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July 25, 2018

Telestroke: Life-saving care at a distance

By: SharonRose Airhart

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Think of it as the difference between Drano and Roto-Rooter.

Two very different treatments for ischemic stroke: the drug tPA (tissue plasminogen activator) dissolves clots, while the other, newer treatment EVT (endovascular treatment) physically removes clots. Both save lives and prevent disability.

Some 18 years ago, Dr. Frank Silver and Dr. Ed Brown made history by creating Telestroke. The objective was to use telemedicine to make tPA available throughout the province. Without on-site stroke expertise, ER doctors are not able to determine whether tPA will help or, in the case of hemorrhagic stroke, harm. And tPA must be administered within 4.5 hours of the first stroke symptoms, precluding patient transport to distant stroke centres.

Telestroke connects ER doctors and their patients to stroke neurologists at major centres through data transmission and videoconference. There were eight Telestroke consultations in 2002. In 2017, there were 2,127 consultations. It’s now delivered through OTN in partnership with CritiCall and funded by the Ministry of Health and Long-Term Care.

The Telestroke protocol has now been updated to include EVT, long used in cardiac treatment and now a standard of care for clinical management of hyper-acute ischemic strokes, as per the Canadian Stroke Best Practice Recommendations.

“Telestroke is a great example of the value of integrated telemedicine,” says Dr. Brown, CEO, OTN. “Telestroke advanced health care in Ontario by making tPA administration available in most of the province. Now, 18 years later, Telestroke facilitates another important advance in health care: EVT.”

But it’s complicated. tPA can’t be administered to patients taking blood thinners or who have recently had surgery. It works slowly, carries a risk of bleeding and doesn’t always open the involved artery. Not every patient is eligible for EVT, either, and time is equally of the essence.

The current standard is that patients must be able to reach an EVT centre within six hours, although in some selected patients there is benefit up to 24 hours after stroke symptom onset. As neurologists say, time is brain. Once indicated and available, however, EVT, from groin puncture to completion, can take as little as 15 minutes to administer.

While there are 28 rural and small hospitals in the Telestroke network able to administer tPA, only 10 hospitals in Ontario are EVT centres.

“If Telestroke hadn’t existed, we would have had to figure out a system to help us extend the reach of EVT centres,” says Dr. Silver, Medical Director of the University Health Network Stroke Program. He notes that the volume of Telestroke consultations has increased dramatically from six calls a day to as many as 15.

“There’s increased stroke awareness among patients who know they should get themselves to the hospital and more physician awareness that we have treatments that can make a difference but they have to be fast. Because of Telestroke, once you’re in the ER, it’s 10 minutes until a card-carrying stroke neurologist is giving advice to the doctor and talking to the patient and family.”

Dr. Silver says you don’t have to be a statistician to know Telestroke is cost effective. “You have a patient who is unable to speak, no vision, paralyzed after a stroke. The outcome is either severe disability or death. The fact that we have a treatment that can reverse that inevitable outcome is amazing.”

In spite of this, remarkably, not all doctors in Ontario know about Telestroke. A 2015 Ipsos Reid survey revealed that only 24 per cent of doctors who work in Ontario hospitals are aware of Telestroke.

For Dr. Silver personally, there’s been an additional reward from Telestroke. “I went from a situation where people said ‘why would you want to focus on stroke which can be diagnosed but not treated’ to a healthcare system offering tPA and EVT. There is nothing more rewarding that seeing a patient who can’t move or speak start moving and talking as soon as the clot is removed and watch that patient go home the next day.”

For more information on Telestroke, please visit otn.ca/telestroke.

About the author: SharonRose Airhart is an OTN writer and editor who has worked in and written about Ontario health care for more than three decades.