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BRIEF REPORT
Year : 2010  |  Volume : 58  |  Issue : 5  |  Page : 740-742

Feasibility and safety of remote radiology interpretation with telephone consultation for acute stroke in Thailand


1 Neurology Division, Thammasat University, Pathum Thani, Thailand
2 Internal Medicine Resident, Thammasat University, Pathum Thani, Thailand
3 Department of Radiology, Thammasat University, Pathum Thani, Thailand

Date of Acceptance08-Jul-2010
Date of Web Publication28-Oct-2010

Correspondence Address:
Sombat Muengtaweepongsa
Faculty of Medicine, Thammasat University, Rangsit Campus, Paholyothin Rd., Pathum Thani 12120
Thailand
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.72162

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 » Abstract 

"Telestroke" is emerging as a potential timesaving, efficient means for evaluating patients experiencing acute ischemic stroke. It provides an opportunity for administration of thrombolytic drugs within the short therapeutic time window associated with AIS. We describe our experiences of the feasibility and safety of remote radiology interpretation with telephone consultation. Thammasat Stroke Center employs a computed tomography-digital imaging and communication in medicine (CT-DICOM) image transfer by PACS (SYNAPSE-Fujifilm), providing a real-time CT image transferred directly to the stroke consultants. The patient data are communicated by traditional telephone conversation. Here, we assessed patients who received intravenous rt-PA treatment for ASI between October 2007 and January 2009. A total of 458 patients with AIS and transient ischemic attack (TIA) were admitted to a stroke unit during the study period. One hundred patients received intravenous rt-PA (21%). Median NIHSS before thrombolysis was 15 (3-34). Mean door-to-needle time was 54 minutes (15-125). Mean onset-to-treatment time OTT was 160 minutes (60-270). There were 13 asymptomatic intracerebral hemorrhages and two (one fatal) symptomatic intracerebral hemorrhages. At 3 months, 42 patients had achieved excellent recovery (mRS, 0-1) and 14 had died. Administration of rt-PA for AIS with remote radiology interpretation with telephone consultation was feasible and safe, and the system was well received. Further studies are needed to determine the benefit of this method as compared to the conventional telephone consultation alone.


Keywords: Acute ischemic stroke, telemedicine, thrombolysis


How to cite this article:
Muengtaweepongsa S, Dharmasaroja PA, Maungboon P, Wattanaruangkowit P. Feasibility and safety of remote radiology interpretation with telephone consultation for acute stroke in Thailand. Neurol India 2010;58:740-2

How to cite this URL:
Muengtaweepongsa S, Dharmasaroja PA, Maungboon P, Wattanaruangkowit P. Feasibility and safety of remote radiology interpretation with telephone consultation for acute stroke in Thailand. Neurol India [serial online] 2010 [cited 2019 Nov 17];58:740-2. Available from: http://www.neurologyindia.com/text.asp?2010/58/5/740/72162



 » Introduction Top


Intravenous thrombolytic therapy has been approved as a standard treatment for acute ischemic stroke (AIS) patients. [1],[2] However, thrombolytic treatment rates in clinical practice are relatively low. [3] Time is the core of effective management in acute ischemic stroke (AIS), particularly for administration of recombinant tissue-plasminogen activator (rt-PA). [4] Clinicians may be at increased liability risk for medicolegal issues if they do not use rt-PA for eligible patients. [5] Telestroke is emerging as a potential timesaving, efficient means for evaluating patients experiencing AIS. [6] Several methods of telestroke are available, mostly in the developing world. [7] These methods provide an opportunity for administration of thrombolytic drugs within the short therapeutic time w0indow associated with AIS. [8],[9] We reort our initial experience of feasibility and safety of the administration of rt-PA in patients with AIS with remote radiology interpretation and telephone consultation.


