Stroke telemedicine assessed

Jan 19 2009

Stroke telemedicine is a lifesaving practice that deserves further advancement, Mayo researchers write in the January 2009 issue of Mayo Clinic Proceedings.

Since its inception, stroke telemedicine has developed nationally and internationally as a reliable means of aiding patients. Yet certain key systematic components need to be developed more fully while specific unsettled issues must be resolved.

Called a "telestroke," a patient with suspected stroke symptoms presents to a local hospital emergency department to undergo a remote stroke assessment by a vascular neurologist at a hub hospital. Described as a consultative modality, stroke telemedicine consults specialists at stroke centers to facilitate the care of patients with acute stroke at underserviced hospitals. In the article, Mayo researchers explain: Telecommunications, which started with the telephone and advanced to audiovisual (AV) communication, has changed the face of medicine not only in remote areas but also in urban areas with a shortage of subspecialties. A surge in the use of telestroke across the United States, Canada and Europe occurred in the late 1990s and early 2000s, resulting in the development of 20 new telestroke networks. The implementation of telemedicine for stroke is a vital piece to the puzzle of creating universal access to emergency care for all patients with stroke, regardless of geographic location or hospital resources.

"Well-designed studies have shown that this consultative modality is valid, accurate and reliable. Numerous telestroke networks exist worldwide, and most of these networks have published their implementation experiences and early outcome results," reports study author Bart Demaerschalk, M.D., Mayo Clinic neurologist. "Successfully delivered promises of telestroke include remote instant expert stroke diagnoses, delivery of short-term therapies, and secondary prevention advice."

In the article, researchers caution, "Promises of telestroke applications that have been slower to materialize include widespread national and international telestroke networks that offer standardized evidence-based care, telestroke research networks for testing new stroke therapies, standardized measurements of telestroke quality of care, and acceptable guidelines for telestroke practice. "The long-term sustainability and growth of telestroke practice remains threatened by unresolved legal, economic and market factors." These factors include medical liability regulation and state licensing, substantial capital investment requirements and profit or self-sustaining plans relating to private and insurance payers.

Mayo researchers conclude, "Telestroke practitioners and investigators should focus attention on analyzing and solving the business issues of the practice to allow further advances in the telestroke field and longevity of telestroke practice."

Mayo Researchers Offer Recommendations for Prevention of Recurrent Stroke

"Stroke is the leading cause of death and disability in the United States," according to Harold Adams Jr., M.D., of the University of Iowa, Iowa City, in the January 2009 issue of Mayo Clinic Proceedings . "The economic consequences of stroke, including health care costs and lost economic productivity, are substantial. These are the reasons that stroke prevention, including treatment of underlying causes, are clearly of critical importance."

Vascular disease is the leading cause of ischemic stroke caused by insufficient blood supply, according to the article. Preventing stroke or recurrent stroke involves controlling those factors that promote the course of the disease through thorough treatment.

"Some risk factors associated with increased likelihood of advanced atherosclerosis and ischemic disease are not modifiable," Dr. Adams writes. "These risk factors include age, sex, ethnicity, family history and premature vascular disease. However, several conditions that augment the course of atherosclerosis can be effectively addressed across the continuum of care. Among these risk factors, hypertension, hyperlipidemia, diabetes mellitus and smoking are especially important, and their control is fundamental to management strategies for lowering the likelihood of recurrent ischemic events among patients with ischemic heart disease, ischemic stroke, or peripheral arterial disease."

The core of treatment management for preventing recurrent stroke and other cardiovascular events in at-risk patients is administration of antiplatelet agents, Dr. Adams stresses.

"Use of an integrated treatment approach involving risk-factor management, antiplatelet therapy and surgical procedure when indicated presents the opportunity to lower the risk of recurrent stroke and other ischemic events in patients with recent ischemic stroke," Dr. Adams writes. "Future research may provide support for using new medications, clarify the role of currently available medications, and better define the appropriate role of surgery, particularly endovascular treatments."

Mayo Neurologist Places Vital Importance on Stroke Prevention and Treatment

In an editorial in the January issue of Mayo Clinic Proceedings , Mayo Clinic neurologist James Meschia, M.D., validates that the prevention and treatment of stroke are acutely important health care considerations. In doing so, he cites the two articles above as being of particular importance.

Referring to the article about stroke telemedicine, Dr. Meschia asks, "Is this rapid adoption of telemedicine technology for assessing and treating brain attack justified?" After citing positives and still problematic concerns, he says, "It is unknown how widely telemedicine for stroke will be used. However, if it proves financially sustainable, its use in many aspects of stroke care will likely grow."

Concerning the Dr. Adams article he writes, "After the immediate post-thrombolytic period, care needs to focus on secondary prevention. Patients with acute ischemic stroke are at high risk of recurrent stroke. If successful reperfusion therapy is like dodging a bullet, successful secondary prevention is like being caught in the line of fire again. His (Dr. Adams') review will be welcomed by clinicians seeking guidance beyond evidence-based guidelines."

A peer-review journal, Mayo Clinic Proceedings publishes original articles and reviews dealing with clinical and laboratory medicine, clinical research, basic science research and clinical epidemiology. Mayo Clinic Proceedings is published monthly by Mayo Foundation for Medical Education and Research as part of its commitment to the medical education of physicians. The journal has been published for more than 80 years and has a circulation of 130,000 nationally and internationally. Articles are available online at www.mayoclinicproceedings.com.