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Table of Contents    
Year : 2016  |  Volume : 64  |  Issue : 7  |  Page : 110-112

Telemedicine and stroke: Stroke Emergency Mobile Unit - A new approach to stroke care

1 Department of Neurology, Institute of Neurosciences, Indraprastha Apollo Hospitals, New Delhi, India
2 Department of Internal Medicine, Indraprastha Apollo Hospitals, New Delhi, India

Date of Web Publication3-Mar-2016

Correspondence Address:
Pushpendra Nath Renjen
Department of Neurology, Institute of Neurosciences, Indraprastha Apollo Hospitals, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.178050

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How to cite this article:
Renjen PN, Chaudhari D. Telemedicine and stroke: Stroke Emergency Mobile Unit - A new approach to stroke care. Neurol India 2016;64, Suppl S1:110-2

How to cite this URL:
Renjen PN, Chaudhari D. Telemedicine and stroke: Stroke Emergency Mobile Unit - A new approach to stroke care. Neurol India [serial online] 2016 [cited 2021 Jan 19];64, Suppl S1:110-2. Available from:


Stroke is one of the leading causes of death and the most frequent reason for permanent disability. [1] Thrombolysis with recombinant tissue plasminogen activator (rtPA) remains the major therapy for acute ischemic stroke. The benefit of this therapy is, however, extremely time sensitive.The number of patients needed to treat to achieve a good outcome (defined as modified Rankin's scale < 2) is 4.5 if treatment starts within 1.5 h. This number doubles to 9 if treatment is initiated between 1.5 to 3 h. [2],[3] An improvement in the number of patients treated per year has been seen after enhancements in the treatment chain were made. [3] The "time is brain" concept, that has been derived from such observations, is also supported by earlier experimental animal research [4],[5],[6] and by calculations indicating that for each minute in which stroke remains untreated, as many as 1.9 million neurons and 14 billion synapses may die. [6]

A specific management in specialized hospital facilities has been shown to improve process quality and outcomes in a variety of diseases. [7],[8],[9] In the context of neurological disorders, this applies to the treatment of acute stroke in stroke units or the management of intracranial hemorrhages in hospitals with organized stroke care or neurosurgical facilities. [10],[11] A correct pre-hospital diagnosis is important because it avoids admissions to inappropriate hospitals where suboptimal care would be provided. This may also lead to time-consuming secondary patient transfers. In addition, the pre-hospital diagnostic work up can accelerate emergency management by an advanced notification transmitted to the hospital teams. [12],[13] However, the diagnosis of neurological disorders is often difficult with a wide variety of symptoms, presentations, and causes being found at the initial encounter with the patient. For example, the initial diagnosis of stroke in the Emergency Department (ED) yielded a stroke mimic rate of 19%, based on history and clinical examination only. [14] If additional laboratory findings and a computed tomographic (CT) scan were available, the stroke mimic rate was only 4%. [15]

According to the PreHospital Acute Neurological Therapy and Optimization of Medical Care in Stroke (PHANTOM-S) study, the patient care in the stroke emergency mobile (STEMO) units was safe, increased the rate of intravenous thrombolysis in patients with ischemic stroke, and reduced the time-to-treatment. [16] The PHANTOM-S study has been designed to demonstrate a reduced alarm-to-needle time in STEMO compared with the usual care. Given the close association between time-to-treatment and outcome in acute ischemic stroke patients, the study will show whether this concept should be incorporated as an integral part of the standard stroke care. Future studies may then explore which constituents of STEMO play the most important role in the pre-hospital stroke care.

Recently, 2 groups in Germany have installed a CT scanner on an ambulance, along with either an on-board or remote (via telemedicine) stroke expertise, and point-of-care laboratory testing to take the stroke unit to the patient and to facilitate an early treatment. [17],[18] This mobile stroke unit (MSU) concept moves the stroke treatment from the ED to the prehospital environment. Performing the assessment in the ED, as is done in the conventional setting, is often associated with inherent delays caused by the processes of ED triage, registration, evaluation and testing of the patients prior to the initiation of treatment.

A STEMO unit is an ambulance staffed with a specialized stroke team and equipped with a computed tomographic scanner and point-of-care laboratory. In a study by Wendt et al., an improved prehospital triage of patients with stroke was established by the use of specialized stroke ambulances for the transportation of the patients. [19] The study compared the pre-hospital triage of patients with suspected stroke at the dispatcher level. The patients either received STEMO care or conventional care. The study also assessed the transport destination in patients with different diagnoses. Patients who received STEMO care were physically examined by the STEMO neurologist upon arrival in the hospital. If necessary, point-of-care laboratory investigations, including the blood count, glucose, electrolytes, international normalized ratio, and creatinine, were performed. A CT scan was performed, if indicated, for an immediate therapeutic decision making or for conducting the patient's triage. An additional CT angiography was performed whenever additional information about a specific arterial occlusion was requested. Imaging data was sent via tele-radiology to the neuroradiologist on call, who interpreted these images immediately and gave feedback to the STEMO physician. In difficult cases that needed to include decisions regarding thrombolysis, a senior neurologist was also involved via a telephone or video-conferencing. Following this assessment, the patients were transported to the nearest hospital based on the judgment of the emergency physician (respecting the patient's preference). The status at discharge from the hospital was used as a short-term outcome. [19]

