P-014 Effectiveness of IV tPA administered in a telemedicine network for patients having moderate and severe ischemic strokes
Authors: Turner R , Turk A , Chaudry I 
Published: July 2012

Introduction

Intravenous tPA is a recommended first line therapy for the treatment of ischemic stroke. Its administration has increased because of telemedicine networks as part of a “drip and ship” methodology for patients that have moderate and severe strokes (NIHSS >8). REACH-MUSC is a telemedicine network of 12 hospitals in rural South Carolina, all of which are a minimum of 60 miles from MUSC. We performed a retrospective review of prospectively collected data evaluating the clinical outcomes of patients who qualified for IV tPA that presented to MUSC or one of the REACH-MUSC telemedicine sites.

Methodology

A prospective database of all MUSC and telemedicine patients is maintained which includes time of onset, presenting NIHSS, administration of IV tPA, and 90-day modified Rankin Scores. A retrospective review of these patients from July 2010-June 2011 was completed.

Results

Seventy-three patients received IV tPA after presenting to MUSC or its telemedicine system. The mean NIHSS = 12.4 (range 2–28), 47 patients had NIHSS >8 (moderate or severe stroke), and 26 patients had NIHSS ≤8 (mild stroke). Overall, 28 patients (38%) had a good 90-day outcome (mRS 0–2). 77 of the 73 patients either presented directly to MUSC or were transferred to MUSC after IV tPA to be evaluated to IA therapy. Six patients remained at the local hospital or transferred to another facility for acute care. Eleven patients (15%) who presented to a telemedicine hospital with a presenting NIHSS >8 had a good 90-day outcome (mRS 0–2). Imaging upon arrival to MUSC demonstrated completed infarct in 90% of the patients who were transferred from these facilities. During the same time period, an additional 15 patients received IV tPA from local non-telemedicine hospitals (all within 15 miles of MUSC) and were transferred for IA thrombectomy evaluation. The mean NIHSS was 17. Overall, six patients (40%) had a good 90-day outcome (mRS 0–2). Of these 15 patients, 13 were suffering a moderate or severe stroke (NIHSS >8), with five patients (38%) achieving a good 90-day outcome mRS (0–2). All 13 patients underwent IA intervention after IV tPA.

Discussion

Although our overall good outcome (mRS 0–2) is on par with current literature, this was driven by the minority of patients (37%) having a mild stroke—65% of those mild stroke victims achieved a good 90-day outcome. The telemedicine patients with moderate or severe strokes were less likely to achieve the 90-day good outcome compared to those who presented to a local hospital (15% vs 38%). All patients transferred to MUSC underwent re-imaging with CT/CTA/CTP to evaluate for IA therapy. Based on that imaging, only 10% of those arriving from the telemedicine hospitals qualified for IA intervention, with zero patients achieving a 90-day mRS of 0–2. Time required to transport and intensity of care before and during transport are possible reasons for the discrepancy.

Conclusion

Patients presenting to hospitals in time for IV tPA did well overall, however this benefit is lost in patients with moderate and severe strokes.

Competing interests

R Turner: Microvention, Codman. ev3, Penumbra, Mindframe. A Turk: None. I Chaudry: None.