The telemedicine experience: using principles of clinical excellence to identify disparities and optimize care.

ABSTRACT: The use of telemedicine has increased significantly during the Corona virus disease 2019 pandemic. This manuscript serves to identify the underlying principles of clinical excellence in telemedicine and to determine whether effective care practices can be generalized as a one-size-fits-all model or must instead be tailored to individual patient populations.A survey assessing care quality and patient satisfaction for patients using telemedicine was created and administered via email to 2 urban cohorts of varying demographics and socioeconomic backgrounds: a population of patients with prior stroke and cerebrovascular disease, and a cohort of patients followed for interstitial lung disease. Results were compared across groups to determine the generalizability of effective practices across populations.Individuals taking part in telemedicine were more likely to be White, more affluent, and woman, regardless of clinical diagnosis compared with a similar cohort of patients seen in-person the year prior. A lower-than-expected number of patients who were Black and of lower socioeconomic status followed up virtually, indicating potential barriers to access. Overall, patients who participated in televisits were satisfied with the experience and felt that the care met their medical needs; however, those who were older were more likely to experience technical difficulties and prefer in-person visits, while those with less education were less likely to feel that their questions were addressed in an understandable way.When thoughtfully designed, telemedicine practices can be an effective model for patient care, though implementation must consider population characteristics including age, education, and socioeconomic status, and strategies such as ease of access versus optimization of communication strategies should be tailored to meet individual patient needs.

Bilaterally Reduced Rolandic Beta Band Activity in Minor Stroke Patients.

Stroke patients with hemiparesis display decreased beta band (13-25 Hz) rolandic activity, correlating to impaired motor function. However, clinically, patients without significant weakness, with small lesions far from sensorimotor cortex, exhibit bilateral decreased motor dexterity and slowed reaction times. We investigate whether these minor stroke patients also display abnormal beta band activity. Magnetoencephalographic (MEG) data were collected from nine minor stroke patients (NIHSS < 4) without significant hemiparesis, at ~1 and ~6 months postinfarct, and eight age-similar controls. Rolandic relative beta power during matching tasks and resting state, and Beta Event Related (De)Synchronization (ERD/ERS) during button press responses were analyzed. Regardless of lesion location, patients had significantly reduced relative beta power and ERS compared to controls. Abnormalities persisted over visits, and were present in both ipsi- and contra-lesional hemispheres, consistent with bilateral impairments in motor dexterity and speed. Minor stroke patients without severe weakness display reduced rolandic beta band activity in both hemispheres, which may be linked to bilaterally impaired dexterity and processing speed, implicating global connectivity dysfunction affecting sensorimotor cortex independent of lesion location. Findings not only illustrate global network disruption after minor stroke, but suggest rolandic beta band activity may be a potential biomarker and treatment target, even for minor stroke patients with small lesions far from sensorimotor areas.

Multidomain cognitive dysfunction after minor stroke suggests generalized disruption of cognitive networks.

OBJECTIVE: Although small strokes typically result in "good" functional outcomes, significant cognitive impairment can occur. This longitudinal study examined a cohort of patients with minor stroke to determine the pattern of deficits, evolution over time, and factors associated with outcome. METHODS: Patients admitted to the hospital with their first clinical minor stroke (NIH Stroke Scale [NIHSS] ≤ 10, absence of severe hemiparesis, aphasia, or neglect) were assessed at 1 month post-infarct, and a subset were followed over time (with 6- and 12-month evaluations). Composite scores at each time point were generated for global cognition, verbal memory, spatial memory, motor speed, processing speed, and executive function. Paired t-tests evaluated change in scores over time. Regression models identified factors associated with initial performance and better recovery. RESULTS: Eighty patients were enrolled, evaluated at 1 month, and prospectively followed. The average age of the participants was 62.3 years, and mean education was 13.5 years. The average stroke volume was 6.6 cc; mean NIHSS score was 2.8. At 1 month, cognitive scores were below the normative range and > 1 standard deviation below the patient's peak ("recovery") score for every cognitive domain, strongly suggesting that they were well below patients' prestroke baselines. Forty-eight patients followed up at 6 months, and 39 at 12 months. Nearly all (98%) patients significantly improved in global cognition (averaged across domains) between 1 and 6 months. Between 6 and 12 months, recovery was variable. Higher education, occupational class, and Caucasian race were associated with higher recovery scores for most domains. CONCLUSIONS: Cognitive impairment across multiple domains is common following minor stroke regardless of infarct location, suggesting a global process such as network dysfunction that improves over 6 months. Degree of recovery can be predicted using baseline factors.

The Routine Follow-up Head CT: Is it Still a Necessary Step in the Thrombolysis Pathway?

