When Time is Brain, TeleStroke Changes LivesBy: Irene Goliash
More than 25 years ago, neurologist Camilo R. Gomez, M.D., coined the phrase “Time is Brain” to describe the urgency of timely treatment for stroke survivors. It is estimated that we lose 1.9 million brain cells a minute when a stroke blocks blood flow to the brain, so every moment of delayed treatment increases the risk of death and/or long-term disability.
Yet most stroke patients do not receive timely treatment, according to the American Stroke Association. Many put off going to the emergency room, and when they do show up their hospital is unlikely to have a neurologist on call — particularly if they live in a rural area. That’s why the American Heart Association and the American Stroke Association strongly advocate for the expanded use of telestroke programs.
What Is Telestroke?
Telestroke is the use of interactive videoconferencing technologies to make stroke specialists available, anytime day or night, to remotely diagnose and treat stroke patients in collaboration with on-site emergency room physicians and other medical professionals.
About 87 percent of strokes are ischemic strokes, which happen when a clot blocks a vessel supplying blood to the brain. Less common are hemorrhagic strokes, which occur when a blood vessel ruptures and bleeds into the brain. The goal in treating a hemorrhagic stroke is to control the bleeding and pressure on the brain, usually with drugs and/or surgery. The goal in treating the more common ischemic stroke is to dissolve or remove the blood clot.
The single most promising treatment for ischemic strokes is a fast-acting, clot-dissolving blood thinner known as tissue Plasminogen Activator or tPA, which was approved by the FDA in 1996. But though we know that tPA can reverse stroke symptoms and significantly improve patient outcomes, it is used in only an estimated 3 to 6 percent of stroke patients.
Why? Because it works best if administered intravenously within an hour of the onset of symptoms. The sooner the treatment, the more likely a patient will survive with minimal or even zero disability. After three to four-and-a-half hours (the timing varies for individual patients and requires assessment by a neurologist), the risk of serious side effects — mainly bleeding in the brain — outweighs any potential benefits.
Telemedicine for Strokes: A Success Story
A 2016 American Heart Association/American Stroke Association review of the literature on telemedicine and stroke outcomes described telestroke as “one of the most successful applications of telemedicine.” Early studies found that the risk of serious complications increased significantly when tPA was administered by inexperienced doctors. Subsequent studies found that telestroke networks led to better adherence to protocols for administering the drug and better outcomes for patients.
With telestroke, a neurologist can immediately interview and virtually examine the patient, read their CT scan, evaluate blood tests, and determine both the type of stroke and the safest and most effective possible treatment. Without being able to see the patient and the CT scan for themselves, even an experienced neurologist — during a phone consultation, for instance — can easily misdiagnose a stroke.
“Stroke mimics,” for instance, are medical conditions that present with similar symptoms. The most common are seizures, but they can include migraines, brain tumors, and even low sodium or low blood sugar. Misdiagnosing a patient and treating stroke mimics or hemorrhagic strokes with tPA can put a patient at extreme risk.
Using telemedicine for strokes, neurologists can supervise timely treatment with intravenous tPA and minimize the attendant risks. And they can screen patients who might benefit from other interventions, including endovascular therapy — in which a catheter is used to remove the clot from the vessel inside the brain — and oversee their transfer to a stroke center for that procedure and further evaluation and treatment.
Telestroke Saves Patients and Money
For at least two decades, stroke experts have been advocating for telestroke to promote timely care and save lives. Telestroke has been shown to increase the use of tPA in hospitals, and it allows hospitals to treat patients with tPA on site rather than transferring them to the nearest stroke center where they are likely to arrive after the narrow window of time during which the drug can be safely and effectively administered. Telestroke has also been shown to be highly cost effective for hospitals and society at large because timely treatment allows patients to be discharged sooner and reduces the need for rehabilitative care.
Telestroke technology has come a long way since Drs. Steven R. Levine and Mark Gorman coined the term in 1999 to describe their proposal that rural emergency rooms use bedside video cameras to connect to urban stroke specialists.
Today, using the most sophisticated audio-video conferencing and digital image sharing technology now available, telestroke platforms help emergency room doctors fulfill that 1999 dream — transcending time and space to bring neurological expertise to their patients’ bedsides at the moment they need it.
Learn how Caregility can change how you delivery stroke care with a customized telestroke program.