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Table 2 Stroke

From: Telemedicine in pre-hospital care: a review of telemedicine applications in the pre-hospital environment




Summary of findings


Waite et al. [[10]]

Journal of Telemedicine and Telecare 2006;12:141–145. Telestroke: a multi-site, emergency-based telemedicine service in Ontario

Multicentre observational study to test the feasibility of telestroke consulting over a wired broadband. Neurologist in an academic centre carried the teleconsult for two peripheral emergency departments

88 consults with 24 patients receiving t-PA. Demonstrating that telestroke consulting was feasible

This is an observational study that demonstrates the feasibility of telemedicine across a network of hospitals

Hess et al. [[11]]

Stroke 2005;36:2018–2020. REACH: clinical feasibility of a rural telestroke network

Descriptive study of a new telestroke web-based consult linking eight rural hospitals with a neurology unit

194 stroke consults seen with 36 receiving tPA. Onset to treatment time dropped by 32 min during the course of the study

This is an observational study that demonstrates the feasibility of a hub and spoke telestroke system

Liman et al. [[12]]

Stroke 2012;43:2086–2090. Telestroke ambulances in prehospital stroke management. Concept and pilot feasibility study

To test the technical feasibility of telestroke over a 3G public network to a telemedicine-equipped ambulance with a simulated stroke patient

18 out of 30 scenarios could not be completed due to poor audiovisual quality. Poor network reliability was identified as a cause of unreliable results

This study highlights the challenges of a mobile telehealth platform using GSM network and demonstrates that it was not technically feasible at least in the location studied

Gonzalez et al. [[13]]

Stroke 2011;42:1522–1527. Reliability of prehospital real-time cellular video phone in assessing the simplified National Institutes of Health Stroke Scale in patients with acute stroke

Test of reliability of simplified NIHSS scale done remotely (over a cellular videophone on a 3G network) by a physician assisted locally by an emergency medical technician compared with bedside examination by physician

480 paired comparisons were done. The authors concluded that assessment over videophone was as reliable as bedside and could be a timely method for remote patient assessment

This study analyses the feasibility of conducting NIHSS assessment remotely over a 3G network but does not simulate real-life situation as the participants were not mobile

Pedragosa et al. [[14]]

Journal of Telemedicine and Telecare 2009;15:260–263 Impact of a telemedicine system on a stroke care in a community hospital

Retrospective case control of quality of care before and after introduction of telemedicine services

198 patients were managed with telemedicine compared to 201 cases the year before its introduction. Quality of care improved after introduction of telemedicine with reduction in transfers to stroke centre increased review by neurology specialist

This study compares a telestroke programme with historical control before introduction of this service and requires further studies to confirm their conclusions

Demaerschalk et al. [[15]]

Telemedicine Journal and E-health 2012;18:230–237 Efficacy of telemedicine for stroke: pooled analysis (STRokE DOC)

Pooled analysis of two prospective randomized controlled studies comparing telephone with telemedicine neurological consultation for stroke

276 pooled patients were evaluated. Telemedicine patients had better outcome with increased tPA treatment and reduced post-tPA bleeding, although 90-day mortality was similar

Although the two studies were identically designed, pooled analysis presents the challenge that the characteristics of the two sampled group may not be identical

Nelson et al. [[16]]

Neurology 2011;77(17):1590–1598 The cost-effectiveness of telestroke in the treatment of acute ischemic stroke

Cost-effectiveness of telestroke was analysed using a decision analytic model constructed by the team

There are higher upfront cost for telemedicine, but over the lifetime, telestroke is cost-effective

This study focuses only on analysing the cost-effectiveness of telemedicine in acute ischaemic stroke and not on other types of stroke. Also, due to lack of published data, some of the conclusions were based on assumptions and estimates

Demaerschalk et al. [[17]]

Stroke 2012;43:3095–3097 CT interpretation in a telestroke network: agreement among a spoke radiologist, hub vascular neurologist, and hub neuroradiologist

Randomized double-blind study analysing CT interpretation agreement among spoke radiologist, stroke neurologist, and central radiology adjudication committee

