Telemedicine and cerebrovascular disease: The telestroke advantage in Alberta Ashfaq Shuaib MD FRCPC University of Alberta Canada Competing Interests Declaration Competing interests I chair the steering committee of the SENTIS and FastFlo trials and am an advisor to CoAxia I am on the steering committees of the DIAS 4 and MAST trials In the past 5 years, I have received speaker fees from: Sanofi-Aventis/BMS, BI, Pfizer, Merck, Roche, Servier, AstraZeneca In the past 5 years, I have served on advisory boards for: AstraZeneca, BI, Sanofi-Aventis/BMS, Roche, Pfizer Learning Objectives 1. Management issues in stroke 2. Telemedicine and its role in treatment of cerebrovascular diseases 3. Tele-stroke in Alberta Stroke treatment Organized care, especially Stroke Units, offers the best opportunity for recover after an acute stroke The most important goals of stroke treatment focus on prevention Prevention of complications Prevention of recurrent stroke It is important to recognize the important role of rehabilitation services in recovery Acute stroke treatment Stabilize patient Consider thrombolysis if the patient meets criteria less than 3% of acute stroke patients currently getting therapy Offer plan for immediate care and prevention of recurrence Recovery < 3 Hours from onset NINDS tpa Trial Parts A and B NNT= 6-8 Complete Incomplete Poor Death Placebo 21 35 24 20 rt-pa 38 31 15 17 Major problem: less than 5 % treated / requires a stroke program
< 3 Hours from onset NINDS tpa Trial age < 60 Parts A and B Placebo rt-pa n=174 NNT=4 to cure Recovery Sympt ICH 5% Complete Incomplete Poor Death 29 43 13 16 56 19 12 13 Lack of timely access (out of window) Patient s lack of awareness Physical Delayed recognition Physician attitude Geographical location Lack of expertise / unwillingness
Why is CT essential? Hemorrhage or No hemorrhage Calcification or Hemorrhage???? Learning Objectives Teleconferencing and medicine 1. Management issues in stroke 2. Telemedicine and its role in treatment of cerebrovascular diseases 3. Tele-stroke in Alberta Cardiology Pediatrics ICU Trauma Stroke
Telemedicine and cerebrovascular diseases Acute stroke Prevention of stroke Lancet Neurol 2008 Learning Objectives 1. Management issues in stroke 2. Telemedicine and its role in treatment of cerebrovascular diseases 3. Tele-stroke in Alberta
Minimize Delay- Hospital Bypass So what do we do with this information for Rural Alberta? Small communities with hospitals at considerable distances from major tertiary centers 8 miles Local hospital No CT scanner Minimize Delay- Hospital Bypass Minimize Delay- Hospital Bypass 40 miles CT scanner 8 miles 40 miles CT scanner unavailable 8 miles Local hospital No CT scanner Local hospital No CT scanner 70 miles iv rt-pa rfviia Helical or multislice CT scanner 24h/365 d coverage Primary Stroke Center Transfer for Rescue Therapy 8 miles 40 miles CT scanner Local hospital No CT scanner 70 miles intraclot lysis ICH evacuation iv rt-pa rfviia 170 miles Early ICA revascularization Helical or multislice CT scanner 24h/365d coverage Primary Stroke Center Interventional Facilitiesinterventional neurorad, neurosurgery Comprehensive Stroke Center
Case #1 A 56 year old lady with hypertension experienced unusual episodes of altitudinal L eye visual loss for two weeks Then she experienced two episodes of complete visual loss in the left eye Later that day she collapsed with inability to speak and right hemiplegia She is brought to your hospital 170 km from Edmonton Case 1 What do you need to do immediately? Rapid history Assessment TIME OF ONSET (OR WHEN LAST SEEN WELL) Contra-indications to tpa Family contacts/information Rapid physical exam (ABCs first) Neuro exam quick but complete Examine heart and lungs Temp, HR, BP!! Case 1 (cont) Time windows of importance Your centre is located 2 hours transport by ground from Edmonton Will this patient be a candidate for intravenous tpa? Should the acute stroke physician be notified? 0-3 hours 3-4.5 hours 0-6 hours Intravenous tpa therapy* ECASS III positive Intra-arterial tpa therapy Catheter devices
