Background to Stroke Thrombolysis and Telemedicine in Scotland

Approximately 80% of strokes are caused by a blockage of blood supply to part of the brain. Thrombolysis is the use of clotbusting drugs to open up these blocked arteries. This can allow blood flow to be restored to brain cells and reduce the amount of damage that is done by the stroke. The recent national strategy recommends that all eligible patients be given access to this treatment (1, 2)

Thrombolysis treatment for stroke must be given within 4.5 hours of onset of symptoms (10). In 2007 in the UK less than 3% of eligible stroke patients received thrombolysis as opposed to 10-20% in some areas of Europe(3,4), USA(5) and Canada(6). These figures were achieved in part by successful telestroke programmes. As the main barriers to achieving a higher percentage in Scotland were the length of time it took a patient to travel through the clinical pathway and the relative shortage of specialist stroke consultants (7,8), it therefore made sense to develop a telestroke network

Current protocols maintain that the stroke specialist must view a patient’s CT brain image and carry out a face-to-face consultation before any treatment decision is made. The Telestroke development aims to achieve this within the required timeframe by ensuring specialist stroke medical cover is achievable for a network of hospitals via video conferencing (VC) and PACS imaging. The patient is taken to the nearest hospital with a CT head scanner and a stroke unit even if there is no stroke specialist available on-site. The on call stroke specialist will then access the CT brain scan remotely from their office or home, consult with the patient via VC, and then give the decision whether to offer thrombolysis or not.

In 2008 a steering group to take forward the development of Telestroke in Scotland, was set as part of the Stroke National Advisory Committee Managed Clinical Network sub group, chaired by Professor Peter Langhorne. £190,000 capital funding was identified from central funding and the SCT was asked to facilitate and manage the initial projects. The SCT joined NHS 24 in April 2010 and is now the Scottish Centre for Telehealth and Telecare (SCTT) it has continued to manage and also resource the capital cost of ongoing developments for the overarching Telestroke Programme.

Each health board has a Telestroke project team in place, where possible with representation from the following areas:

  • SCT
  • Local Clinical lead
  • Local operational project/manager/coordinator
  • IT/Videoconferencing lead
  • Radiology representatiev
  • A&E representative
  • Nursing representative
  • MCN patient/public representative
  • Evaluation representative
  • Scottish Ambulance representative
  • Planning Representative

This is a complex technical and clinical Programme that involves; development of operational and clinical patient protocols and pathways, identification of the most effective/appropriate infrastructure, equipment procurement, installation and training and the evaluation of the developments at relevant stages.

The Telestroke Programme has been widened to cover cardiac and stroke conditions. The Programme continues to work in collaboration with both the Stroke and Cardiac National Advisory Committees, Managed Clinical Network’s (MCN’s), NHS Scotland eHealth, Scottish Ambulance Service, patients/public, territorial health board IT departments, Chest Heart & Stroke Scotland, Stroke Association and the Regional Planning Groups.

Anne Reoch
SCTT Cardiac & Stroke Clinical Lead
March 2012
Mob: 07825 386323
anne.reoch@nhs.net

 

  1. Better Heart Disease and Stroke Care Action Plan. The Scottish Government 2009.

  2. National Stroke Strategy. DOH 2007

  3. Wahlgren N, Ahmed N, Davalos A et al., Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study, Lancet 369 (2007), pp. 275–282.

  4. Audebert HJ, Kukla C, Clarmann Vc, Kuhn J, Vatankhah B, Schenkel J et al. Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany. Lancet Neurology; 2006, 5: 742-748.

  5. Hess DC, Wang S, Hamilton W, Lee S, Pardu C, Waller JL, et al. REACH: clinical feasibility of a rural Telestroke network. Stroke 2005; 36 (9): 2018-2020.

  6. Waite K, Silver F, Jaigoban C, Black S, Lee L, Murray B et al. Telestroke a multi-site, emergency-based telemedicine service in Ontario. Journal of Telemedicine & Telecare 2006; 12 (3): 141-145.

  7. Scottish Stroke Audit 2011.

  8. Wardlaw JM, Keir SL, Seymour J, Lewis S, Sandercock PAG, Dennis ML et al. What is the Best Imaging Strategy for Acute Stroke? Health Technology Assessment 8 (1). 2004.

  9. Wu O, Langhorne P. The Challenge of acute-stroke management: Does telemedicine offer a solution? Review article. International Journal of Stroke 2006; vol 1: 201-207

  10. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti A,Larrue V, Lees KR, Medeghri K, Machnig T, Schneider D, von Kummer R, Wahlgren N, Toni.D for the ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke NEJM 2008;359:1317-29.

  11. Meyer BC, Raman R, Hemmen T, Obler R, Zivin JA, Rao R, Thomas RG, Lyden PD Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study. Lancet Neurol 2008; vol 7: 787-795.

  12. IST

  13. Schawamm LH,et al. A Review of the Evidence for Use of Telemedicine within Stroke Systems of Care. A scientific statement from the American Heart Association/American Stroke Association. Stroke. 2009;40:00-00