Despite the growing demand for emergency neurological evaluations and neurohospitalists, the supply of neurologists remains relatively fixed over time. Telemedicine is a unique tool that has the ability to put a medical specialist like a neurologist in 2 places in a relatively short period of time, expanding expertise in many rural and in some underserved urban facilities that would ordinarily be devoid of such expertise. Teleneurology is a branch of telemedicine that consults and practices through remote neurological evaluation. Telestroke is defined as remote stroke evaluation. The demand for timely neurological evaluation, especially acute stroke evaluation and treatment with intravenous recombinant tissue plasminogen activator (IV rtPA), continues to fuel the growth of neurohospitalists, telestroke, and teleneurology services. Remote, rural, or underserved urban emergency departments and hospitals which are unable to successfully recruit a neurologist or neurohospitalist to provide this service are uniquely suited to a teleneurology option. The number of private practices and academic centers providing telestroke services has grown significantly in the past decade with continued growth expected. We describe the benefits and drawbacks of teleneurology/telestroke, as well as other practical aspects for the teleneurohospitalist.
SchwammLHAudebertHJAmarencoPRecommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the American Heart Association. Stroke. 2009;40(7):2635–2660.
13.
SchwammLHHollowayRGAmarencoPA review of the evidence for the use of telemedicine within stroke systems of care: a scientific statement from the American Heart Association/American Stroke Association. Stroke. 2009;40(7):2616–2634.
14.
DemaerschalkB.Telestrokologists: Treating Stroke Patients Here, There, and Everywhere with Telemedicine. Semin Neurol .2011;30(5):477–491.
15.
CapampanganDJWellikKEBobrowBJTelemedicine versus telephone for remote emergency stroke consultations: a critically appraised topic. Neurologist. 2009;15(3):163–166.
16.
BiglanKMVossTSDeuelLMTelemedicine for the care of nursing home residents with Parkinson's disease. Mov Disord. 2009;24(7):1073–1076.
17.
BremnerFKennedyCReesAAchesonJMurdochI. Usefulness of teleconsultations in neuro-ophthalmology. J Telemed Telecare. 2002;8(5):305–306.
18.
AdamORFerraraJMAguilar TaboraLGNashatizadehMMNegoitaMJankovicJ. Education research: patient telephone calls in a movement disorders center: lessons in physician-trainee education. Neurology. 2009;73(10):e50–e52.
19.
AhmedSNMannCSinclairDBFeasibility of epilepsy follow-up care through telemedicine: a pilot study on the patient's perspective. Epilepsia. 2008;49(4):573–585.
20.
BreenPMurphyKBrowneGFormative evaluation of a telemedicine model for delivering clinical neurophysiology services part II: the referring clinician and patient perspective. BMC Med Inform Decis Mak. 2010;10:49.
21.
ChuaRCraigJEsmondeTWoottonRPattersonV. Telemedicine for new neurological outpatients: putting a randomized controlled trial in the context of everyday practice. J Telemed Telecare. 2002;8(5):270–273.
CraigJPattersonV. Introduction to the practice of telemedicine. J Telemed Telecare. 2005;11(1):3–9.
24.
HarveyRRoquesPKFoxNCRossorMN. CANDID—counselling and diagnosis in dementia: a national telemedicine service supporting the care of younger patients with dementia. Int J Geriatr Psychiatry. 1998;13(6):381–388.
25.
DorseyERDeuelLMVossTSIncreasing access to specialty care: A pilot, randomized controlled trial of telemedicine for Parkinson's disease. Mov Disord. 2010;25(11):1652–1659.
26.
DuncanCDorrianCCrowleyPColemanRPattersonV. Safety and effectiveness of telemedicine for neurology outpatients. Scott Med J. 2010;55(1):3–5.
27.
HubbleJP. Interactive video conferencing and Parkinson's disease. Kans Med. 1992;93(12):351–352.
28.
HubbleJPPahwaRMichalekDKThomasCKollerWC. Interactive video conferencing: a means of providing interim care to Parkinson's disease patients. Mov Disord. 1993;8(3):380–382.
29.
JabreJFStalbergEVBassiR. TeleMedicine and Internet EMG. Suppl Clin Neurophysiol. 2000;53:163–167.
30.
LarnerAJ. Use of the internet and of the NHS direct telephone helpline for medical information by a cognitive function clinic population. Int J Geriatr Psychiatry. 2003;18(2):118–122.
31.
