Stroke team remote evaluation using a digital observation camera in Arizona: the initial mayo clinic experience trial.

BACKGROUND AND PURPOSE: Telemedicine techniques can be used to address the rural-metropolitan disparity in acute stroke care. The Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) trial reported more accurate decision making for telemedicine consultations compared with telephone-only and that the California-based research network facilitated a high rate of thrombolysis use, improved data collection, low risk of complications, low technical complications, and favorable assessment times. The main objective of the STRokE DOC Arizona TIME (The Initial Mayo Clinic Experience) trial was to determine the feasibility of establishing, de novo, a single-hub, multirural spoke hospital telestroke research network across a large geographical area in Arizona by replicating the STRokE DOC protocol. METHODS: Methods included prospective, single-hub, 2-spoke, randomized, blinded, controlled trial of a 2-way, site-independent, audiovisual telemedicine system designed for remote examination of adult patients with acute stroke versus telephone consultation to assess eligibility for treatment with intravenous thrombolysis. The primary outcome measure was whether the decision to give thrombolysis was correct. Secondary outcomes were rate of thrombolytic use, 90-day functional outcomes, incidence of intracerebral hemorrhages, and technical observations. RESULTS: From December 2007 to October 2008, 54 patients were assessed, 27 of whom were randomized to each arm. Mean National Institutes of Health Stroke Scale score at presentation was 7.3 (SD 6.2) points. No consultations were aborted; however, technical problems (74%) were prevalent in the telemedicine arm. Overall, the correct treatment decision was established in 87% of the consultations. Both modalities, telephone (89% correct) and telemedicine (85% correct), performed well. Intravenous thrombolytic treatment was used in 30% of the telemedicine and telephone consultations. Good functional outcomes at 90 days were not significantly different. There were no statistically significant differences in mortality (4% in telemedicine and 11% in telephone) or rates of intracerebral hemorrhage (4% in telemedicine and 0% in telephone). CONCLUSIONS: It is feasible to extend the original STRokE DOC trial protocol to a new state and establish an operational single-hub, multispoke rural hospital telestroke research network in Arizona. The trial was not designed to have sufficient power to detect a difference between the 2 consultative modes: telemedicine and telephone-only. Whether by telemedicine or telephone consultative modalities, there were appropriate treatment decisions, high rates of thrombolysis use, improved data collection, low rates of intracerebral hemorrhage, and equally favorable time requirements. The learning curve was steep for the hub and spoke personnel of the new telestroke network, as reflected by frequent technical problems. Overall, the results support the effectiveness of highly organized and structured stroke telemedicine networks for extending expert stroke care into rural remote communities lacking sufficient neurological expertise.

The state of emergency stroke resources and care in rural Arizona: a platform for telemedicine.

A rural-urban disparity exists in acute stroke management practices in Arizona. A proposed solution is a statewide acute stroke care plan centered on stroke telemedicine. Our purpose was to evaluate the emergency stroke resources available at and care provided by remote Arizona hospitals and to formulate a 5-year stroke telemedicine plan for Arizona rural residents. We used the Arizona Hospital and Healthcare Association Web site to identify all eligible institutions. Consenting personnel were mailed the survey on behalf of the Arizona Department of Health Services. To construct the 5-year telemedicine plan, we used survey data as well as our previously designed stroke telemedicine research trial. We estimated the resources, the geographic coverage, and the operating costs. Thirty-five hospitals met survey eligibility criteria; however, 24/35 (69%) hospitals completed the survey. Only one hospital had neurologists on call 24/7. Hospitals thrombolysed 2%-4% of all stroke patients annually. Ninety percent of the hospitals were interested in participating in a statewide telemedicine initiative. The stroke telemedicine plan divided Arizona into two regions, each with a one-hub to three-spoke ratio. The budget was estimated to be U.S. $8,141,217.10 for 5 years. Remote communities of Arizona were underserviced with regard to the availability of neurologists and the delivery of emergency stroke care. The majority of the remote emergency departments were interested in participating as spoke sites in a statewide stroke telemedicine initiative. Telemedicine may be an effective method to provide expert care to stroke patients located in rural areas.

Stroke telemedicine.

Stroke telemedicine is a consultative modality that facilitates care of patients with acute stroke at underserviced hospitals by specialists at stroke centers. The design and implementation of a hub-and-spoke telestroke network are complex. This review describes the technology that makes stroke telemedicine possible, the members that should be included in a telestroke team, the hub-and-spoke characteristics of a telestroke network, and the format of a typical consultation. Common obstacles to the practice of telestroke medicine are explored, such as medicolegal, economic, and market issues. An example of a state-based telestroke network is thoroughly described, and established international telestroke networks are presented and compared. The opportunities for future advances in telestroke practice, research, and education are considered.

Does cervical manipulative therapy cause vertebral artery dissection and stroke?

OBJECTIVE: Does cervical manipulative therapy (CMT) cause vertebral arterial dissection (VAD) and subsequent ischemic stroke? What is the best estimate of the incidence of CMT associated with VAD and ischemic stroke? METHODS: The questions were addressed with a structured evidence-based clinical neurologic practice review. Participants included neuroscience students, consultant neurologists, clinical epidemiologists, medical librarians, and clinical content experts. A critically appraised topic format was employed, starting with a clinical scenario and structured question. The participant group devised search strategies, located and compiled the best evidence, performed critical appraisals, synthesized the results, summarized the evidence, provided commentary, and declared bottom-line conclusions. RESULTS: The search yielded 169 citations, of which 55 were deemed most relevant. From this return, we selected 26 publications of the highest evidence available: 3 case-control studies, 8 prospective and retrospective case series studies, 4 illustrative case reports, 1 survey, 1 systematic review of observational research, 5 reviews, and 4 opinion and expert commentary pieces. Five of the applicable 7 criteria for causation were satisfactorily met and supported weak to moderate strength of evidence for causation between CMT and VAD and associated stroke, especially in young adults. Young vertebrobasilar artery territory stroke patients were 5 times more likely than controls to have had CMT within 1 week of the event date (OR 5.03, 95% CI, 1.32-43.87). No significant associations were found for those > or =45 years of age. The best available estimate of incidence is approximately 1.3 cases of VAD or occlusion attributable to CMT for every 100,000 persons <45 years of age receiving CMT within 1 week of manipulative therapy. CONCLUSIONS: Weak to moderately strong evidence exists to support causation between CMT and VAD and associated stroke. Ultimately, the acceptable level of risk associated with a therapeutic intervention like CMT must be balanced against evidence of therapeutic efficacy. Further research, employing prospective cohort study designs, is indicated to uncover both the benefits and the harms associated with CMT.