54 patients were recruited for the study. No significant difference in agreement between telemedicine group and standard method

The patients were randomized, but bias may be introduced by how the choice of telestrokologist is chosen. Sample size of study is small

Wang et al. [[18]]

Stroke 2003;34:e188–e191 Remote evaluation of acute ischemic stroke: reliability of National Institutes of Health Stroke Scale via telestroke

Case-control study comparing bedside telemedicine-based NIHSS assessment in stroke patients

20 patients were recruited for the study. There was no significant difference between bedside and telemedicine-based NIHSS

Small sample size. Larger sample size required to validate the result. Participating physicians not randomized introduce the possibility of bias

LaMonte [[19]]

Journal of Stroke and Cerebrovascular Diseases 2004;13(4):148–154 Shortening time to stroke treatment using ambulance telemedicine: TeleBAT

Case-control study comparing the reliability of NIHSS assessment of stroke video images transmitted through telemedicine ambulance (TeleBAT) and TV/VCR

Validity testing indicates that there was no significant difference between TV/VCR and assessment of video transmitted over the telemedicine system

Title indicates study on shortening of time to treatment but study is on analysing the reliability of radiological images transmitted from an ambulance

Handschu et al. [[20]]

Stroke 2003;34:2842–2846 Telemedicine in emergency evaluation of acute stroke : interrater agreement in remote video examination with a novel multimedia system

Case-control study comparing bedside with real-time remote video-based NIHSS assessment of stroke patients

41 patients were recruited for this study. It demonstrated that remote video-based NIHSS assessment was both feasible and comparable to bedside assessment


Puetz et al. [[21]]

Neurology 2013;80:332–338 Reliability of brain CT evaluation by stroke neurologists in telemedicine

Retrospective analysis of the reliability and therapeutic impact of telemedicine-based CT interpretation in stroke patients

CT scans from 536 patients were analysed. There was high inter-observer agreement between telemedicine diagnosis and expert reviewers and minimal impact on clinical outcome


Bergrath et al. [[22]]

PLoS ONE 2012;7(5):e36796 Feasibility of prehospital teleconsultation in acute stroke—a pilot study in clinical routine

A case-control study comparing telemedicine with standard paramedical care in the pre-hospital management of stroke

18 telemedical and 46 control patients were included in the study. No major effects on clinical processes but improvements in transfer of stroke specific data with corresponding clinical benefits


Thomas et al. [[23]]

Frontiers in Neurology 2012;3:128 Variability in the perception of informed consent for IV-tPA

Retrospective analysis of the quality of informed consent taken during a telemedical consultation of stroke patients. Quality of 20 randomly selected video-taped consults was analysed by five raters

There was very high variability in the perception of consent, but 78.6% rated informed consent as adequate

Study would have been more informative if compared to face-to-face informed consent

Zaidi [[24]]

Stroke 2011;42:3291–3293 Telestroke-guided intravenous tissue-type plasminogen activator treatment achieves a similar clinical outcome as thrombolysis at a comprehensive stroke center

Prospective case-controlled study of telemedical vs. face-to-face management of stroke

Favourable outcome rates were similar between the two groups (42.1% versus 37.5%, P = 0.7)

No randomization. Face-to-face patients seen by hub team, while telemedical group seen my the spoke team

Chowdhury et al. [[25]]

Postgraduate Medical Journal 2012;88:134–137 Telemedicine versus face-to-face evaluation in the delivery of thrombolysis for acute ischaemic stroke: a single centre experience

Retrospective case-control study comparing telemedicine with face-to-face management of stroke patient

97 patients were assessed in the study; 52 (54%) face-to-face and 45 (46%) via telemedicine. Treatment delay was longer in the telemedicine group, but clinical outcome was similar

Method poorly described. Only CT scan appears to be viewed remotely. No information on whether patient assessment was done remotely. No info on how choice was made to use telemedicine

Pervez et al. [[26]]

Stroke 2010;41:e18–e24 Remote supervision of IV-tPA for acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe

Retrospective case-control study comparing telemedicine with face-to-face supervision of IV-tPA in the management of stroke patient

