Abstract
AimsPenumbral selection is best‐evidence practice for thrombectomy in the 6‐24 hour window. Moreover, it helps to identify the best responders to thrombolysis. Multimodal computed tomography (mCT) at the primary centre—including noncontrast CT, CT perfusion, and CT angiography—may enhance reperfusion therapy decision‐making. We developed a network with five spoke primary stroke sites and assessed safety, feasibility, and influence of mCT in rural hospitals on decision‐making for thrombolysis.MethodsConsecutive patients assessed via telemedicine from April 2013 to June 2018. Clinical outcomes were measured, and decision‐making compared using theoretical models for reperfusion therapy applied without mCT guidance. Symptomatic intracranial hemorrhage (sICH) was assessed according to Safe Implementation of Treatments in Stroke Thrombolysis Registry criteria.ResultsA total of 334 patients were assessed, 240 received mCT, 58 were thrombolysed (24.2%). The mean age of thrombolysed patients was 70 years, median baseline National Institutes of Health Stroke Scale was 10 (IQR 7‐18) and 23 (39.7%) had a large vessel occlusion. 1.7% had sICH and 3.5% parenchymal hematoma. Three months poststroke, 55% were independent, compared with 70% in the non‐thrombolysed group.ConclusionImplementation of CTP in rural centers was feasible and led to high thrombolysis rates with low rates of sICH.
Highlights
As part of the network, the local hospitals were equipped with cameras and the physicians were trained in the face arm speech time (FAST) scale. Multimodal computed tomography (mCT) was introduced and performed routinely by trained radiology technicians
Our local protocol was that a thrombolysis decision was based on both standard guideline‐based clinical criteria[14] plus mCT imaging decision assistance using the presence or absence of “salvageable tissue”, defined as at least 15 mL of penumbra assessed by automated perfusion software
We describe our first five‐year experience of a telestroke network with routine use of multimodal computed tomography (CT)
Summary
Almost 20 years ago, the term telestroke was coined to define the emergent use of telemedicine in acute stroke.[1] Using a camera and having access to brain computed tomography (CT), neurologists at remote sites were able to determine whether a patient would be candidate for reperfusion treatment with intravenous thrombolysis. Our principal hypothesis was that the use of mCT implemented in regional hospitals and supported by telestroke would deliver more refined patient selection for thrombolysis— that it would allow selection of those most likely to benefit from therapies—based on presence of a vessel occlusion and “target” mismatch—, and of those unlikely to benefit, such as stroke mimics, large infarct cores, or small perfusion lesions where the natural history is excellent.[10]
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