Video consultation improves accuracy of stroke treatment decisions in remote locations

August 02, 2008

Use of stroke telemedicine consultations result in more accurate decision making compared with telephone consultations in remote locations. Telemedicine could help deliver vitally needed treatment to people who live outside large cities, in the vital three-hour treatment window that follows a stroke. These are the conclusions of authors of an Article published early Online and in the September issue of Lancet Neurology.

To increase the effective use of thrombolytic drugs for stroke, the expertise of vascular neurologists must be disseminated more broadly, and used more frequently and more effectively. Dr Brett C. Meyer, University of California San Diego School of Medicine Stroke Center, USA, and colleagues prospectively assessed whether telemedicine (real-time, two-way audio and video and digital imaging and communications) or telephone was superior for decision-making in acute telemedicine consultations. From January 2004 to January 2007, 222 patients older than 18 years who presented at one of four remote sites in California were randomly assigned to telemedicine (111 patients) or telephone consultation (111) to assess their suitability for treatment with thrombolytic drugs. Whether the decision to give or not give these drugs was correct was then decided through a stringent, multi-level central adjudication.

The researchers found that correct treatment decisions were made in 98% of telemedicine consultations versus 82% of telephone consultations. More patients in the telemedicine group (31%) were given thrombolytics than in the telephone group (25%), though this was not statistically significantly different. After three months there was no difference in rates of stroke recurrence or mortality, but the authors suggest this could be because the trial did not study enough patients to determine such a difference, as it was halted early because of clear benefit of telemedicine regarding treatment decisions.

The authors conclude: "The results of this trial show that telemedicine is efficacious for making acute medical decisions. Stroke telemedicine is widely implemented and discussed, but despite its dissemination, its efficacy has not previously been shown. Our results support the use of telemedicine to make urgent treatment decisions, such as whether to use thrombolytic therapy for acute stroke."

In an accompanying Reflection and Reaction comment, Dr Pierre Amarenco, Clinical Research in Atherothrombosis and Denis Diderot University, Bichat Stroke Centre, Paris, France, discusses the gulf in treatment experienced by patients who live in big cities and those who live rurally in high-income countries. He concludes: "The next step is to show that telethrombolysis is equivalent to or better than the gold standard* treatment to improve the percentage of patients with no handicap at three months. This would represent top level evidence for using and developing telemedicine for equal and improved access to alteplase in all patients with stroke. Such a study is currently recruiting patients in France...In the meantime, the study by Meyer and colleagues reinforces that telethrombolysis should be strongly preferred to telephone consultation."
Dr Brett C. Meyer, University of California San Diego School of Medicine Stroke Center, USA T) +1 619-543-7760

Dr Pierre Amarenco, Clinical Research in Atherothrombosis and Denis Diderot University, Bichat Stroke Centre, Paris, France T) +331-4025-8726 E)

Notes to editors: *comment author's definition of gold standard treatment= immediate transfer of eligible patients to a stroke unit for alteplase therapy given by a trained stroke physician

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