Mortality rates and functional outcomes for telemedicine-linked community hospitals and stroke centers were similar and comparable to the results from randomized trials.

Background and Purpose-Systemic thrombolysis is the only therapy proven to be effective for ischemic stroke.Telemedicine may help to extend its use. However, concerns remain whether management and safety of tissue plasminogen activator (tPA) administration after telemedical consultation are equivalent in less experienced hospitals compared with tPA administration in academic stroke centers. Methods-During the second year of the ongoing Telemedical Pilot Project for Integrative Stroke Care, all systemic thrombolyses in stroke patients of the 12 regional clinics and the 2 stroke centers were recorded prospectively. Patients' demographics, stroke severity (National Institutes of Health Stroke Scale), frequency of administration, time management, protocol violations, and safety were included in the analysis. Results-In 2004, 115 of 4727 stroke or transient ischemic attack patients (2.4%) in the community hospitals and 110 of 1889 patients in the stroke centers (5.8%) received systemic thrombolysis. Prehospital latencies were shorter in the regional hospitals despite longer distances. Door to needle times were shorter in the stroke centers. Although blood pressure was controlled more strictly in community hospitals, symptomatic intracerebral hemorrhage rate (7.8%) was higher (Pϭ0.14) than in stroke centers (2.7%) but still within the range of the National Institute of Neurological Disorders and Stroke trial. In-hospital mortality rate was low in community hospitals (3.5%) and in stroke centers (4.5%). Conclusions-Although with a lower rate of systemic thrombolysis, there was no evidence of lower treatment quality in the remote hospitals. With increasing numbers of tPA administration and growing training effects, the telestroke concept promises better coverage of systemic thrombolysis in nonurban areas.

on behalf of the TEMPiS GroupBackground and Purpose-Systemic thrombolysis represents the only proven therapy for acute ischemic stroke, but safe treatment is reported only in established stroke units. One major goal of the ongoing Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria is to extend the use of tissue plasminogen activator (tPA) treatment in nonurban areas through telemedic support. Methods-The stroke centers in Munich-Harlaching and in Regensburg established a telestroke network to provide consultations for 12 local hospitals in eastern Bavaria. The telemedic system consists of a digital network that includes a 2-way video conference system and CT/MRI image transfer with a high-speed data transmission up to 2 Mb/s. Each network hospital established specialized stroke wards in which qualified teams treat acute stroke patients. Physicians in these hospitals are able to contact the stroke centers 24 hours per day. Results-A total of 106 systemic thrombolyses were indicated via teleconsultations between February 1, 2003, and April 7, 2004. During the first 12 months, the rate of thrombolyses was 2.1% of all stroke patients. Mean age was 68 years, and median National Institutes of Health Stroke Scale score was 13. Mean delay between onset and hospital admission was 65 minutes, and door-to-needle time was on average 76 minutes, which included 15 minutes for the teleconsultation. Symptomatic hemorrhage occurred in 8.5% of patients, and in-hospital mortality was 10.4%. Conclusions-The present data suggest that systemic thrombolysis indicated via stroke experts in the setting of teleconsultation exhibits similar complication rates to those reported in the National Institute of Neurological Disorders and Stroke trial. Therefore, tPA treatment is also safe in this context and can be extended to nonurban areas. (Stroke. 2005;36:287-291.)

Background and Purpose-Basilar artery occlusion (BAO) is a stroke subtype with poor prognosis, but recanalizing therapies have been reported to be effective. We investigated whether initial admission to telemedically linked general hospitals with subsequent stroke-center transfer is related to poorer outcome than direct admission to stroke centers. Methods-All BAO cases of 3 stroke centers in Munich and 1 center in Regensburg between March 1, 2003 and December 31, 2004 were included, either if patients were directly admitted to stroke centers (nϭ23) or had initial admission to general hospitals of the telemedical network for integrative stroke care (TEMPiS) and secondary transfer to stroke centers (nϭ16). BAO was defined as angiographically (CTA, MRI or conventional angiography) confirmed occlusion of the basilar artery. Baseline parameters and therapeutic procedures were recorded. One-year follow-up was conducted prospectively. Results-Differences in baseline parameters were not statistically significant. Time from onset to first angiography was significantly longer in patients with secondary transfer (mean: 355Ϯ93 minutes versus 222Ϯ198 minutes; PϽ0.01), mainly attributable to transfer duration (mean:156Ϯ73 minutes). In-hospital mortality (22% versus 75%; PϽ0.01) and 1-year-mortality (30% versus 81%; PϽ0.01) were lower for patients with direct admission to stroke centers. Fifty-two percent of directly admitted patients versus 13% of patients with secondary transfer (Pϭ0.02) were living at home after 1 year. Conclusions-BAO patients who were admitted primarily to community hospitals had a worse prognosis. Patients with typical symptoms should have direct access to stroke centers, or may need bridging therapies.

