New stroke guidelines give nod for telemedicine, thumbs up for MRI

Telemedicine is as effective as a bedside evaluation for acute stroke, according to a guideline released last week by the American Heart Association (AHA)/American Stroke Association (ASA). Additionally, imaging data, preferably from MRI, should be the determining factor in defining transient ischemic attack (TIA), which should be treated as urgently as a full-blown stroke.

The two statements and a policy statement were published online May 7 in Stroke. 

Stroke and brain imaging specialists are often required to evaluate if stroke patients are eligible for time-sensitive treatment such as tissue plasminogen activator (tPA) that can save brain function and reduce disability. However, the United States has only an average of four neurologists per 100,000 people, and not all of them specialize in stroke, according to the joint statement.

Telemedicine, or telestroke, allows the patient, family and the bedside and distant healthcare providers to see and hear each other in full color and in real time. Coupled with teleradiology, telestroke technology can "broaden the reach of neurologists in a cost-effective and time-efficient manner," according to the statement.

"Telemedicine is an effective avenue to eliminate disparities in access to acute stroke care, erasing the inequities introduced by geography, income or social circumstance," said lead author Lee Schwamm, MD, associate professor of neurology at Harvard Medical School and vice chairman of neurology at Massachusetts General Hospital in Boston.

Schwamm said that in order to be effective, however, the reimbursement for telemedicine activities must change. For that, policy recommendations were released along with the scientific statement, which recommend:

• Deploying telestroke systems to supplement resources where around-the-clock local, on-site acute stroke expertise is insufficient.
• Increasing Medicare reimbursement for telestroke assessment, diagnosis and approval to use tPA to reflect the increased upfront costs of implementation.
• Developing a mechanism for uniform, streamlined credentialing for telestroke providers and uniform national telemedicine licensure by state medical boards.
• Increasing funding sources for stroke telemedicine programs which could include designating support from the federal American Recovery and Reinvestment Act of 2009.

Imaging TIA

The risk of stroke after a TIA is higher than previously thought; therefore, immediate action and thorough testing should be done, much like the exam after a full-blown stroke, according to the authors.

The authors recommended that MRI with diffusion sequences be the preferred neuroimaging evaluation within 24 hours of symptom onset for potential TIA. Additionally, noninvasive imaging of the cervical vessels should be performed and noninvasive imaging of intracranial vessels is considered reasonable.

"We think a TIA should be treated as an emergency, just like a major stroke," said J. Donald Easton, MD, writing chair of the statement and professor and chair of the department of clinical neurosciences at Alpert Medical School of Brown University and the Rhode Island Hospital in Providence, R.I. "Because we know the high risk of a future stroke, this is a golden opportunity to prevent a catastrophic event."

The traditional, clinical definition of TIA is "a sudden, focal neurological deficit of presumed vascular origin lasting less than 24 hours," the authors wrote.

AHA/ASA has changed the definition to "a transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia, without acute infarction."

"Research around the globe has shown that the arbitrary threshold based on duration of symptoms was too broad, because up to half of TIAs defined this way actually caused sustained brain injury according to an MRI," Easton said. Medical advances have made it easier to tell whether a patient has had a TIA or stroke, so an MRI is key to diagnosing a TIA, Easton and colleagues noted.

According to the paper, 10 percent to 15 percent of TIA patients experience a stroke within three months of a TIA, with half of those strokes occurring in the first 48 hours after TIA. "Acute treatments for TIA also have evolved, with new data supporting early rather than delayed carotid endarterectomy for TIA patients with carotid stenosis," the paper.


Additional diagnostic workup such as vessel imaging, cardiac evaluation and laboratory testing should be completed according to AHA acute stroke guidelines, the authors concluded.