and implementation in the world, especially in our country.