Background and Purpose-Whether the time of hospital admission is relevant for short-term outcome after stroke is under debate and may depend on care facilities. Methods-We retrospectively analyzed medical records from patients who received thrombolytic therapy within 4.5 hours of stroke onset in a stroke unit of the Charité-University Hospital Berlin (Charité; nϭ291) or within the stroke telemedicine (TEMPiS) network, comprising 12 community hospitals with telestroke units in Bavaria (nϭ616). Results-Thrombolytic therapy was administered during nonworking hours in 59.5% (Charité) and 55.0% (TEMPiS) of patients. A trend toward a lower rate of symptomatic intracranial hemorrhage (3.4% versus 9.2%; Pϭ0.053), clinical worsening (11.9% versus 19.7%; Pϭ0.079), and 7-day mortality (3.4% versus 8.7%; Pϭ0.073) after admission during working hours was seen at Charité. However, multivariable analysis did not show a significant impact of the time of admission on clinical worsening, symptomatic intracranial hemorrhage, or 7-day mortality in both cohorts. Thrombolysis based on brain computed tomography instead of magnetic resonance imaging (odds ratioϭ4.98, 95% CI, 1.09 to 22.7) and more severe National Institutes of Health Stroke Scale score on admission (odds ratioϭ1.15 per point; 95% CI, 1.07 to 1.24) were associated with 7-day mortality at Charité. National Institutes of Health Stroke Scale score on admission (odds ratioϭ1.13 per point; 95% CI, 1.06 to 1.19) and older age (odds ratioϭ1.05 per year; 95% CI, 1.004 to 1.09) were correlated with 7-day mortality in TEMPiS. National Institutes of Health Stroke Scale on admission was the only independent predictor of symptomatic intracranial hemorrhage or clinical worsening in both cohorts. Conclusions-The majority of stroke patients received thrombolysis during nonworking hours. The time of hospital admission did not significantly influence the short-term outcome after thrombolysis. (Stroke. 2011;42:2521-2525.)

Stroke care, including t-PA thrombolysis in non-urban areas, is feasible using a modern stroke unit concept within a telestroke network. With the expertise of specialized stroke centers accessed via telemedicine and the design of a stroke-code-box for t-PA thrombolysis, nearly one-third of patients presented with a possible indication for systemic thrombolysis can be treated with t-PA, thereby increasing the options for a successful stroke treatment.

Intravenous thrombolysis leads to a reduction of post-stroke disability. No data exist about whether depression and poor quality of life (QoL) remain relevant problems in patients with good functional outcome. We assessed mood and QoL at 3 and 6 months after stroke in consecutive patients who received intravenous thrombolysis in stroke centers and telemedicine hospitals within the TEMPiS network. The Beck Depression Inventory (BDI) was used with BDI ≥18 indicating clinically relevant depressive symptoms. Stroke specific quality of life (SSQOL) was used for QoL assessment with the definition of SSQOL total score <60% for poor QoL. Associations of BDI and SSQOL with baseline parameters and modified Rankin scale (mRS) in follow-up were analyzed. In patients with known mRS 0-4 at 3 months (N = 213), BDI was available in 74% and SSQOL in 77%. At 3 and 6 months, 23 and 18% of patients had clinically relevant depressive symptoms; 25 and 24% reported a poor QoL. The mRS at 3 months correlated with BDI (r = 0.43, p < 0.01) and SSQOL (r = -0.75, p < 0.01). BDI ≥18 was observed in 11% of patients with mRS 0-1 and 16% in mRS 0-2. Severe stroke (NIHSS ≥12) at admission (OR 1.23, 0.57-2.66; p = 0.57) was not predictive for depressive symptoms but for poor QoL (OR 2.77, 95%CI 1.34-5.74). Depressive symptoms and impaired QoL are observed in a substantial proportion of stroke patients at 3 months after intravenous thrombolysis. Health professionals should be aware that thrombolysed patients may have relevant mood disorders despite good functional outcome.

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