Unassisted Assessment of Stroke Severity Using Telemedicine

Abstract

This prospective monocentric study was approved by the Medical Ethics Committee of the Universitair Ziekenhuis Brussel. Patients were recruited over an 8-week period at the Stroke Unit and at the Emergency Department of the Universitair Ziekenhuis Brussel. Patients with unstable vital functions and those for whom telestroke examination would delay any diagnostic or therapeutic intervention were excluded. All patients or their proxy gave written informed consent before the evaluation. Patient characteristics of the study corpus of 45 subjects with suspicion of acute stroke are described in the online-only Data Supplement (Table I).Background and Purpose-Quantification of stroke severity through telemedicine consultation is challenging and relies on professional support at the patient's bedside. We aimed to develop a novel scale for assessing stroke severity through telemedicine without assistance from a third party (Unassisted TeleStroke Scale [UTSS]). Methods-Stroke severity was assessed in 45 patients with suspicion of acute stroke by bedside examination using the National Institutes of Health Stroke Scale (NIHSS) and by teleconsultation using the UTSS. Scale reliability was evaluated by intrarater and interrater variability, internal consistency, and rater agreement. Concurrent and predictive validity were tested by relating the UTSS with the NIHSS and long-term outcome (modified Rankin Scale and mortality at 6 months). Clinimetric analysis of the UTSS was obtained via the Rasch model. Results-The mean examination time for the UTSS was 3.1 minutes (SD, 1.1) versus 8.5 minutes for the NIHSS (SD, 2.6; P<0.001). Both UTSS and NIHSS showed excellent intrarater variability (r=0.97 and 0.98; P<0.001) and interrater variability (r=0.96 and 0.98; P<0.001), as well as excellent internal consistency and rater agreement. The UTSS correlated strongly with the NIHSS and was identified as an independent predictor of stroke outcome in logistic regression analysis. Rasch analysis indicated that the UTSS represents a unidimensional scale of stroke severity. Conclusions-The UTSS is a rapid, reliable, and valid tool for unassisted assessment of stroke severity through telemedicine. (Stroke. 2013;44:1249-1255.)

Clinical Scales Do Not Reliably Identify Acute Ischemic Stroke Patients With Large-Artery Occlusion

“…FNR represents the proportion of patients who would not have been sent to a CSC despite LAO, hence delaying optimal treatment, and FPR represents the proportion of patients who would have been sent to a CSC despite lack of LAO (futile transfers). The highest accuracy (79%; 95% confidence interval, 77-82) was observed for NIHSS score ≥11 (FNR, 27% [22][23][24][25][26][27][28][29][30][31][32]; FPR, 17% [14][15][16][17][18][19][20]), NIHSS score ≥14 (FNR, 39% [34][35][36][37][38][39][40][41][42][43][44]; FPR, 12% [9][10][11][12][13][14]), and RACE score ≥5 (FNR, 33% [28][29][30][31][32][33][34][35][36][37][38]; FPR, 15% [12][13][14]…”

“…We could not assess the predictive ability of 3 other interesting scores that include several parts of the neurological examination not collected in our database. 24,34,35 Two additional scales designed to identify stroke in the prehospital settings, namely Los Angeles Pre-Hospital Stroke Screen and Melbourne Ambulance Stroke Screen, could not be assessed in the present study because grip strength is not collected in our database. 36 Although these scales seem to have good sensitivity and specificity for identifying patients with stroke, 36 a major limitation of both scales is that patients aged >45 years are automatically excluded, which raises concerns as stroke incidence is increasing in young patients.…”

Telemedicine Quality and Outcomes in Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

“…31 The new 4G technology with higher bandwidth and optional prioritization in public mobile networks appears to be more appropriate for the use of ambulance-based telestroke applications. 13,32 A streamlined unassisted telestroke scale 33 was evaluated with healthy volunteers mimicking stroke syndromes during ambulance transportation 34 and demonstrated sufficient stability in a moving ambulance using 4G connectivity. Further testing in actual acute stroke transport situations is needed to assess this promising approach.…”

Prehospital Unassisted Assessment of Stroke Severity Using Telemedicine

“…5 Application of a multilingual software tool allowed standardized telestroke assessments, which were randomized to be performed in Dutch (n=12), French (n=15), or English (n=14). To mimic real-life transportations, we tested the potential impeding effects of activating the ambulance sirens and the application of an oxygen mask to the actor's face, each in 5 scenarios.…”

“…[2][3][4] We recently developed a scale for assessing stroke severity through telemedicine without assistance from a third party (Unassisted TeleStroke Scale [UTSS]). 5 This study aims to evaluate the feasibility and the reliability of remote stroke severity quantification in the prehospital setting using the UTSS via a telestroke ambulance system and a fourth-generation mobile network.…”