Implementation of multimodal computed tomography in a telestroke network: Five‐year experience

Abstract

Aims Penumbral selection is best‐evidence practice for thrombectomy in the 6‐24 hour window. Moreover, it helps to identify the best responders to thrombolysis. Multimodal computed tomography (mCT) at the primary centre—including noncontrast CT, CT perfusion, and CT angiography—may enhance reperfusion therapy decision‐making. We developed a network with five spoke primary stroke sites and assessed safety, feasibility, and influence of mCT in rural hospitals on decision‐making for thrombolysis. Methods Consecutive patients assessed via telemedicine from April 2013 to June 2018. Clinical outcomes were measured, and decision‐making compared using theoretical models for reperfusion therapy applied without mCT guidance. Symptomatic intracranial hemorrhage (sICH) was assessed according to Safe Implementation of Treatments in Stroke Thrombolysis Registry criteria. Results A total of 334 patients were assessed, 240 received mCT, 58 were thrombolysed (24.2%). The mean age of thrombolysed patients was 70 years, median baseline National Institutes of Health Stroke Scale was 10 (IQR 7‐18) and 23 (39.7%) had a large vessel occlusion. 1.7% had sICH and 3.5% parenchymal hematoma. Three months poststroke, 55% were independent, compared with 70% in the non‐thrombolysed group. Conclusion Implementation of CTP in rural centers was feasible and led to high thrombolysis rates with low rates of sICH.

The global impact of COVID‐19 on acute stroke care

“…Our data indicate that while there was a drop in the number of thrombolysis and thrombectomy treatments, the thrombolysis and thrombectomy rates did not decrease, indicating that stroke patients will be well‐taken care of if they are sent to capable stroke centers during the COVID‐19 crisis 2 . Implementation of multimodal computed tomography in a telestroke network has shown to be able to increase thrombolysis rate 7 . This approach could potentially be useful during COVID‐19, in combination with chest computed tomography at the same time 5 …”

No Evidence of the “Weekend Effect” in the Northern New South Wales Telestroke Network

“…The use of perfusion imaging (either CTP or MR-Perfusion) is important for the selection of patients for MT in the extended time-window of 6-to 24-h after symptom onset, into which a significant proportion of our patients fall once the lengthy transfer times between spokes and hub are accounted for. Our group has recently published a comprehensive analysis of the effects of mCT on clinical decision-making and outcomes in this telestroke network (12). Amongst 80 patients who met standard NCCT and clinical criteria for thrombolysis, 36 (45%) were not thrombolysed based on mCT criteria, 6 because mCT demonstrated a large established core (>70 mL) that was not visible on NCCT, while the remainder had very small or no lesions and 12 of these patients were subsequently diagnosed as stroke mimics.…”

“…In cases where the patient received both thrombolysis and MT, thrombolysis would be initiated at the spoke site prior to transfer. For more details about our telestroke workflow, we direct the reader to our previous results (1,12).…”

Air vs. Road Decision for Endovascular Clot Retrieval in a Rural Telestroke Network

“…When it was deemed necessary to give thrombolysis with ECR, thrombolysis was always initiated at the spoke hospital prior to transfer for ECR. Repeat imaging was not routinely performed at the hub because of the commitment to transfer patients across very large distances after the decision for transfer was made and the good baseline selection of patients using advanced imaging (22). Road transfers occurred by road ambulance directly from the spoke hospital to JHH.…”

“…All connecting transfers to the rural airports from the respective spoke hospitals in order to facilitate air retrievals occurred by road ambulance. For more details of the telestroke setup, we direct the reader to our published experience (22,23).…”