Perspectives in Medicine (2012) 1, 7779

Bartels E, Bartels S, Poppert H (Editors):

New Trends in Neurosonology and Cerebral Hemodynamics an Update.
Perspectives in Medicine (2012) 1, 7779

journal homepage: www.elsevier.com/locate/permed

Telestroke How does that work?

Sandra Boy

Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Universittsstrasse 84, 93053 Regensburg,
Germany

KEYWORDS Summary The signicance of cerebrovascular disorders is steadily increasing due to the demo-
graphic changes in western industrial societies. Therefore the implementation of telemedical
Stroke;
networks seems tempting to improve deliverance of specialised stroke care in non-urban areas.
Telemedicine;
Networks like TEMPiS, located in the rural area of south-eastern Bavaria, have shown to deliver
TEMPiS network
high experienced stroke therapy to underserved areas.
Mandatory for a high quality of supply is the appropriate technical equipment. Moreover,
beside the teleconsultations, a continuous training should be performed. Mobile solutions allow
more exibility for the teleconsultants.
2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

Introduction neurologists with access to Digital Imaging and Communi-

Cerebrovascular disorders, specically ischemic stroke,
remain the third most common cause of death and leading
cause of disability [1]. Its signicance is steadily increas-
ing due to the demographic changes in western industrial
societies. The introduction of IV thrombolysis with recombi-
nant tissue plasminogen activator (rtPA) more than a decade
ago was a milestone in stroke therapy; however, still only a
minority of patients all over Europe and the world bene-
t from this treatment, especially due to the narrow time
window [25]. Moreover, thrombolysis as well as stroke-unit
treatment, which also has been proven to be benecial in
stroke treatment [6], needs expertise and experience. Espe-
cially rural areas are lacking of this expertise. Therefore the
implementation of telemedical networks seems tempting to
improve deliverance of specialised stroke care in non-urban
areas. Several studies have shown, that remote neurological
examination via videoconferencing is reliable and feasible
[711]. Also the accuracy of teleradiologic assessment of
computerized tomography (CT) scans in acute stroke by
E-mail address: sandra.boy@medbo.de
cations in Medicine (DICOM) format data has been shown
[12].
In essence, the implementation of telemedical networks
more patients should be able to reach a hospital provid-
ing specialised stroke care more quickly and the quality of
stroke care in these hospitals should be improved due to
the close cooperation between stroke centres and network
hospitals.
The TEMPiS-Network
In Germany, Bavaria is a typical example for a rural area with
only a few specialised stroke units. However, in congested
urban areas the density of stroke units appears adequate,
the south-eastern part of Bavaria, a very non-urban area,
lacks adequate stroke unit care.
Therefore the Telemedic Pilot Project for Integrative
Stroke Care (TEMPiS) Network was founded with the aim
to provide modern stroke management and advanced stroke
expertise in these rural areas. It was supported by the Bavar-
ian health insurance companies, the Bavarian State Ministry
for Employment and Social Order, Family and Women, and
the German Stroke Foundation.

