Telemedicine is improving outcomes for patients with stroke

Technology is revolutionising medicine, and telemedicine is having a measurable impact on stroke care

Technology is revolutionising medicine, and telemedicine for patients with stroke (telestroke) is now having a measurable impact on outcomes. Acute stroke care is challenging for many reasons: stroke mimics are common (about 30% of all cases initially suspected to be stroke);1 patients with intracerebral haemorrhage and ischaemic stroke can present with identical syndromes, making brain imaging essential for diagnosis; treatments must be initiated without delay, and some require transfer for tertiary intervention (eg, endovascular thrombectomy). The lack of specialist stroke physicians in regional Australia and underinvestment in stroke care results in poor access for many Australians. Unwarranted clinical variation is unacceptable, so why do some regions of Australia, even today, have no access to specialist stroke care? The answers are complex, but some are clear (too few specialists in regional areas), while some are more difficult to understand (health providers declining offers of help).

As reported in this issue of the MJA, Bladin and colleagues have evaluated the impact of the Victorian Stroke Telemedicine (VST) program during its first 12 months by analysing data for more than 6000 patients in a study with a before and after design.1 Their primary findings were that processes of care were performed with less delay and the number of patients with ischaemic stroke receiving thrombolysis increased somewhat after the program was implemented. Most importantly, safety improved significantly; the proportion of patients with symptomatic intracranial haemorrhage was reduced from 16% to 4%, and that of those who died from 20% to 6%. Any clinician can provide thrombolysis, but not all can do so safely, and the findings of Bladin and his co‐authors suggest that telestroke facilitates more appropriate delivery of thrombolysis.

Thrombolysis for patients with stroke has been incredibly difficult to implement, even 25 years after the famous National Institute of Neurological Disorders and Stroke trial.2 In 1995, thrombolysis was regarded as effective but not useful because of formidable barriers to its use: poor public knowledge of the importance of stroke; lack of immediate brain imaging (at least initially); lack of neurological expertise in emergency departments (EDs); fear of intracranial bleeding; lack of data about the effect of thrombolysis in people over 80 years of age; and, in some hospitals, the cost of alteplase. Twenty‐five years later, public awareness of stroke has been improved by public health campaigns (such as the FAST campaign3), computed tomography (CT) scanners are widely available in EDs, and we have thrombolysis data for people over 80 (one‐third of all patients with stroke).4

But it has been more difficult to improve the 24‐hour availability of neurological expertise in the ED. The impressive safety results achieved by the VST with respect to thrombolysis‐associated intracranial haemorrhage are therefore important. Clinicians in the ED who previously hesitated to provide stroke thrombolysis can, supported by a competent telestroke service, be assured that locally delivered treatment is appropriate, safe, and effective. Reducing the medico‐legal risks, both of treating and not treating patients with stroke, is also beneficial.

The improved process times associated with the VST add to its public health impact. It has been estimated that each minute of delay in stroke treatment can lead to the loss of 1.9 million neurons, 14 billion synapses, and 12 km of myelinated fibres.5 We also know from observational data that reducing onset to treatment time improves thrombolysis outcomes.6 Appropriate delivery of thrombolysis is, of course, not the only important component of acute stroke care. All people presenting with stroke should receive care in a specialist stroke unit.7 Minor ischaemic stroke and transient ischaemic attack are also medical emergencies, and patients presenting with these conditions benefit from acute interventions other than thrombolysis.8 Telestroke will also identify people who should be transferred for urgent thrombectomy.9 Active management of patients with intracerebral haemorrhage, including rapid lowering of blood pressure, has also dramatically improved.10,11 All these interventions and advice will be available everywhere through a telestroke consultation with a highly trained stroke physician.

Factors that underlie the success of the VST program include excellent clinical leadership and recurrent financial support. Funding is required not only for establishing the program at individual sites, but to ensure that the technology works and that the 24‐hour on‐call stroke physician (in Australia, usually a neurologist) is adequately rewarded for their quarantined time and expertise. Assessment by a neurologist (rather than a generalist) is known to increase thrombolysis rates.12 This funding will also facilitate national capacity building in stroke expertise, as well as bringing the specialist closer to the patient.

The VST is now expanding to Tasmania, telestroke care is also available in South Australia and parts of Western Australia, and funding in New South Wales will commence in 2020: nationwide coverage is within our reach.