Kara Jo Swafford, MD

Wysocki NA, Bambhroliya A, Ankrom C, Vahidy F, Astudillo C, Trevino A, et al. Outcomes Among Patients With Ischemic Stroke Treated With Intravenous tPA (Tissue-Type Plasminogen Activator) via Telemedicine: Is the Drip-and-Stay Model Safe? Stroke. 2019;50:895–900.

Telemedicine has expanded patient access to acute stroke treatment, including administration of intravenous (IV) tPA. It supports the “hub and spoke model,” providing immediate patient access to a stroke specialist at a remote hospital to help guide emergent treatment. After initial telemedicine consultation and administration of IV tPA, whether the safety and outcomes of transferring the patient to the hub hospital (“drip-and-ship”) or remaining at the spoke hospital (“drip-and-stay”) are similar is uncertain.

Wysocki et al. conducted an observational retrospective review of prospectively collected data from a telemedicine stroke registry. The study included patients with acute ischemic stroke who received IV tPA at one of 17 network hospitals and then either stayed or were transferred to the hub hospital. Those who had planned endovascular therapy were excluded because all were transferred to the hub hospital. Primary outcomes included in-hospital mortality, length of stay, discharge disposition, rates of symptomatic ICH, and good functional outcome based on achieving a 90-day mRS score of 0-1.

Median NIHSS score on presentation was lower for drip-and-stay compared to drip-and-ship patients, demonstrating that patients with more severe strokes were more likely to be transferred to the hub hospital. Despite this difference in initial stroke severity, patients did not differ in in-hospital mortality, length of stay, discharge disposition, or rates of symptomatic ICH. There was no difference in 90-day mRS scores; however, interpretation was limited due to incomplete reporting.

This study generally supports the practice of transferring select patients who received IV tPA to an advanced stroke center based on the need for a higher level of care, and having more stable patients remain at the spoke hospital. A limitation of this observational study was its retrospective design with a potential for unmeasured confounding. A future consideration could be a prospective study randomizing tPA-treated patients to either drip-and-stay versus drip-and-ship. Missing 90-day mRS score data limited assessment of differences in functional outcomes. This study was based on a single system hub and spoke model, which may not reflect practices at small rural community hospitals that are not within a telestroke system of care.