Therapy of Basilar Artery Occlusion: Individual Protocols Needed

Neurology International

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 v...

Stroke, 2016

Intravenous thrombolysis with tissue-type plasminogen activator (tPA) for acute ischemic stroke is more effective when delivered early. Timely delivery is challenging particularly in rural areas with long distances. We compared delays and treatment rates of a large, decentralized telemedicine-based system and a well-organized, large, centralized single-hospital system. We analyzed the centralized system of the Helsinki University Central Hospital (Helsinki and Province of Uusimaa, Finland, 1.56 million inhabitants, 9096 km(2)) and the decentralized TeleStroke Unit network in a predominantly rural area (Telemedical Project for Integrative Stroke Care [TEMPiS], South-East Bavaria, Germany, 1.94 million inhabitants, 14 992 km(2)). All consecutive tPA treatments were prospectively registered. We compared tPA rates per total ischemic stroke admissions in the Helsinki and TEMPiS catchment areas. For delay comparisons, we excluded patients with basilar artery occlusions, in-hospital stroke...

Stroke, 2015

T elestroke, video teleconferencing to support remote stroke interventions, has been endorsed in guidelines of thrombolysis for acute ischemic stroke. 1 Studies of telestroke suggest similar mortality, intracerebral hemorrhage rates, and outcomes in comparison to trials and usual clinical practice. 2-4 Data for thrombolysis using telephone consultation are limited. In a randomized study of telestroke versus telephone consultation, correct treatment decisions were made more often with telestroke but with no difference in adverse events. 5 A single center study in the United Kingdom of telephone advice with teleradiology showed similar outcomes between patients treated remotely or in person. 6 We present the results of a larger cohort of patients treated within a regional UK stroke network using telephone advice and teleradiology. Methods The Avon, Gloucestershire, Wiltshire, and Somerset Stroke Network covers 2.25 million people in south west England. Seven hospitals participate in a remote (out of hours) thrombolysis rota. All hospitals have stroke units, stroke specialists, and emergency physicians who provide in-house thrombolysis. There is a network-wide thrombolysis protocol and a training program based on the Safe Implementation of Treatments in Stroke training. 7 Potential patients enter a standard pathway; treatment decisions are made by the on call remote thrombolysis consultant (one of 10 stroke physicians and 1 neurologist) after a telephone discussion with the in-house thrombolysis-certified clinician via a structured checklist. National Institute of Health Stroke Scale (NIHSS) scoring is reviewed and CT head viewed remotely by the on call clinician. The time window is 4.5 hours (details in the online-only Data Supplement). A cohort of ≥100 consecutive patients from each center was retrospectively analyzed, comparing the remote group and patients thrombolysed in-house (standard group). Outcomes were Safe Implementation of Treatments in Stroke definition (hemorrhage with neurological deterioration >4 points on NIHSS or death within 7 days) symptomatic intracerebral hemorrhage, 8 death (7 and 90 days), NIHSS scores at 24 and 7 days (or discharge if sooner), and modified Rankin score at 90 days dichotomized to good (0-2) and poor (3-6) outcomes. The Oxfordshire Community Stroke Project Classification was used to categorize strokes as total anterior circulation, partial anterior circulation, lacunar, and posterior circulation infarcts. 9 Student's t test, Wilcoxon rank-sum test, or chi-squared tests were used as appropriate. The Cochran-Mantel-Haenszel Test was used for ordinal analysis of modified Rankin scores. Logistic regression models were used to identify predictors for symptomatic intracerebral hemorrhage and poor outcomes. Missing data were dealt with by complete case analysis for univariate statistics and multiple Background and Purpose-There is limited evidence for remote stroke thrombolysis using telephone consultation and teleradiology. Results from a UK network using this treatment model are presented. Methods-Retrospective study of consecutive patients thrombolysed in 5 hospitals, with well organized stroke services, between 2012 and 2013. Remote thrombolysis was compared with thrombolysis delivered in person for symptomatic intracerebral hemorrhage, death within 7 days, and 90-day modified Rankin scores. Results-Of 586 patients, 220 (37.5%) were thrombolysed remotely. The 2 groups were well matched (median age 77 years, NIHSS 12). Remote thrombolysis increased treatment time by 22 minutes. Outcomes were no different in the 2 groups (remote versus standard): symptomatic intracerebral hemorrhage (3.6% versus 4.6%), death within 7 days (6.4% versus 7.1%), modified Rankin score <2 (46.0% versus 46.1%), and modified Rankin score 6 (15% versus 17.5%) at 90 days. Conclusion-Telephone advice and teleradiology, within an organized system of care, can be an effective method of delivery of intravenous thrombolysis.

