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Atallah E, Bekelis K, Saad H, Chalouhi N, Dang S, Li J, Kumar A, Turpin J, Barsoom R, Tjoumakaris S, Hasan D, Deprince M, Labella G, Rosenwasser RH, Jabbour P. A comparison of two stroke cohorts cared for by two different specialties in a practice-based tele-stroke population. Clin Neurol Neurosurg 2018. [PMID: 29525730 DOI: 10.1016/j.clineuro.2018.02.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Neurologists have continually led the assessment and management of Acute Ischemic Stroke(AIS) by use of IV-rtPA, anti-platelet therapy, antihypertensives, and other pharmacologic agents. Since the advent of mechanical thrombectomy(MT) and its proven efficacy, neurovascular surgeons(NS) are playing an increasingly important role in the management and overall care of AIS. We assessed outcomes of AIS patients managed by NS, who have been traditionally managed by neurologists. PATIENTS AND METHODS Outcomes of AIS patients who presented to the telestroke system, over a 5-year period, were assessed. NIHSS and mRS stroke scales were used as outcome metrics. Multivariate analysis was conducted to compare outcomes of patients treated by neurovascular surgeons and those treated by neurologists. RESULTS 1353 AIS patients were identified. 21.6% received care from neurosurgeons and 78.4% received care from neurologists. Of the neurologist-managed group: 7.8% received MT and were followed by NS, 34% received IVrt-PA, average discharge NIHSS = 9.0 (SD = 8.42), latest follow-up mRS < 2 = 57.5% and mortality rate = 9.4%. Of the neurovascular surgeon-managed group: 7.4% patients received MT, 20% received IVrt-PA, average discharge NIHSS = 0.14(SD = 0.72), latest follow-up mRS ≤2 = 98.6% and mortality rate = 8.3%. There were no significant differences between groups in MT use (OR 1.22; CI95%, 0.971-2.09; p = 0.464), IVrt-PA administration (OR 0.98; CI95%, 0.70-1.38; p = 0.924), mortality rate (OR 1.21; 0.71-2.03; p = 0.483) and patients' latest mRS, p = 0.873. CONCLUSIONS AIS requires multidisciplinary management. Care provided by neurosurgeons has similar efficacy and patient outcomes as the care provided by neurologists. These findings support the role and ability of neurosurgeons to manage and care for these patients.
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Affiliation(s)
- Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
| | - Kimon Bekelis
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
| | - Hassan Saad
- Department of Neurosurgery, Arkansas Institute of Neurosciences, Little Rock, AR, USA.
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
| | - Sophia Dang
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
| | - Jonathan Li
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
| | - Ayan Kumar
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
| | - Justin Turpin
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
| | - Randa Barsoom
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
| | - David Hasan
- Departement of Neurosurgery, University of Iowa, Hawkins Drive Iowa City, Iowa, USA.
| | - Maureen Deprince
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
| | - Giuliana Labella
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
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Mazighi M, Meseguer E, Labreuche J, Miroux P, Le Gall C, Roy P, Tubach F, Amarenco P. TRUST-tPA trial: Telemedicine for remote collaboration with urgentists for stroke-tPA treatment. J Telemed Telecare 2016; 23:174-180. [PMID: 26656722 DOI: 10.1177/1357633x15615762] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Previous observational studies have shown that telemedicine is feasible and safe to deliver intravenous (IV) recombinant tissue plasminogen activator (rt-PA). However, implementation of telemedicine may be challenging. To illustrate this fact, we report a study showing that telemedicine failed to improve clinical outcome and analyze the reasons for this shortcoming. Methods We established a tele-stroke network of 10 emergency rooms (ERs) of community hospitals connected to a stroke center to perform a randomized, open-label clinical trial with blinded outcome evaluation. Eligible patients were randomly assigned to either a usual care arm (i.e. immediate transfer to the stroke center and administration of IV rt-PA if indication was confirmed upon stroke arrival) or tele-thrombolysis arm (i.e. immediate administration of IV rt-PA in ER and transfer to the stroke center). The primary efficacy outcome was an excellent outcome (modified Rankin scale (mRS) 0-1 at 90 days). Secondary endpoints included favorable outcome (90-day mRS 0-2) and early neurological improvement (NIHSS score 0-1 at 24 hours or a decrease of ≥ 4 points within 24 hours). Safety outcomes included symptomatic intracerebral hemorrhage (ICH) per ECASS II definition, any ICH and all-cause mortality. Results During an accrual time of 48 months, because of a slow enrollment rate, only 49 of 270 patients initially planned for inclusion were randomized into usual care ( n = 23) and tele-thrombolysis ( n = 26). Despite random assignment, patients allocated to tele-thrombolysis were older and had more severe stroke than patients allocated to usual care. The median duration of video-conference was 23 minutes in the usual care arm and 73 minutes in the tele-thrombolysis arm. Eighty-four percent of patients in the tele-thrombolysis arm were treated by IV rt-PA in comparison to 18% in the usual care arm. In univariate analysis but not after adjustment for age and baseline NIHSS, patients allocated in the usual care arm had a higher rate of excellent or favorable outcome. There were no differences in safety outcomes, with only one symptomatic ICH occurring in the tele-thrombolysis arm. Conclusions Stroke patients included in the telemedicine arm of the TRUST-tPA trial increased their rt-PA eligibility five-fold. However, the efficacy and safety remains to be determined (ClinicalTrials.org, NCT00279149).