 » Materials and Methods Top


Thammasat Stroke Center employs a computed tomography-digital imaging and communication in medicine (CT-DICOM) image transfer by PACS (SYNAPSE-Fujifilm), providing a real-time computerized tomography (CT) image transferred directly to the stroke consultants (S.M. and P.D.). The patient data are communicated to the stroke consultants by traditional telephone conversation. Here we assessed patients who received intravenous rt-PA treatment for AIS at Thammasat Hospital between October 2007 and January 2009. Main outcome measures, included: intravenous othrombolytic treatment rate, door-to-needle time, initial NIHSS, onset-to-treatment time (OTT), intracerebral hemorrhage, morbidity and mortality, at 3 months.

Acute stroke protocol

Thammasat Hospital is a 460-bed community-based hospital with a 64-slide CT but no magnetic resonance imaging (MRI) machines. The acute stroke service was launched in May 2007, while the remote radiology interpretation system was initiated in October 2007.

In Thailand, patients with acute stroke seek self referral and admit themselves to the hospitals as the networkd of emergency medical system (EMS) is not well doveloped. The medical screening front desks, screening nurses and registration officers at Thammasat Hospital have been trained to recognize initial stroke symptoms using modified Cincinnati pre-hospital stroke screening model. If acute stroke is suspected, the patients would be immediately sent to the Emergency Department (ED), and stroke fast-track treatment would be activated. An intern (a first-year post-licensed doctor) or an internal medicine resident on-duty would approach the patients immediately at the ED and notifies stroke consultants. The images of non-contrast CT brain as for the stroke protocol would be immediately uploaded to the PACS servers. The stroke consultants are able to log on to the servers by Virtual Private Network Application under Microsoft Windows from their personal laptops or desktops, which are able to connect to the internet. By SYNAPSE application with Virtual Private Network Access, stroke consultants are able to watch the real-time images from their laptops or desktops at home or in the office [Figure 1]. All clinical details are communicated by traditional telephone conversation. Intravenous rt-PA is administrated by an intern or an internal medicine resident at the ED. After completing 1-hr intravenous rt-PA at ED, patients would be transferred to Stroke Unit or Medical Intensive Care Unit (MICU). The inclusion and exclusion criteria for intravenous rt-PA were that of the National Institute for Neurological Disorders and Stroke (NINDS). [10]
Figure 1: The SYNAPSE application

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 » Results Top


Of the 458 patients admitted with acute ischemic stroke (AIS) and transient ischemic attack (TIA), 100 (21%) patients received intravenous rt-PA. Median National Institutes of Health Stroke Scale (NIHSS) score before thrombolysis was 15 (range, 3-34). Mean door-to-needle time was 54 minutes (range, 15-125). Mean onset-to-treatment time (OTT) was 160 minutes (range, 60-270). There were two patients receiving thrombolytic therapy during the period of 3 to 4.5 hours according to European Cooperative Acute Stroke Study (ECASS) III protocol.

There were 13 asymptomatic intracerebral hemorrhages and two symptomatic intracerebral hemorrhages. One patient expired as a result of hemorrhage, while the other survived with a significant deficit. At 3-months, 42 patients had achieved excellent recovery (modified Rankin Scale (mRS), 0-1) and 14 had died (mRS, 6). The outcomes were comparable to the results of the NINDS, as shown in [Figure 2]. Some outcome parameters compared to the previous Telestroke reports are shown in [Table 1].
Figure 2: Comparison of mRS at 3 months

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Table 1: Comparison of main outcome measures in our study (Thammasat) with those in other studies

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 » Discussion Top


Benefit of teleconsultation for acute stroke has been demonstrated by previous studies from Europe and the United States. [6],[8],[12],[14] The complete protocol of teleconsultation for acute stroke, or telestroke, consists of video-teleconferencing (VTC); and remote assessment of neuroimaging in acute stroke - teleradiology. [7],[15],[16] However, implementation of complete teleconsultation with both VTC and teleradiology is expensive, [12] hence it is not possible to run the complete teleconsultation at such a community-based hospital in a developing country like Thailand. Therefore, we have gone by partial teleconsultation with remote radiology interpretation alone. Our system of teleradiology was well received.