Stroke, 2010

Background and Purpose-Because of a shortage of stroke specialists, many outlying or "spoke" hospitals initiate intravenous (IV) thrombolysis using telemedicine or telephone consultation before transferring patients to a regional stroke center (RSC) hub. We analyzed complications and outcomes of patients treated with IV tissue plasminogen activator (tPA) using the "drip and ship" approach compared to those treated directly at the RSC. Methods-A retrospective review of our Get With the Guidelines Stroke (GWTG-Stroke) database from 01/2003 to 03/2008 identified 296 patients who received IV tPA within 3 hours of symptom onset without catheter-based reperfusion. GWTG-Stroke definitions for symptomatic intracranial (sICH), systemic hemorrhage, discharge functional status, and destination were applied. Follow-up modified Rankin Score was recorded when available. Results-Of 296 patients, 181 (61.1%) had tPA infusion started at an outside spoke hospital (OSH) and 115 (38.9%) at the RSC hub. OSH patients were younger with fewer severe strokes than RSC patients. Patients treated based on telestroke were more frequently octogenarians than patients treated based on a telephone consult. Mortality, sICH, and functional outcomes were not different between OSH versus RSC and telephone versus telestroke patients. Among survivors, mean length of stay was shorter for OSH patients but discharge status was similar and 75% of patients walked independently at discharge. Conclusions-Outcomes in OSH "drip and ship" patients treated in a hub-and-spoke network were comparable to those treated directly at an RSC. These data suggest that "drip and ship" is a safe and effective method to shorten time to treatment with IV tPA. (Stroke. 2010;41:e18-e24.

Stroke, 2013

Stroke, 2015

Background and Purpose— There is limited evidence for remote stroke thrombolysis using telephone consultation and teleradiology. Results from a UK network using this treatment model are presented. Methods— Retrospective study of consecutive patients thrombolysed in 5 hospitals, with well organized stroke services, between 2012 and 2013. Remote thrombolysis was compared with thrombolysis delivered in person for symptomatic intracerebral hemorrhage, death within 7 days, and 90-day modified Rankin scores. Results— Of 586 patients, 220 (37.5%) were thrombolysed remotely. The 2 groups were well matched (median age 77 years, NIHSS 12). Remote thrombolysis increased treatment time by 22 minutes. Outcomes were no different in the 2 groups (remote versus standard): symptomatic intracerebral hemorrhage (3.6% versus 4.6%), death within 7 days (6.4% versus 7.1%), modified Rankin score &lt;2 (46.0% versus 46.1%), and modified Rankin score 6 (15% versus 17.5%) at 90 days. Conclusion— Telephone ad...

JAMA neurology, 2015

Mobile stroke treatment units (MSTUs) with on-site treatment teams that include a vascular neurologist can provide thrombolysis in the prehospital setting faster than treatment in the hospital. These units can be made more resource efficient if the need for an on-site neurologist can be eliminated by relying solely on telemedicine for physician presence. To test whether telemedicine is reliable and remote physician presence is adequate for acute stroke treatment using an MSTU. Prospective observational study conducted between July 18 and November 1, 2014. The dates of the study analysis were November 1, 2014, to March 30, 2015. The setting was a community-based study assessing telemedicine success of the MSTU in Cleveland, Ohio. Participants were the first 100 residents of Cleveland who had an acute onset of stroke-like symptoms between 8 am and 8 pm and were evaluated by the MSTU after the implementation of the MSTU program at the Cleveland Clinic. A vascular neurologist evaluated ...

Journal of the American Heart Association, 2014

The majority of established telestroke services are based on &quot;hub-and-spoke&quot; models for providing acute clinical assessment and thrombolysis. We report results from the first year of the successful implementation of a locally based telemedicine network, without the need of 1 or more hub hospitals, across a largely rural landscape. Following a successful pilot phase that demonstrated safety and feasibility, the East of England telestroke project was rolled out across 7 regional hospitals, covering an area of 7500 square miles and a population of 5.6 million to enable out-of-hours access to thrombolysis. Between November 2010 and November 2011, 142 telemedicine consultations were recorded out-of-hours. Seventy-four (52.11%) cases received thrombolysis. Median (IQR) onset-to-needle and door-to-needle times were 169 (141.5 to 201.5) minutes and 94 (72 to 113.5) minutes, respectively. Symptomatic hemorrhage rate was 7.3% and stroke mimic rate was 10.6%. We demonstrate the safet...

Stroke, 2003

Background and Purpose-Telemedicine is emerging as a potential timesaving, efficient means for evaluating patients experiencing acute stroke. In areas where local stroke care specialists are not available, telemedicine can link an emergency department physician with a specialist in a stroke treatment center. This consultation provides an opportunity for administration of thrombolytic drugs within the short therapeutic time window associated with ischemic stroke.

Frontiers in Neurology, 2012

Carolina (MUSC) provides stroke consults via the internet in South Carolina. From May 2008 to April 2011 231 patients were treated with intravenous (IV) thrombolysis and 369 were transferred to MUSC including 42 for intraarterial revascularization [with or without IV tissue plasminogen activator (tPA)]. Medical outcomes and hemorrhage rates, reported elsewhere, were good (Lazaridis et al., 2011). Here we report operational features of REACH MUSC which covers 15 sites with 2,482 beds and 471,875 Emergency Department (ED) visits per year. Eight Academic Faculty from MUSC worked with 165 different physicians and 325 different nurses in the conduct of 1085 consults. For the 231 who received tPA, time milestones (in minutes