Page 28 - Delaware Medical Journal - July 2017
P. 28
Telemedicine and the Treatment of Acute Stroke
Robert J. Varipapa, MD
Revolutionary advances in the the introduction of tissue
plasminogen activator (tPA) in 1996, and the recent development of endovascular “catheter-based” treatments have remarkably improved patient outcomes and reduced long-term disability.
ACUTE STROKE THERAPY
tPA is indicated for the acute treatment
of patients with stroke who arrive in the emergency room within three to four and one-half hours from onset of symptoms (See Table 1). Stroke mimics should
be considered, especially for patients
with unclear presentation (See Table
2). Neurologists working within the hospital setting have developed formalized protocols, fostered by the establishment
of primary and comprehensive stroke centers by the American Heart Association and the American Stroke Association. Primary stroke centers are required
to provide rapid evaluation of stroke patients and appropriate administration
of tPA within established guidelines. Currently, Saint Francis, Kent General, Beebe, and Nanticoke hospitals are listed under this category. Christiana Hospital
is a comprehensive stroke center with
the additional capability to provide endovascular treatment.
THE GOLDEN HOUR
by R. Adams Cowley, MD, at the
University of Maryland Medical Center in Baltimore in the treatment of trauma patients. Improved survival was shown
to be possible with more rapid access to the same concept to the brain and coined the term “Time is Brain” to signify the importance of speed in the evaluation and treatment of stroke patients.
The goal for tPA currently is to initiate infusion within 60 minutes of the
patient’s arrival to the Emergency Room. Endovascular treatment should be instituted within six hours, although recent literature suggests longer time periods may
ACCESS TO STROKE CARE
To improve access in the care of stroke patients, Tele-stroke Centers have been created throughout the United States, especially in more rural areas where there
is limited neurology coverage, especially after hours. Typically a ‘Spoke and Hub’ concept is utilized, with primary stroke centers as the spokes and a comprehensive stroke center as the hub. In the past, Bayhealth utilized the University of Pennsylvania as a referral source and
for back-up telemedicine services, with the idea that they would be available for endovascular intervention, which was not yet available within Delaware.
ENDOVASCULAR TREATMENT
Initial studies of endovascular treatment
operator technique and experience along with more limited selection of catheters. Subsequent improvements both in technical skills of interventional physicians and development of more sophisticated catheters led to studies which showed vessel thrombosis.
TABLE 1: Common Stroke Presentation
Asymmetric facial weakness
Asymmetric arm weakness
Asymmetric leg weakness
Speech disturbance
Visual field deficit
TABLE 2: Stroke Mimics
Migraine or severe headache (consider subarachnoid hemorrhage)
Bell’s Palsy (idiopathic facial nerve palsy)
Seizures or Syncope (consider post ictal state, Todd’s paralysis)
Vertigo or dizziness (vestibular disease)
Multiple Sclerosis or other demyelinating disease
Other Intracranial Process (prior stroke, tumor, bleed, infection)
Psychiatric, conversion disorder
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Del Med J | July 2017 | Vol. 89 | No. 7