The outcomes of intravenous thrombolytic therapy in our study are comparable to those in NINDS trial and other previous telestroke reports. [6],[10],[12],[13] Our study indicates that administration of rt-PA to AIS patients with remote radiology interpretation and telephone consultation was feasible and safe. This method of teleconsultation may be a viable alternative to complete telestroke, especially in a resource-limited setting. However, further study is needed to determine the benefit of this method as compared to that of the complete telestroke or conventional telephone consultation alone.

 
 » References Top

1.Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: A guideline from the american heart association/american stroke association stroke council, clinical cardiology council, cardiovascular radiology and intervention council, and the atherosclerotic peripheral vascular disease and quality of care outcomes in research interdisciplinary working groups: The american academy of neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007;38:1655-711.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.European Stroke Organisation (ESO) Executive Committee; ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008;25:457-507.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Reeves MJ, Arora S, Broderick JP, Frankel M, Heinrich JP, Hickenbottom S, et al. Acute stroke care in the us: Results from 4 pilot prototypes of the paul coverdell national acute stroke registry. Stroke 2005;36:1232-40.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Saver JL. Time is brain-quantified. Stroke 2006;37:263-6.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Weintraub MI. Thrombolysis (tissue plasminogen activator) in stroke: A medicolegal quagmire. Stroke 2006;37:1917-22.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Meyer BC, Raman R, Hemmen T, Obler R, Zivin JA, Rao R, et al. Efficacy of site-independent telemedicine in the stroke doc trial: A randomised, blinded, prospective study. Lancet Neurol 2008;7:787-95.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Demaerschalk BM, Miley ML, Kiernan TE, Bobrow BJ, Corday DA, Wellik KE, et al. Stroke telemedicine. Mayo Clin Proc 2009;84:53-64.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Miley ML, Demaerschalk BM, Olmstead NL, Kiernan TE, Corday DA, Chikani V, et al. The state of emergency stroke resources and care in rural arizona: A platform for telemedicine. Telemed J E Health 2009;15:691-9.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Wang DZ. Editorial comment--telemedicine: The solution to provide rural stroke coverage and the answer to the shortage of stroke neurologists and radiologists. Stroke 2003;34:2957.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Tissue plasminogen activator for acute ischemic stroke. The national institute of neurological disorders and stroke rt-pa stroke study group. N Engl J Med 1995;333:1581-7.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Audebert HJ, Kukla C, Vatankhah B, Gotzler B, Schenkel J, Hofer S, et al. Comparison of tissue plasminogen activator administration management between telestroke network hospitals and academic stroke centers: The telemedical pilot project for integrative stroke care in bavaria/germany. Stroke 2006;37:1822-7.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  
12.Audebert HJ, Kukla C, Clarmann von Claranau S, Kuhn J, Vatankhah B, Schenkel J, et al. Telemedicine for safe and extended use of thrombolysis in stroke: The telemedic pilot project for integrative stroke care (Tempis) in Bavaria. Stroke 2005;36:287-91.  Back to cited text no. 12
    
13.Schwab S, Vatankhah B, Kukla C, Hauchwitz M, Bogdahn U, Furst A, et al. Long-term outcome after thrombolysis in telemedical stroke care. Neurology 2007;69:898-903.  Back to cited text no. 13
    
14.Hess DC, Wang S, Hamilton W, Lee S, Pardue C, Waller JL, et al. Reach: Clinical feasibility of a rural telestroke network. Stroke 2005;36:2018-20.  Back to cited text no. 14
[PUBMED]  [FULLTEXT]  
15.Schwamm LH, Holloway RG, Amarenco P, Audebert HJ, Bakas T, Chumbler NR, et al. A review of the evidence for the use of telemedicine within stroke systems of care: A scientific statement from the American Heart Association/American Stroke Association. Stroke 2009;40:2616-34.  Back to cited text no. 15
[PUBMED]  [FULLTEXT]  
16.Schwamm LH, Audebert HJ, Amarenco P, Chumbler NR, Frankel MR, George MG, et al. Recommendations for the implementation of telemedicine within stroke systems of care: A policy statement from the American heart association. Stroke 2009;40:2635-60.  Back to cited text no. 16
[PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]

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