Telemedicine in Stroke Systems of Care

Acute ischemic stroke is a public health crisis in the United States and around the world. A concerted effort has been made to apply best practices to ischemic stroke care with the goal of improving post-stroke outcomes. However, geography, distance, time, and stroke expert personnel shortages contribute to disparities in access to stroke care, especially among a significant proportion of the population that lives beyond the immediate catchment of an acute stroke-ready hospital, primary stroke center, or comprehensive stroke center. In an attempt to address this rural-to-metropolitan disparity and expand the availability of best stroke practices, Levine and Gorman proposed the development of telemedical outreach for acute stroke evaluation and management, which they called “telestroke.” Since that time, evidence supporting telestroke has been published, which demonstrated excellent inter- and intra-rater agreement of the National Institutes of Health Stroke Scale (NIHSS) score between telemedicine-enabled versus bedside assessment, increased correct thrombolysis decision-making by telestroke as compared to telephone-only consultation, telestroke acute treatment decisions and treatment rates that are comparable with patients treated in-person at a stroke center, and cost-effectiveness of the telestroke model from a hospital as well as from a societal perspective. As a consequence of these healthcare delivery research discoveries and the recognition of clinical benefits by stroke providers, patients, and family, telestroke networks have expanded rapidly in the United States and beyond. Additional research is necessary to more clearly understand the potential benefits of the telestroke infrastructure for other phases of stroke care including pre-hospital emergency medical systems, post-stroke hospitalization, rehabilitation, repatriation, reintegration into the community, avoidance of re-admission to hospital, reduction of complications, prevention of recurrent stroke, and education of patients, family, and health providers.