The results from May 2011 to January 2013 revealed that 1804 of 6182 (29%) patients received the STEMO care and 4378 of 6182 (71%) patients received the conventional care. Two hundred and forty-five of the 2110 (11.6%) patients with cerebrovascular events were sent to hospitals that did not have a stroke unit in the conventional care subgroup, when compared with 48 of 866 (5.5%; P < 0.01%) patients in the STEMO care subgroup. In patients with ischemic stroke, the STEMO care reduced transport to hospitals without a stroke unit from 10.1% (151 of 1497) to 3.9% (24 of 610; P < 0.01). The delivery rate of patients with intracranial hemorrhage to hospitals without the neurosurgery department was 43.0% (65 of 151) in the conventional care subgroup, and 11.3% (7 of 62) in the STEMO care subgroup (P < 0.01). There was a slight trend toward higher rates of neurological patients being discharged to undergo domiciliary care in the STEMO subgroup when compared with the conventional care subgroup (63.5% versus 60.8%; P = 0.096). It was concluded that the triage of patients with cerebrovascular events to specialized hospitals might be improved by STEMO ambulances. [19]

The idea of the MSU has actually been around for quite some time, but it is now that the technology has become advanced enough for us to actually be able to realize and utilize its potential applications. Germany had introduced the first MSUs. The doctors at the University of Saarland were the pioneers of the concept of MSUs and have probably been applying it in their practice for the last 7-8 years. They have a significantly different model in which physicians and often neuroradiologists accompany the MSUs to interpret the imaging. This concept, of course, is not practical in India or even in the United States.

In addition to having CT scanners that are small enough to fit inside an ambulance, we now also have better technology for transmission of images. Using long-term evolution (LTE) networks and the fourth generation (4G) of mobile telecommunication technology, we are able to transmit images much more quickly so that they may be read at a remote location. In addition, we can use telemedicine to allow our physicians to beam into the vehicle and actually assess the patient, make a tele-examination, and talk to the family and the crew in the ambulance.

Everybody is concerned about the cost of this venture, so this is a question that needs to be addressed. There is the cost of the physical unit, which is probably around $1 million and then there is the recurring cost of staffing these units. It would have to be unequivocally shown that improvements in outcomes and disability translates to significant cost-savings down the line. I think in the current healthcare environment, where people are very concerned about the rising costs of treatment, it would have to be proven that introduction of this facility is going to be cost-effective.

By using systems for bidirectional audiovisual video-conferencing and exchange of videos of the examination of the patient and of CT scans, the non-specialized regional hospitals can obtain guidance in stroke treatment from hospitals designated as stroke centers. [20] Previous studies have not only shown that such telemedicine interactions between the two hospitals are reliable and safe, [21],[22],[23],[24] but also that they exert a positive effect on the thrombolysis rates and clinical outcome. [25] More importantly, these telemedicine technologies could, in principle, also allow a bidirectional communication to take place between the emergency medicine services team at the emergency site and the stroke center. Such strategies have been investigated for many years; [26],[27] however, technical problems such as the temporary loss of signals impair a reliable interaction between the ambulance and the hospital even in the recent times. [28],[29]

The major obstacles to successfully establishing the concept of MSU include obtaining adequate funding, the licensure procedures involved, implementing radiation safety protocols, and establishing a smooth communication system within the emergency medical services network. The preliminary data during the run-in phase indicate that there are no significant complications, with roughly two patients being treated with rtPA per week, and one-third within the first 60 min. Further studies are underway to determine the time-saving benefits, clinical outcomes, telemedicine reliability, and cost effectiveness of the MSU strategy. [30]

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Conflicts of interest

There are no conflicts of interest.