BACKGROUND: The 24-h head computed tomography (CT) scan following intravenous tissue plasminogen activator or mechanical thrombectomy (MT) is currently part of most acute stroke protocols. However, as evidence emerges regarding who is at highest risk for treatment complications, the utility of routine neuroimaging for all patients has become less clear. METHODS: Four hundred seventy-five patients presenting with acute ischemic stroke to Johns Hopkins Bayview Medical Center between 2004 and 2018 and treated with intravenous tissue plasminogen activator and/or MT were evaluated. Neuroimaging performed during the first 48 h of hospitalization was reviewed for edema, hemorrhagic transformation (HT), or other findings altering management. Early imaging (< 24 h), performed for neurologic deterioration, was compared with imaging performed per protocol (24 ± 6 h). Factors predictive of radiographically and clinically significant findings on per-protocol imaging were determined. RESULTS: One hundred fifty-three patients (32%) underwent early imaging. These patients generally had more severe strokes. HT was found in 15% of cases. For the remaining patients (n = 322), imaging at 24 h impacted acute management for only 24 patients: resulting in emergent hemicraniectomy in 1 (0.3%) and leading to additional imaging to monitor asymptomatic HT or edema in 23 (7.1%). Advanced age, higher stroke severity, MT, and atrial fibrillation were associated with significant findings on the 24-h CT scan. Only 2 of the 24 patients had an initial National Institutes of Health Stroke Scale score of < 7. CONCLUSIONS: The 24-h head CT scan does not change management for most patients, particularly those with low National Institutes of Health Stroke Scale scores who do not undergo MT. Consideration should be given to removing routine follow-up imaging from postthrombolysis protocols in favor of an examination-based approach.

The Post-Pipeline Headache: New Headaches Following Flow Diversion for Intracranial Aneurysm.

OBJECTIVE: Flow diversion using devices such as the "pipeline" stent is now a common treatment for unruptured intracranial aneurysms. Though much is known about the efficacy of the device, less is reported regarding potential side effects. In this study, we report the frequency and characteristics of the "post-pipeline headache." METHODS: We prospectively enrolled a cohort of 222 patients who underwent pipeline stenting for the treatment of intracranial aneurysm between 2015 and 2018. A follow-up telephone survey was conducted with a mean 21.6 months postprocedure evaluating postprocedure headaches and previous headache history. A post-pipeline headache was defined as a new headache or pain distinct from their prior headache syndrome. Information was collected regarding patient demographics, headache characteristics, headache history, and whether symptoms were ongoing. Logistic regression was used to determine factors associated with post-pipeline headache and the risk of long-term headache persistence. RESULTS: Eighty-eight individuals were reached by phone for follow-up; 48 (55%) of whom reported a new headache postprocedure. Patients experiencing post-pipeline headache were more likely to be young (OR 0.9; 95% CI: 0.85-0.94) and have a history of prior headaches (OR 2.4, 95% CI: 1.02-5.81). Associated motor (OR 6.1; 95% CI: 1.19-31.47), cognitive (OR 7.0; 95% CI: 081-60.33), visual (OR 5.4; 95% CI: 1.05-27.89), and vestibular (OR 4.8; 95% CI: 1.14-20.23) symptoms were associated with ongoing headache. CONCLUSIONS: Post-pipeline headache is common, particularly in younger individuals with prior headache history, and has distinctive features. Symptoms can remit over time; however, two-thirds experience ongoing headaches, particularly those with associated migrainous features.

Resource Allocation: Stable Patients Remain Stable 12-24 h Post-tPA.

BACKGROUND AND PURPOSE: Stroke patients are currently monitored for neurological deterioration for 24 h following treatment with intravenous tissue plasminogen activator (IV tPA) or mechanical thrombectomy. This requires low nursing ratios and an intensive-care-like setting. As the half-life of IV tPA is short, many patients may not require such prolonged intensive monitoring and could be downgraded much earlier. We evaluate the frequency of neurological deterioration in the 0-12 and 12-24 h post-treatment windows. METHODS: Patients presenting with acute ischemic stroke treated with IV tPA and/or thrombectomy at our institution from 2016-2018 were prospectively followed per protocol for 24 h post-therapy (examinations every 15 min for 2 h, every 30 min for 6 h, and hourly thereafter). Neurological deteriorations were recorded along with interventions and complications. Frequency of deterioration within the 0-12 and 12-24 h post-treatment windows was determined, along with factors associated with decline at each time point. RESULTS: A total of 172 patients were treated (IV:135, IA:65, both:30). Thirty-six (21%) experienced a documented neurologic deterioration [8 due to intracerebral hemorrhage (4.7%)]. Five patients deteriorated in the 12-24 h window; all but one had experienced earlier examination changes. Elevated NIHSS was associated with a higher likelihood of deterioration overall. Early fluctuation was associated with decline after 12 h. CONCLUSIONS: New onset of neurologic deterioration is rare 12-24 h after treatment of acute stroke. Stable patients with low NIHSS scores and no ICU needs may not require intensive monitoring greater than 12 h post-treatment.