Telemedicine-guided carotid and transcranial ultrasound: a pilot feasibility study.

BACKGROUND AND PURPOSE: Transcranial Doppler (TCD) and carotid duplex (CD) provide rapid and safe screening for stroke patients but are highly operator dependent. We explored the feasibility of telemedicine (TM)-guided TCD/CD administered by a health care provider inexperienced with ultrasound. METHODS: Dual video screens transmitted real-time TCD/CD images and sound to a neurosonographer. TM TCD/CD characteristics were compared with an in-person (IP) examination independently obtained on the same patient. We compared carotid stenosis, thrombolysis in brain ischemia (TIBI) flow grades, and the time spent on testing. RESULTS: We examined 8 subjects with a median age of 51 (31 to 63 range). IP and TM successfully examined 100% of internal carotid and middle cerebral arteries, 50% versus 44% of anterior cerebral artery, and 100% versus 88% of the basilar arteries, respectively. The median time in minutes IP versus TM was 15 (range 10 to 35) and 30 (15 to 50) for CD (P=0.07) and 18 (15 to 30) and 45 (30 to 55) for TCD (P=0.002), respectively. TM correctly identified all normal CD/TCD examinations in 7 subjects. In 1 patient, TM identified carotid occlusion but misread TIBI flow grades in both middle cerebral arteries. CONCLUSIONS: Our pilot study showed the feasibility of TCD/CD by an inexperienced health professional guided by a sonographer via TM. Tests were completed within times comparable to outpatient setting in a vascular laboratory.

Using telemedicine to facilitate thrombolytic therapy for patients with acute stroke.

BACKGROUND: Recent stroke-care requirements state that all stroke patients should be screened for intravenous recombinant tissue plasminogen activator (rt-PA) and treated, if the appropriate inclusion and exclusion criteria are met. Two community hospitals 90-130 miles east of Houston deployed telemedicine (videoteleconferencing) to provide acute stroke consultative services. DEVELOPING A TELEMEDICINE CAPACITY: According to the Brain Attack Coalition's recommendations, neurosurgical services need to be accessible within two hours. Given their incomplete neurology coverage, the remote-site hospitals identified telemedicine as the best option, with the University of Texas Health Science Center at Houston stroke team as the provider of expertise. RESULTS: In the 13 months preceding the telemedicine project (January 2003-March 2004), 2 (.8%) of 327 patients received rt-PA, compared with 14 (4.3%) of 328 patients during the telemedicine project (April 2004-May 2005), p < .001). Seven patients had > or = 4 points improvement in a stroke scale at 24 hours posttreatment. Three patients worsened during the 24-hour assessment. No intracerebral hemorrhages occurred. Door-to-needle median time was 85 minutes (range, 27-165 minutes). DISCUSSION: Telemedicine facilitated thrombolytic therapy for acute stroke patients and is intended not to replace care provided by remote-site providers but rather to address a time- and spatially related emergency need.