Portal de Periódicos da CAPES

The Future is Now

2012; Lippincott Williams & Wilkins; Volume: 70; Issue: 4 Linguagem: Inglês

10.1227/01.neu.0000413224.88090.66

1524-4040

Rudy J. Rahme, Andrew J. Fishman, H. Hunt Batjer, Bernard R. Bendok,

Cerebrovascular and Carotid Artery Diseases

Stroke is the leading cause of disability and the 3rd leading cause of mortality in the United States. Each year, approximately 600 000 individuals in the United States suffer a new stroke, while an additional 180 000 experience recurrent attacks1; ischemic stroke accounts for 87% of all strokes.1 Time is arguably the most important factor in the treatment and outcome of acute ischemic stroke. Ischemic brain tissue may be salvageable for only a brief time window after the thromboembolic event occurs. Intravenous tissue plasminogen activator (IV tPA) has been shown to improve outcome if given up to 4.5 hours after a stroke occurs in select patients,2-4 with earlier recanalization associated with better outcomes.5 Unfortunately, it is estimated that less than 5% of stroke patients receive FDA-approved thrombolytic therapy.6 This is at least in part due to the narrow treatment time window, the need to perform a battery of tests to cover the AHA/ASA guidelines exclusion/inclusion criteria for administering the IV tPA such as ruling out intracranial bleeding,4 difficulties related to stroke patient assessment by general practitioners and other non stroke specialists, and the limited number of centers with the proper expertise particularly in rural areas.7 Due to these time constraints, it becomes evident that the logistics of care delivery must be improved so that more patients are properly and promptly evaluated with potential transfer to appropriate treatment centers. Telemedicine has long been touted as a mechanism to overcome these challenges. In fact the use of telemedicine in the absence of a vascular neurologist on site is an AHA/ASA class I, level A recommendation.8 Most telemedicine systems, however, are expensive and may not be affordable to smaller hospitals. Handheld devices however, have been touted as potential portals for telemedicine. They are ubiquitous and relatively cheap. In an effort to test their efficacy as telemedicine devices, Anderson et al9 hypothesized that the iPhone 4 (Apple Inc., Cupertino, CA) through its FaceTime technology would be a relatively inexpensive communication technology that would allow the remote assessment of stroke patients. The study enrolled 20 patients who had an ischemic stroke. Patients were examined at bedside by an investigator to determine the National Institute of Health Stroke Scale (NIHSS). The exam was simultaneously transmitted through FaceTime to an off-site physician. Both physicians were blinded to the other's NIHSS score. Both had no clinical information on the patient prior to the exam. The mean remote evaluation time was 8.45 minutes. The results showed excellent overall agreement on the NIHSS score between the 2 physicians. The detailed interrater reliability in the assessment of specific component of the NIHSS is summarized in Table 1. Ataxia was the only component that revealed poor agreement. The intraclass correlation coefficient for the 2 investigators was very high at 0.98 (confidence interval 95%, 0.96-0.99).TABLE 1: Interrater Reliability Between Bedside and Remote Evaluation of NIHSS ComponentsThe importance of this study lies in its practicality. The authors were able to reproduce a telemedicine system at a relatively low cost, with widely available and basic requirements—an iPhone 4 and Wi-Fi connectivity. Beyond merely proving the validity of the iPhone 4 as a telemedicine device, this study, through the simplicity of its design, opens the door for similar cheap devices and approaches that could potentially replace high-cost telemedicine systems. The study as performed though has its limitation as pointed out by the authors. First, both physicians in this study were well versed with the NIHSS assessment making the exam fluid and quick. This would not necessarily be the case in the real-life setting where the need for this technology stems exactly from the lack of experience of the bedside physician in stroke patient assessment. Second, the clinical examination of a stroke patient is not limited to the NIHSS. Brain imaging is required to safely and completely assess the patient's status and eligibility for IV tPA. Third, a remote exam does not replace the physical presence of a physician from a clinical point of view and from a physician-patient relationship perspective. That physical presence at bedside is essential to build trust and therefore to allow the patient and the physician alike to make confident assured decisions. In addition, before this technology can be applied on a larger scale a few important issues need to be addressed including reimbursement and legal implications. The telemedicine system needs to be HIPAA compliant. Transfer of patient information has to be done over strictly secure networks with no third party involvement. Further studies are warranted to improve upon the system presented in this paper. First and above all, a study analyzing the efficacy of telemedicine systems with multiple centers “plugged-in” to one central institution would allow for a more realistic perspective. It would allow for a better understanding of the feasibility and validity of this telemedicine approach with a more complete assessment of potential failings and weak points. Also, incorporating the currently available technology for patient imaging transfer would allow the remote expert physician to look at brain computed tomographic scans and perfusion imaging to rule out intracranial bleeding and possibly clear the patient for IV tPA. In addition, perhaps if the patient could see and talk to the remote physician, it would help build the physician-patient relationship and the trust that comes with it. Finally, the use of handheld devices as educational tools for physicians and patients alike may further enhance stroke care. The next wave of wireless technology adoption is well underway. As devices and applications become more affordable and user-friendly and as wireless and network coverage becomes more widespread, mobile handheld devices will very likely play an increasingly facilitative role in the care of patients with neurological diseases. The need and potential for telemedicine for stroke care in particular, and for neurosurgical care in general, is becoming clearer. Neurosurgeons and neurosurgical patients could benefit from telemedicine systems if they are applied thoughtfully.