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Affiliation(s)
- Mikael Mazighi
- 1 Department of Neurology and Stroke Centre, Bichat University Hospital, France.,2 INSERM LVTS-1148 and Paris-Diderot University, France
| | - Elena Meseguer
- 1 Department of Neurology and Stroke Centre, Bichat University Hospital, France.,2 INSERM LVTS-1148 and Paris-Diderot University, France
| | - Julien Labreuche
- 1 Department of Neurology and Stroke Centre, Bichat University Hospital, France.,2 INSERM LVTS-1148 and Paris-Diderot University, France
| | | | | | - Patricia Roy
- 5 Emergency Department, Provins Hospital, Provins, France
| | - Florence Tubach
- 6 APHP, Département D'Epidémiologie et Recherche Clinique, Hôpital Bichat, France; Univ Paris Diderot, Sorbonne Paris Cité, UMR 1123, France; INSERM, CIC-EC 1425, UMR 1123, France
| | - Pierre Amarenco
- 1 Department of Neurology and Stroke Centre, Bichat University Hospital, France.,2 INSERM LVTS-1148 and Paris-Diderot University, France
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Freeman WD, Barrett KM, Vatz KA, Demaerschalk BM. Future neurohospitalist: teleneurohospitalist. Neurohospitalist 2013; 2:132-43. [PMID: 23983878 DOI: 10.1177/1941874412450714] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Despite the growing demand for emergency neurological evaluations and neurohospitalists, the supply of neurologists remains relatively fixed over time. Telemedicine is a unique tool that has the ability to put a medical specialist like a neurologist in 2 places in a relatively short period of time, expanding expertise in many rural and in some underserved urban facilities that would ordinarily be devoid of such expertise. Teleneurology is a branch of telemedicine that consults and practices through remote neurological evaluation. Telestroke is defined as remote stroke evaluation. The demand for timely neurological evaluation, especially acute stroke evaluation and treatment with intravenous recombinant tissue plasminogen activator (IV rtPA), continues to fuel the growth of neurohospitalists, telestroke, and teleneurology services. Remote, rural, or underserved urban emergency departments and hospitals which are unable to successfully recruit a neurologist or neurohospitalist to provide this service are uniquely suited to a teleneurology option. The number of private practices and academic centers providing telestroke services has grown significantly in the past decade with continued growth expected. We describe the benefits and drawbacks of teleneurology/telestroke, as well as other practical aspects for the teleneurohospitalist.
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Affiliation(s)
- William David Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA ; Department of Critical Care, Mayo Clinic, Jacksonville, FL, USA
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Abstract
PURPOSE OF REVIEW Tissue-type plasminogen activator is the only pharmacological treatment approved for acute ischemic strokes but is administered to less than 5% of the patients. Excessive prehospital and in-hospital delays and lack of stroke center coverage are major issues that negatively impact stroke care. New strategies are being developed and evaluated to increase the number of tissue-type plasminogen activator-treated patients. RECENT FINDINGS Factors that limit rapid access to acute stroke care are discussed, including those influencing time intervals from stroke onset to hospital admission. We also describe strategies that hold promise to reduce prehospital delays and increase access to acute stroke treatment. SUMMARY The shortening of prehospital delays requires education of patients and health professionals and optimization of transport strategies. Future developments may include video conferencing offering telestroke expertise, strategies (i.e. therapeutic interventions) that might help to treat acute stroke patients with tissue-type plasminogen activator, and prehospital selection of candidates for endovascular therapies.
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Schwamm LH, Holloway RG, Amarenco P, Audebert HJ, Bakas T, Chumbler NR, Handschu R, Jauch EC, Knight WA, Levine SR, Mayberg M, Meyer BC, Meyers PM, Skalabrin E, Wechsler LR. A review of the evidence for the use of telemedicine within stroke systems of care: a scientific statement from the American Heart Association/American Stroke Association. Stroke 2009; 40:2616-34. [PMID: 19423852 DOI: 10.1161/strokeaha.109.192360] [Citation(s) in RCA: 341] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this new statement is to provide a comprehensive and evidence-based review of the scientific data evaluating the use of telemedicine for stroke care delivery and to provide consensus recommendations based on the available evidence. The evidence is organized and presented within the context of the American Heart Association's Stroke Systems of Care framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class of evidence. Evidence-based recommendations are included for the use of telemedicine in general neurological assessment and primary prevention of stroke; notification and response of emergency medical services; acute stroke treatment, including the hyperacute and emergency department phases; hospital-based subacute stroke treatment and secondary prevention; and rehabilitation.
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