International Stroke Conference
February 19–21, 2020
Burton J. Tabaac, MD
With a room filled with astute and engaged listeners, this talk was aimed at featuring some of the most preeminent minds in the field of vascular neurology to comment on particular intricacies as pertains to telestroke. The session was subdivided into four sections, with each delving into a specific approach and perspective on the spectrum of telemedicine.
The first talk, titled “Expansion of Telestroke Networks” was illustriously given at the lectern by Dr. Jennifer Majersik. This presentation highlighted post-hyperacute care options for community hospitals without neurologists, underscored the value of inpatient stroke follow up via telestroke, and outlined suggested requirements to conduct post-acute stoke follow up. The acute telestroke consult relies on three main questions: 1. Is the patient likely having an acute ischemic stroke? 2. Is a large vessel occlusion (LVO) present / Is the patient a candidate for mechanical thrombectomy? 3. Would the patient benefit from transfer to a higher level of care? Majersik details, “The goal of the telestroke consult is to provide accurate and fast revascularization for patients with acute ischemic stroke, and stroke care does not end after this goal is met.” The neurologist should aim to assist with avoidance of complications, consider the underlying stroke etiology, and discuss initiation of targeted secondary preventative therapies. Majersik succinctly concluded the talk by suggesting the following telestroke follow up requirements: the local availability of stroke diagnostic tools (MRI, ECHO, vessel imaging, and potentially non-stroke diagnostics such as EEG), the local availability of rehabilitation services, personnel training (nursing, other physicians, teleprompter), as well as administrative assistance (EMR, scheduling, financial agreement(s) between hospitals, and adequate neurologist staffing).
The second talk, “Tele-ICU,” was orated by Dr. Matthew Koenig. Perhaps the most salient concept of this presentation was when Koenig discussed post thrombolytic monitoring. Important considerations as pertains to telemedicine include triage of patients to determine which candidates are deemed safe and appropriate to remain at the originating hospital. One must consider nurse-driven monitoring of the neurological examination, and whether a facility abides by proactive vs. reactive monitoring of stroke patients. This talk on Tele-ICU for stroke patients status post thrombolytic therapy demonstrated how imperative it is to consider and assess the availability of nurses and allied health professionals from the Comprehensive Stroke Center. Working up the underlying etiology of the patient’s stroke often continues through the ICU course, which is enhanced with telepresence. Koenig concluded this portion of the talk by listing other indications for tele-neurocritical care consultation: non-operative intracerebral hemorrhage (ICH), seizures and status epileptics, management of Guillain-Barre and other causes of neuromuscular weakness, encephalopathy, pain-agitation-delirium, and assistance with brain death determination.
Dr. Steven Cramer was next up and was articulate in delving into “Telerehabilitation.” The main focus of this talk was to define telerehabilitation, explain how the term can be applied to many different therapies, and to present a meta-analysis. Telerehabilitation has been defined as, “Delivery of rehabilitation services via information and communication technologies, and encompasses a range of rehab services that include assessment, monitoring, prevention, intervention, supervision, education, consultation, and counseling.”(1) Cramer aptly provided the following quote, “Home-based post-stroke telerehabilitation should include support that spans an array of rehabilitation, medication, mental health, and other services.”(2) Telerehabilitation means very different things to different people, with wide variation in dose, content of therapy, and device employed. Assessing overall efficacy of telerehab may be confusing. In conducting a meta-analysis of telerehab for stroke, the following results declared themselves: There is no difference on any endpoint between telerehab vs. usual care and no difference between telerehab vs. in-person rehab. Cramer was keen to highlight that the most significant unmet need is the delivery of large doses of rehab therapy. Due to financial constraints, limitations in the ability to travel, shortage of rehab in some regions, poor patient compliance, and the limited dose during stroke rehab, the quantity of rehab therapy is often low. Cramer concluded with a quote from L. Dodakian, “The best treatment program is of little help to patients if they do not adhere to it.”
The ISC session dedicated to telemedicine and stroke concluded with a fantastic presentation by Dr. Christine Holmsted titled “Outpatient Telestroke Follow-up.” This speaker took the time to assess certain outcomes measured when analyzing telemedicine as a medium of providing care. Holmsted quantified the average miles, gallons of gas, and hours of driving saved per patient by utilizing this technology. The presentation engaged the audience by showing how applying teleneuroscience can readily assist in completing a comprehensive clinical trial teleconsent process. Stroke clinical trial follow-ups via telemedicine technology can decrease the burden on subjects (e.g. time, method of travel, gas cost, and caregiver availability for transportation), improve recruitment, and assist with retention, thus allowing for better adherence to study procedures and medical management parameters.
With so many great minds dedicating their time and studies to telestroke advancement, I am confident that more patients will be afforded the opportunity to receive neurological consultation, and ultimately will have improved care and outcomes. The potential applications for this technology are vast, including acute telestroke when making decisions regarding thrombolytic therapy and intra-arterial interventions, but also in the ICU setting, providing stroke rehabilitation, and coordinating auxiliary care.
(1) D. Brennan, et al. Int J Telerehab. 2010; 2:31-34.
(2) G. Demiris, et al. J Med Syst. 2005; 29:595-603.