296 patients were included in the study, of which 181 (61.1%) started IV-tPA remotely and 115 (38.9%) under direct supervision. The telestroke group had older patients on the average, but clinical outcomes were similar between both groups


Meyer et al. [[27]]

Journal of Stroke and Cerebrovascular Diseases 2012;21(4):259–264 Assessment of long-term outcomes for the STRokE DOC telemedicine trial

Retrospective review of the 6-month outcome of telemedicine vs. telephone management

6-month outcome was not different between the two groups, and mortality was also the same at 18%


Schwab et al. [[28]]

Neurology 2007;69:898–903 Long-term outcome after thrombolysis in telemedical stroke care

Prospective review of 3- and 6-month clinical outcomes after stroke thrombolysis with telemedicine supervision compared to face-to-face care in a stroke hub

11.2% mortality of the telemedical group compared to 11.5% in the face-to-face group in first 3 months. Favourable functional outcome was also similar between the two groups

Control group was treated in a stroke centre, while telemedicine group was treated in a community hospital

Audebert et al. [[29]]

Stroke 2006;37:1822–1827 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

Prospective observational study comparing stroke thrombolysis in regional hospitals remotely supervised over a telemedicine link with thrombolysis in academic stroke unit

115 patients were treated in the regional hospitals, and 110 were treated in the stroke centres. The rate of IV-tPA was higher in stroke centres compared to regional hospitals although the quality of care was similar in both groups

Larger sample size is required to confirm the conclusions in this study

Ang et al. [[30]]

European Journal of Emergency Medicine 2013;20(5):322–326 Telestroke: rapid treatment of acute ischemic stroke patients using telemedicine in a Singapore emergency department

Retrospective observational analysis of the use of telemedicine in stroke management in a single centre (spoke). Teleconsultants were neurologist based at a specialist national centre (hub)

45 patients were enrolled into the telestroke programme, of which 18 were thrombolysed. Limited conclusion was reached due to the descriptive nature of the study

Limited conclusion can be drawn from this study due to the study design and small sample size

Switzer [[31]]

Stroke 2010;41:566–569 A telestroke network enhances recruitment into acute stroke clinical trials

Descriptive study analysing whether a hub and spoke telemedicine network enhances recruitment of patients for acute stroke trials

19 of 28 patients enrolled into two clinical trails were identified at the spoke level. Another nine patients were identified but could not be transported to the hub

This study explores an added advantage of telemedicine as an aid for patient recruitment into clinical studies

Agarwal et al. [[32]]

Journal of the American Heart Association 2014;3:e000408 Thrombolysis delivery by a regional telestroke network—experience from the UK National Health service

Observational study to demonstrate the safety and efficacy of out-of-hours telestroke service by a horizontal network of hospitals that have thrombolysis service during working hours. Out-of-hours service was provided by a rota of specialists across the network

A 4-month pilot phase with 15 patients demonstrated safety and feasibility. 164 patients were subsequently recruited over a 12-month period. There was significant increase in the number of thrombolysis carried out with outcomes that are comparable wit published studies

This study explores a different model to the traditional ‘hub and spoke’

Richard et al. [[33]]

Neurological Science 2014;35:683–685 Use of telemedicine to manage severe ischaemic strokes in a rural area with an elderly population

Observational study analysing the effectiveness and safety of a telestroke programme in a rural area with a high elderly population

53 patients were recruited to the study over a 16-month period. Outcome was worse than those in the published studies but the average age of this study group is much higher than those in other published data

Sample size is small, and study design does not allow clear conclusions from the study

Demaerschalk et al. [[34]]

Stroke 2012;43:3098–3101 Smartphone teleradiology application is successfully incorporated into a telestroke network environment

Case-control study assessing the reliability of smartphone-based CT interpretation by comparing it with PACS-based system

53 patients were recruited. There was an agreement (95% CI) between smartphone-based and PACS-based systems, suggesting that smartphone based systems are a reliable alternative

This study compares the interpretation by neurologists on smartphone with radiologists on PACS system, introducing a possible bias based on different specialties. Like-for-like comparison may be required to validate their study