High-quality videoconferencing can increase patient access to stroke specialists, especially in rural or other underserved areas; and a transient ischemic attack (TIA), once known as a “mini” or “warning” stroke, should be treated with the same urgency as a full-blown stroke, according to two separate scientific statements and a policy statement published today in Stroke: Journal of the American Heart Association.
Telemedicine Statement Highlights:
A stroke exam via videoconferencing — known as telemedicine or telestroke — is as effective as a bedside exam. The statement recommends establishing systems to support the widespread use of telestroke, including having Medicare cover this service. Telemedicine for stroke A new scientific statement says a remote exam using high-quality videoconferencing equipment is as effective as a bedside stroke evaluation.
Physicians must quickly evaluate stroke patients to determine if they’re eligible for time-sensitive treatment such as tissue plasminogen activator (tPA) that can save brain function and reduce disability. Stroke and brain imaging specialists are often required to perform the evaluation. However, the United States has only an average of four neurologists per 100,000 people, and not all of them specialize in stroke, according to the statement.
Telemedicine, or telestroke, uses interactive videoconferencing via webcams connected to a TV or computer screen, which allows the patient, family and the bedside and distant healthcare providers to see and hear each other in full color and in real time.
Telestroke is coupled with teleradiology, which allows remote review of brain images. This technology can broaden the reach of neurologists in a cost-effective and time-efficient manner.
“Telemedicine is an effective avenue to eliminate disparities in access to acute stroke care, erasing the inequities introduced by geography, income or social circumstance,” said Lee Schwamm, M.D., lead author of a scientific statement and policy statement on telemedicine, and associate professor of neurology at Harvard Medical School and Vice Chairman of Neurology at Massachusetts General Hospital.
To be effective, however, there needs to be changes in how telemedicine activities are reimbursed, he said. For that, policy recommendations were released along with the scientific statement. The policy statement recommends:
Deploying telestroke systems to supplement resources where around-the-clock local, on-site acute stroke expertise is insufficient. Increasing Medicare reimbursement for telestroke assessment, diagnosis and approval to use tPA to reflect the increased upfront costs of implementation. Developing a mechanism for uniform, streamlined credentialing for telestroke providers and uniform national telemedicine licensure by state medical boards. Increasing funding sources for stroke telemedicine programs which could include designating support from the federal American Recovery and Reinvestment Act of 2009.
TIA Statement Highlights:
Imaging data, rather than how long temporary symptoms last, should be used to define a transient ischemic attack (TIA) — once known as a “mini” stroke or “warning” stroke. Patients with suspected TIA should be evaluated as soon as possible — preferably with a specialized MRI. Re-defining transient ischemic attack (TIA)
Another statement addressed TIAs. The authors said the risk of stroke after a TIA is higher than previously thought. Therefore, they re-defined the condition to urge immediate action and thorough testing — much like the exam after a full-blown stroke.
“We think a TIA should be treated as an emergency, just like a major stroke,” said J. Donald Easton, M.D., writing chair of the statement and professor and chair of the Department of Clinical Neurosciences at Alpert Medical School of Brown University and the Rhode Island Hospital in Providence, R.I. “Because we know the high risk of a future stroke, this is a golden opportunity to prevent a catastrophic event.” [Dr. Easton talks about TIA vs. stroke, and the need for urgent care].
The traditional, clinical definition of TIA, which dates to the mid-1960s, is “a sudden, focal neurological deficit of presumed vascular origin lasting less than 24 hours,” the authors wrote.
In the new statement, the American Heart Association/American Stroke Association changes the definition to “a transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia, without acute infarction.” Infarction is tissue death, the main distinction between TIA and stroke. Infarction can be determined by magnetic resonance imaging (MRI).
“Research around the globe has shown that the arbitrary threshold based on duration of symptoms was too broad, because up to half of TIAs defined this way actually caused sustained brain injury according to an MRI,” Easton said. Medical advances have made it easier to tell whether a patient has had a TIA or stroke, so an MRI is key to diagnosing a TIA, according to the paper.
According to the paper, 10 percent to 15 percent of TIA patients experience a stroke within three months of a TIA, with half of those strokes occurring in the first 48 hours after TIA.