[Show abstract][Hide abstract] ABSTRACT: 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.
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).
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.
Joint Commission journal on quality and patient safety / Joint Commission Resources 04/2006; 32(4):199-205.
[Show abstract][Hide abstract] ABSTRACT: We hypothesized that patients with clinically severe strokes but less severe early ischemic changes on brain CT (i.e., clinical-CT mismatch) may respond better to intravenous recombinant tissue plasminogen activator (i.v. rt-PA) within 3 h of symptom onset.
In this secondary analysis of the CLOTBUST data, patients with middle cerebral artery occlusions on transcranial Doppler (TCD) were treated with i.v. rt-PA. Alberta Stroke Program Early CT Scores were obtained with raters blinded to the NIH Stroke Scale and TCD results. Two mismatch criteria and three criteria of response to therapy were explored.
Of 126 patients, 67% had a mismatch type 1 and 74% had a mismatch type 2. The presence of clinical-CT mismatch by either definition did not correlate with any of the three criteria of response to rt-PA. Recanalization was a strong determinant of response, whether or not mismatch was present.
Mismatch between severity of neurological deficit and CT findings is common but does not predict response to rt-PA therapy given within 3 h.
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
[Show abstract][Hide abstract] ABSTRACT: This chapter discusses a general diagnostic algorithm for transient ischemic attack (TIA) and ischemic stroke patients, and provides illustrations of the way this process can be tailored in selected cases in order to provide timely information for making therapeutic decisions. The major consideration is whether a TIA or stroke has occurred. The chapter examines whether the focal neurological deficit is of a vascular or nonvascular origin and examines the mechanism of cerebral ischemia. The preventive measures are similar, although attention to addressing rehabilitation needs and treatment of poststroke depression needs to be consolidated for the stroke patients. After clinical assessment confirms TIA or persistent stroke symptoms, a noncontrast brain computed tomography (CT) scan is usually the procedure of choice because of short scanning times, wide availability at most emergency centers, and rapid visualization of conditions that contraindicate administration of thrombolytic therapy. On the other hand, magnetic resonance imaging (MRI) is more sensitive in visualizing the location and extent of acute cerebral ischemia with diffusion-weighted images. The posterior fossa is better visualized with this technology compared with CT.
Blue Books of Practical Neurology 12/2004; 29. DOI:10.1016/S1877-3419(09)70079-0
[Show abstract][Hide abstract] ABSTRACT: We describe the first report of intravenous thrombolytic therapy for acute ischemic stroke given by a rurally based advanced practice nurse (APN) with a telemedicine team of an emergency physician and stroke specialists. A three-way T1 connection between the APN in Dickerson Memorial Hospital in Jasper, TX, the Houston, TX-based Emtel emergency physician, and the University of Texas-Houston Stroke Team physicians facilitated tissue plasminogen activator treatment 80 min into the patient's ischemic stroke, which was manifested by dysarthria, facial palsy, and near-total left-body hemiplegia (NIH Stroke Scale = 9). She was transferred to Memorial Hermann Hospital in Houston for further care. Within 24 h, her neurologic deficits resolved (NIH Stroke Scale = 0), and she was discharged home within 3 days. This represents successful acute stroke care given by an APN under supervision of a telemedicine physician team and may be an option for underserved areas. Educational training of health care providers remains the key for acute stroke care delivery. This case report illustrates a model for telemedicine that has been cost-effective for rural medical care.
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been an available operation for weight loss for the past decade, and bariatric surgery is increasing in the United States. Careful patient screening and follow-up have been the cornerstone for success against the complexities of morbid obesity. Neurologic complications have occurred, such as polyneuropathy and Wernicke-Korsakoff syndrome. We report an 18-year-old female with morbid obesity, steatohepatitis, tobacco, recreational drug, and oral contraceptive use who at 4 months after LRYGBP experienced a generalized seizure and stroke. She was diagnosed with an acute ischemic stroke, possibly venous infarction. Her postoperative course had been complicated by malnutrition and dehydration, apparently related to nausea from chronic cholecystitis. She had a possible protein-S deficiency. Rare neurologic complications emphasize the importance of postoperative surveillance in these patients.
Obesity Surgery 06/2004; 14(6):857-60. DOI:10.1381/0960892041590890 · 3.75 Impact Factor