2211-968X 2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

doi:10.1016/j.permed.2012.02.002
78
It consists of a cooperation of two academic hospitals
(Department of Neurology, University of Regensburg, Bezirk-
sklinikum Regensburg and Klinikum Harlaching, Stdtisches
Klinikum Mnchen GmbH) specialised in acute stroke care
with 12 (meanwhile 15) community hospitals serving for
acute stroke care in the local population.
Before implementation of the network in 2003, none of
these community hospitals provided specialised stroke care.
Each community hospital implemented a stroke ward, con-
sisting of up to eight beds, about half of them equipped
with monitors. Community hospitals in the network formed
stroke teams consisting of doctors, nurses, physiotherapists,
occupational therapists, and speech therapists. All members
of the stroke team underwent continuous medical training
beginning with a 4-day course based on international stroke
treatment guidelines. This was followed by onsite visits of
specialised stroke nurses and stroke neurologists for indi-
vidual training. Additionally, the stroke teams had centrally
conducted courses in transcranial Doppler sonography, swal-
lowing disorders and dysphagia treatment.
A 24 h teleconsultation service is currently provided by
the two stroke centres. The telemedical system consists of
a digital network including a 2-way video conference and
CT/MRI-image transfer using a high-speed-data transmission
(transferring the pictures of the CT-scan within seconds).
Stroke experts are contacted while the patient is still in the
emergency department. The expert, using the 2-way video
conference, can talk to the patient directly and examine the
patient with the help of the local physician. Within minutes
the expert can now decide whether or not a thromboly-
sis therapy is indicated. This service has a job chart with
colleagues who are in the process of advanced specialist
training in neurology and have got at least 1 year of expe-
rience in acute stroke unit management. They work in 24 h
shifts located in the stroke centres [1315].
Effectiveness of TEMPiS
To investigate the effectiveness of telemedical stroke net-
working, ve community hospitals without pre-existing
specialised stroke care were compared to network hospitals
in a non-randomised, open intervention study. The ve com-
munity hospitals were matched individually to the network
hospitals. Between 2003 and 2005 stroke patients who were
admitted consecutively to one of the participating hospitals,
were included in the study. Patients in network and control
hospitals were assessed in the same manner and were fol-
lowed up for vital status, living situation, and disability at 3
months. Poor outcome was dened by death, institutional
care, or disability (Barthel index <60 or modied Rankin
scale >3).
After 3 months there was a substantial difference of
about 10% on patients risk of death, institutionalisation,
or severe disability between those treated in the network
hospitals compared with those receiving usual care. Throm-
bolytic therapy was provided in about 5% of patients of
the network compared with 0.4% of those in control hos-
pitals. This means that use of rtPA in network hospitals
was increased 10-fold. Safety data showed that administra-
tion of rtPA within the TEMPiS network is safe. The rate of
symptomatic haemorrhage of 9% and in-hospital mortality
S. Boy
of 10% is in line with other safety data outside clinical trials
[1416].
But effectiveness was not only shown in comparison
with community hospitals but as well with stroke centres.
Between 2003 and 2004, 170 patients received rtPA in the
network hospitals and 132 patients in the two stroke centres.
Baseline data of these patients were comparable. Mortality
rates as well as good functional outcome after 6 months did
not differ in patients treated in network community hospi-
tals or in stroke centres [17].
Mobile solutions
Teleconsultation may not be limited to workstations in the
hospital requiring the continuous presence of a stroke neu-
rologist in the hospital since TEMPiS provides an immediate
answer to stroke calls made from network hospitals and start
of the video conference within 3 min. Since mobile network
computers are increasingly available, we investigated the
quality of mobile versus stationary telemedical stroke con-
sultation.
Between June and August 2007 a total of 223 teleconsul-
tations with video-examination were conducted. Signicant
differences were assessed for teleconsultants ratings of
video and audio quality with better results for the hospital-
based system and worse audio quality for the ratings from
doctors in the local hospitals for the mobile teleconsulta-
tions. However, the overall quality of the teleconsultations
taking the patient perspective was not different and the
clinical relevance of teleconsultations was rated high for
both forms of teleconsultations.
Therefore mobile teleconsultation using the available
European mobile network technology provides good feasi-
bility and stability.
Whether a mobile or a hospital based solution is preferred
may also depend on individual structures of networks and
the frequency of teleconsultations. As during nighttimes the
number of teleconsultations is lower [18], here the mobile
solution may be favoured in order to reduce hospital nights
of teleconsultants and costs of stafng [19].
Technical requirements
Telemedic stroke care should provide more than just expert
phone care or teleradiology but combine real-time video
conference and electronic transmission of cerebral imaging
data.
Phone based stroke and rtPA care only have been shown
to lead to a poorer outcome and higher mortality compared
to patients treated in specialised stroke wards [20].
For high quality and stable videoconferences connections
with a stable bandwidth of at least 300 kb/s and cameras
with remote control, rotation and zoom functions should be
used. For adequate assessment of CT or MRI scans digital
data (DICOM), which provide better quality and allows post
processing of the images, should be obtained. In community
hospitals and even more important in stroke centres large
monitors with a high resolution are needed [21]. After every
single teleconsultation a written report should be sent to the
remote hospital and be preserved just like the standards for
in-patient documents.
Telestroke work
TEMPiS today
To date more than 6000 patients suffering from stroke have
been treated in the 15 hospitals of the TEMPiS-network every
year. Meanwhile the TEMPiS has emerged from a scientic
stroke research project to regular patient care, and the
health insurances cover the costs by reimbursing the remote
hospitals, which in turn nance the costs of the consulting
stroke centres. Since 2003, more than 25,000 teleconsul-
tations have been performed and more than 2200 patients
received thrombolysis. In Germany today the percentage
of acute stroke patients receiving rtPA is about 10 per-
cent (www.dsg-info.de), whereas in the TEMPiS network it
is 13.8%.
In addition, the TEMPiS-network not only provides
telemedical advice. The ongoing stroke education, provided
to the network hospitals due to on-site visits with ward
rounds, standardised clinical procedures, actualised every
year and updates, performed twice a year in order to update
knowledge concerning new therapeutic options.
The network also provides training courses for young clin-
icians in network hospitals regarding acute stroke therapy.
Hereby face-to-face contact is facilitated, which lowers the
barriers to requests for a teleconsultation and transports
stroke knowledge in both directions. Quality assurance is
given by follow-up presentations in critical patients.
But not only rtPA treatment in acute stroke is improved
in rural areas. As there are new options in acute stroke
therapy like neuroradiological interventions as thrombec-
tomy and treatment of complications like hemicraniectomy
in malignant infarctions, therapies just available in spe-
cialised stroke centres, patients in rural areas can prot
from telemedic networks as well. Due to the videoconfer-
ence and assessment of CT and MRI images patients requiring
more than standard stroke care can be identied and trans-
ferred to stroke centres with the opportunity to provide
these therapeutic options.
Summary
In summary, only a minority of stroke patients all over
Europe receive thrombolytic and specialised stroke unit
therapy. Due to telemedic approaches like the TEMPiS-
network, patients, especially in rural areas can now receive
highly specialized stroke treatment. Therefore a high quality
of the technical equipment is needed and beside the tele-
consultations a continuous training should be performed to
achieve high quality.
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