  References Top

Rothwell PM, Coull AJ, Silver LE, Fairhead JF, Giles MF, Lovelock CE, et al. Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford Vascular Study). Lancet 2005;366:1773-83.  Back to cited text no. 1
Lees KR, Bluhmki E, von Kummer R, Brott TG, Toni D, Grotta JC, et al. Time to treatment with intravenous alteplase and outcome in stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010;375:1695-703.  Back to cited text no. 2
Advani R, Naess H, Kurz MW. Evaluation of the implementation of a rapid response treatment protocol for patients with acute onset stroke: Can we increase the number of patients treated and shorten the time needed? Cerebrovasc Dis Extra 2014; 4: 115-121.  Back to cited text no. 3
Astrup J, Siesjö BK, Symon L. Thresholds in cerebral ischemia - The ischemic penumbra. Stroke 1981;12:723-5.  Back to cited text no. 4
Hossmann KA. Viability thresholds and the penumbra of focal ischemia. Ann Neurol 1994;36:557-65.  Back to cited text no. 5
Saver JL. Time is brain - Quantified. Stroke 2006;37:263-6.  Back to cited text no. 6
Farkouh ME, Smars PA, Reeder GS, Zinsmeister AR, Evans RW, Meloy TD, et al. A clinical trial of a chest-pain observation unit for patients with unstable angina. Chest pain evaluation in the emergency room (CHEER) investigators. N Engl J Med 1998;339:1882-8.  Back to cited text no. 7
Goodacre S, Nicholl J, Dixon S, Cross E, Angelini K, Arnold J, et al. Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ 2004;328:254.  Back to cited text no. 8
MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354:366-78.  Back to cited text no. 9
Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2013;9:CD000197.  Back to cited text no. 10
Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM; STICH II Investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): A randomised trial. Lancet 2013;382:397-408.  Back to cited text no. 11
Meretoja A, Serbian D, Mustanoja S, Tatlisumak T, Lindsberg PJ, Kaste M. Reducing in-hospital delay to 20 minutes in stroke thrombolysis. Neurology 2012;79:306-13.  Back to cited text no. 12
Audebert HJ, Saver JL, Starkman S, Lees KR, Endres M. Prehospital stroke care: New prospects for treatment and clinical research. Neurology 2013;81:501-8.  Back to cited text no. 13
Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Arch Neurol 1995;52:1119-22.  Back to cited text no. 14
Kothari RU, Brott T, Broderick JP, Hamilton CA. Emergency physicians. Accuracy in the diagnosis of stroke. Stroke 1995;26:2238-41.  Back to cited text no. 15
Weber JE, Ebinger M, Rozanski M, Waldschmidt C, Wendt M, Winter B, et al. Prehospital thrombolysis in acute stroke: Results of the PHANTOM-S pilot study. Neurology 2013;80:163-8.  Back to cited text no. 16
Walter S, Kostopoulos P, Haass A, Keller I, Lesmeister M, Schlechtriemen T, et al. Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: A randomised controlled trial. Lancet Neurol 2012;11:397-404.  Back to cited text no. 17
Ebinger M, Winter B, Wendt M, Weber JE, Waldschmidt C, Rozanski M, et al. Effect of the use of ambulance-based thrombolysis on time to thrombolysis in acute ischemic stroke: A randomized clinical trial. JAMA 2014;311:1622-31.  Back to cited text no. 18
Wendt M, Ebinger M, Kunz A, Rozanski M, Waldschmidt C, Weber JE, et al. Improved prehospital triage of patients with stroke in a specialized stroke ambulance: Results of the pre-hospital acute neurological therapy and optimization of medical care in stroke study. Stroke 2015;46:740-5.  Back to cited text no. 19
Schwamm LH, Holloway RG, Amarenco P, Audebert HJ, Bakas T, Chumbler NR, et al. On behalf of the American Heart Association Stroke Council and the Interdisciplinary Council on Peripheral Vascular Disease. 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. 20
Wiborg A, Widder B, for the TESS Study Group. Teleneurology to improve stroke care in rural areas: The Telemedicine in Stroke in Swabia (TESS) Project. Stroke 2003;34:2951-6.  Back to cited text no. 21
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. 22
Pervez MA, Silva G, Masrur S, Betensky RA, Furie KL, Hidalgo R, et al. Remote supervision of IV-tPA for acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe. Stroke 2010;41:e18-24.  Back to cited text no. 23
Wang S, Lee SB, Pardue C, Ramsingh D, Waller J, Gross H, et al. Remote evaluation of acute ischemic stroke: Reliability of National Institutes of Health Stroke Scale via telestroke. Stroke 2003;34:e188-91.  Back to cited text no. 24
Audebert HJ, Schenkel J, Heuschmann PU, Bogdahn U, Haberl RL; Telemedic Pilot Project for Integrative Stroke Care Group. Effects of the implementation of a telemedical stroke network: The Telemedic pilot project for integrative stroke care (TEMPiS) in Bavaria, Germany. Lancet Neurol 2006;5:742-8.  Back to cited text no. 25
LaMonte MP, Xiao Y, Hu PF, Gagliano DM, Bahouth MN, Gunawardane RD, et al. Shortening time to stroke treatment using ambulance telemedicine: TeleBAT. J Stroke Cerebrovasc Dis 2004;13:148-54.  Back to cited text no. 26
Levine SR, Gorman M. "Telestroke": The application of telemedicine for stroke. Stroke 1999;30:464-9.  Back to cited text no. 27
Bergrath S, Reich A, Rossaint R, Rörtgen D, Gerber J, Fischermann H, et al. Feasibility of prehospital teleconsultation in acute stroke - A pilot study in clinical routine. PLoS One 2012;7:e36796.  Back to cited text no. 28
Liman TG, Winter B, Waldschmidt C, Zerbe N, Hufnagl P, Audebert HJ, et al. Telestroke ambulances in prehospital stroke management: Concept and pilot feasibility study. Stroke 2012;43:2086-90.  Back to cited text no. 29
Parker SA, Bowry R, Wu TC, Noser EA, Jackson K, Richardson L, et al. Establishing the first mobile stroke unit in the United States. Stroke 2015;46:1384-91.  Back to cited text no. 30

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