Real-time, full-motion video on broadband width network The Edmonton Telestroke Program In 2003, CH launched TeleStroke to extend specialized stroke care to patients in remote locations. Northern & Central Alberta; Territories, British Columbia and Saskatchewan. Acute TeleStroke program launched in 2006 200 Currently TeleStroke has 52 available sites for clinic visits. 180 160 140 120 2003/04 2004/05 100 80 2005/06 2006/07 Yellowknife, NWT - 1,499 km 60 40 2007/08 2008/09 20 0 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 Tele-stroke clinic TIA (definite + possible) 45 % Stroke follow up 30 % The Acute Telestroke program Seizures / tumor 3 % Migraines 12% Others 15 %
Primary Stroke Care Centers - Partnering Remote Sites Hinton Health Care Center April 2006 Camrose Health Care Center June 2007 Cold Lake Health Care Center September 2007 Red Deer Hospital February 2008 Wainwright Nov 2008 Telestroke Patient 1 Patient 1 Case 1 (cont) This patient received intravenous tpa from the Camrose stroke team with telehealth involvement of the Capital Health/UAH Stroke Team Transferred to the UAH for further investigations to determine etiology Current Stats with acute stroke program
Consultations to date Total acute stroke consults - 216 IV t PA given - 50 Male - 60 % (thrombolysed) Average age - 68 ( 20 93) Diagnosis in the 216 patients Patient treated with tpa 50 Rapid recovery 51 Outside of window 46 Non stroke symptoms 12 ICH/SAH 5 Others 52 Overall results in treated patients Televideo conferencing 38 Teleconsultations 12 Onset to ER 101 m CT to needle 61 m Onset to tpa 162 m Complications Mortality in 90 days 10 patients Symptomatic hemorrhage 2 Asymptomatic hemorrhage 3 No difference in treatment with the two type of treatments
ECH Coverage Area SMH CVA STATISICS Stroke Patient Numbers ¾ 20.4% Received Thrombolytics (rtpa) (National Average 3-5%) ¾ 18.2% Transferred to Stroke Rehabilitation Unit Edmonton Lloydminster Camrose 3 1 Wainwright 2 SMH TIA STATISICS Stroke TIA Numbers ¾ 138 TIA Patients ¾ 1.5% Progressed to full Stroke ¾ 100% Carotid Doppler within 24 hours for high risk TIA SMH Patient Data ¾ Year prior to telestroke 115 patients transferred to UAH for management ¾ Second year of telestroke 15 patients transferred to UAH SMH Time Indicators ¾ Door to CT = 6 minutes ¾ CT to rt-pa = 37 minutes ¾ Total Door to Drug 2007 48 minutes 2008-60.6 minutes* Wainwright Portable CT
Results in the first 3 months 2: The second scan 24 hours after treatment with tpa shows a small paticheal hemorrhage in the region of the stroke. Total consultations 20 Patients treated with tpa 3 Patients with brain hemorrhage 3 Others 16 Patients transferred to UAH 1 Patient 3: The pre-treatment and post-treatment scans do not show any evidence of any ischemic damage in the third patient. This figure shows the CT scan of the only patient who required transfer to a tertiary care facility for treatment of the SAH These CT scans are of the two patients who had presented within three hours from onset of symptoms and were being considered for thrombolysis but the imaging showed large cerebral hemorrhages Conclusions 1. TeleStroke is an acceptable alternative for stroke patients from remote areas. 2. Improved access to specialized stroke care from remote Northern & Central Alberta and surrounding area, especially for prevention. 3. There is room for further expansion of the program in the province.