Telestroke consultation can accurately diagnose ischemic stroke mimics.

INTRODUCTION: Telestroke (TS) networks are standard in many areas of the US. Despite TS systems having approximately 33% mimic rates, it is unknown if TS can accurately diagnose patients with acute ischemic stroke (AIS) versus stroke mimics. METHODS: We performed a retrospective review of consecutive TS consults to 27 TS sites in six states during 2018. Clinical information and diagnosis were extracted from discharge records and compared to those from the TS consult. Discharge diagnoses were verified and coded into 12 categories. Cases without a clear discharge diagnosis and intracerebral haemorrhage were excluded. We report agreement and a Cohen's kappa between TS and discharge diagnoses for the category of AIS/transient ischemic attack (TIA) versus stroke mimic. RESULTS: We included 404 cases in the analysis (mean age 66 years; 54% women). Of these, 225 had a TS diagnosis of AIS/TIA; 102 (45%) received intravenous tissue plasminogen activator. Our study demonstrated a high diagnostic agreement for AIS/TIA (88%) with a kappa of 0.75 for stroke and mimics. Of the 179 patients diagnosed with a stroke mimic on TS, 27 (15%) were diagnosed with AIS/TA by discharge. TS mimic diagnosis had a positive predictive value (PPV) of 85% and a negative predictive value (NPV) of 90%; TS diagnosis of stroke/TIA had PPV 90%, NPV 85%. DISCUSSION: We found excellent correlation between TS and discharge diagnoses for patients with both stroke and stroke mimics. This suggests that TS systems can accurately assess a wider variety of patients with acute neurologic syndromes other than AIS.

Training in Neurology: Adoption of resident teleneurology training in the wake of COVID-19: Telemedicine crash course.

The coronavirus disease 2019 pandemic has changed the way we engage patient care, with a move toward telemedicine-based health care encounters. Teleneurology is now being rapidly embraced by neurologists in clinics and hospitals nationwide but for many, this paradigm of care is unfamiliar. Exposure to telemedicine in neurology training programs is scarce despite previous calls to expand teleneurology education. Programs that provide a teleneurology curriculum have demonstrated increased proficiency, accuracy, and post-training utilization among their trainees. With the current changes in health care, broad incorporation of teleneurology education in resident and fellow training after this pandemic dissipates will only serve to improve trainee preparedness for independent practice.

Less Experienced Telestroke Consultants Are More Likely to Go On-Camera, but Less Likely to Give tPA.

BACKGROUND: Stroke telemedicine (telestroke) increases tPA availability and administration. However, the effective use of telestroke requires training, which is not a standard component of vascular neurology training. As a result, many providers learn telestroke skills "on the job" after finishing their training. AIMS: We sought to explore if providers with more telestroke experience would be more efficient in the utilization of telemedicine, compared to providers with less experience. METHODS: We prospectively collected data on telestrokes between July 2014 and July 2017 at a Comprehensive Stroke Center. Telestrokes are initiated on the telephone and typically, but not always, followed by an on-camera consult. Decision to do a phone-only versus on-camera consult is at the provider's discretion. RESULTS: There were 1,029 telestrokes, of which 807 were on-camera (74%). Of the 8 telestroke providers, 4 had less experience, having just finished stroke fellowship, and 4 had more experience (mean = 7.8 years of telestroke experience at the beginning of the study). Providers with less experience were more likely to go on camera than providers with more experience (79% vs. 67% of consults, p = 0.021), but were less likely to give tPA when on-camera (25% vs. 33%, p = 0.023). The absolute rate of tPA administration, combining phone and camera administration, or the frequency of technical difficulties were not different. CONCLUSIONS: Telestroke consultants with less experience do not triage as many cases by phone and are less likely to administer tPA on-camera, suggesting their use of telemedicine is not optimized. This supports the introduction of telestroke didactics during vascular neurology training.

Outcomes in adults with cerebral venous sinus thrombosis: A retrospective cohort study.

Most patients with cerebral venous sinus thrombosis (CVST) treated with anticoagulation have good outcomes. We examined which factors were associated with poor outcomes after treatment. We retrospectively reviewed patients ≥18 years old who were diagnosed with CVST between 1997 and 2015. Good (modified Rankin score [mRS] ≤2) and poor outcomes were dichotomized. Demographic, historical, clinical, imaging, and treatment characteristics were compared. Eighty-nine patients received treatment for CVST (52.8% males, 74.2% Caucasian). Sixty-eight (76.4%) had good outcomes and 21 (23.6%) had poor outcomes. Poor outcome was associated with systemic or central nervous system (CNS) infection (p = 0.002), lower use of heparin-only therapy than interventional-only treatments (p = 0.003), and increased use of craniectomy (p = 0.002). Good outcomes were associated with migrainous headache on presentation (p = 0.01) and involvement of superficial cortical vessels only (p = 0.02). No prothrombotic or imaging findings correlated with poor outcome. Multivariable analysis showed that any clinical risk factor (p = 0.02) and headache (p = 0.02) predicted improved outcome whereas systemic or CNS infection (p = 0.02) and craniectomy (p = 0.02) predicted poor outcome. A published risk score showed a moderate ability to predict good outcome but not poor outcome. Overall sensitivity (23.8%), specificity (75.0%), and positive (24.0%) and negative (77.0%) predictive value suggested moderate prediction of good outcome and limited prediction of poor outcome. Rates of poor outcomes in CVST were comparable with previous investigations (23.6%), but prediction of poor outcome remains challenging in patients with CVST. Our results suggested that systemic infection and craniectomy were the most robust predictors of poor outcome.

Tissue Plasminogen Activator Prescription and Administration Errors within a Regional Stroke System.

BACKGROUND: Intravenous (IV) tissue plasminogen activator (tPA) utilization in acute ischemic stroke (AIS) requires weight-based dosing and a standardized infusion rate. In our regional network, we have tried to minimize tPA dosing errors. We describe the frequency and types of tPA administration errors made in our comprehensive stroke center (CSC) and at community hospitals (CHs) prior to transfer. METHODS: Using our stroke quality database, we extracted clinical and pharmacy information on all patients who received IV tPA from 2010-11 at the CSC or CH prior to transfer. All records were analyzed for the presence of inclusion/exclusion criteria deviations or tPA errors in prescription, reconstitution, dispensing, or administration, and for association with outcomes. RESULTS: We identified 131 AIS cases treated with IV tPA: 51% female; mean age 68; 32% treated at the CSC, and 68% at CHs (including 26% by telestroke) from 22 CHs. tPA prescription and administration errors were present in 64% of all patients (41% CSC, 75% CH, P < .001), the most common being incorrect dosage for body weight (19% CSC, 55% CH, P < .001). Of the 27 overdoses, there were 3 deaths due to systemic hemorrhage or ICH. Nonetheless, outcomes (parenchymal hematoma, mortality, modified Rankin Scale score) did not differ between CSC and CH patients nor between those with and without errors. CONCLUSION: Despite focus on minimization of tPA administration errors in AIS patients, such errors were very common in our regional stroke system. Although an association between tPA errors and stroke outcomes was not demonstrated, quality assurance mechanisms are still necessary to reduce potentially dangerous, avoidable errors.