LeaDHJohnsonJLEllingwoodSAllanWPatelASmithR. Telegenetics in Maine: Successful clinical and educational service delivery model developed from a 3-year pilot project. Genet Med. 2005;7(1):21–27.
32.
LengyelA. Neurology in the era of the Internet [in Hungarian]. IdeggyogySz. 2002;55(1-2):45–49.
33.
LottITDoranEWalshDMHillMA. Telemedicine, dementia and Down syndrome: implications for Alzheimer disease. Alzheimers Dement. 2006;2(3):179–184.
34.
Pereira-MonteiroJWysocka-BakowskaMMKatsaravaZAntonaciF. Guidelines for telematic second opinion consultation on headaches in Europe: on behalf of the European Headache Federation (EHF). J Headache Pain. 2010;11(4):345–348.
35.
RozzaLTonellaPBertaminiCOrricoDAntoniolGCastellaroL. Telephone transmission of 20-channel digital electroencephalogram using lossless data compression. Telemed J .1996;2(4):267–271.
36.
SamiiARyan-DykesPTsukudaRAZinkCFranksRNicholWP. Telemedicine for delivery of health care in Parkinson's disease. J Telemed Telecare. 2006;12(1):16–18.
37.
SchofferKLPattersonVReadSJHendersonRDPandianJDO'SullivanJD. Guidelines for filming digital camera video clips for the assessment of gait and movement disorders by teleneurology. J Telemed Telecare. 2005;11(7):368–371.
38.
PaivaTCoelhoHAraujoMTNeurological teleconsultation for general practitioners. J Telemed Telecare. 2001;7(3):149–154.
39.
DemaerschalkBMHwangHMLeungG. Cost analysis review of stroke centers, telestroke, and rt-PA. Am J Manag Care. 2010;16(7):537–544.
40.
ScottPAXuZMeurerWJAttitudes and beliefs of Michigan emergency physicians toward tissue plasminogen activator use in stroke: baseline survey results from the INcreasing Stroke Treatment through INteractive behavioral Change Tactic (INSTINCT) trial hospitals. Stroke. 2010;41(9):2026–2032.
41.
AdeoyeOJornungRKhatriPKleindorferD. Recombinant tissue-type plasminogen activator use for ischemic stroke in the United States: A doubling of treatment rates over the course of 5 years. Stroke. 2011;42(7):1952–1955.
42.
KleindorferDXuYMoomawCJKhatriPAdeoyeOHornungR. US geographic distribution of rt-PA utilization by hospital for acute ischemic stroke. Stroke. 2009;40(11):3580–3584.
43.
DemaerschalkBM. Seamless integrated stroke telemedicine systems of care: a potential solution for acute stroke care delivery delays and inefficiencies. Stroke. 2011;42(6):1507–1508.
44.
GoldsteinLB. Statewide hospital-based stroke services in North Carolina: changes over 10 years. Stroke. 2010;41(4):778–783.
45.
GrossHHallCSwitzerJA. Using tPA for acute stroke in a rural setting. Neurology. 2007;68(22):1957–1958; author reply 8.
46.
GrossHHallCEWangSProspective reliability of the STRokE DOC Wireless/Site Independent Telemedicine System. Neurology. 2006;66(3):460.
47.
HandschuRLittmannRReulbachUTelemedicine in emergency evaluation of acute stroke: interrater agreement in remote video examination with a novel multimedia system. Stroke. 2003;34(12):2842–2846.
48.
HandschuRSciborMWillaczekBTelemedicine in acute stroke: remote video-examination compared to simple telephone consultation. J Neurol. 2008;255(11):1792–1797.
49.
HenningerNChowdhuryNFisherMMoonisM. Use of telemedicine to increase thrombolysis and advance care in acute ischemic stroke. Cerebrovasc Dis. 2009;27(suppl 4):9–14.
HessDCWangSHamiltonWLeeSPardueCWallerJLREACH: clinical feasibility of a rural telestroke network. Stroke. 2005;36(9):2018–2020.
52.
ChoiJYPorcheNAAlbrightKCKhajaAMHoVSGrottaJC. Using telemedicine to facilitate thrombolytic therapy for patients with acute stroke. Jt Comm J Qual Patient Saf. 2006;32(4):199–205.
53.
CromeOBahrM. Editorial comment--Remote evaluation of acute ischemic stroke: a reliable tool to extend tissue plasminogen activator use to community and rural stroke patients?Stroke. 2003;34(10):e191–e192.
54.
de BustosEMMoulinTAudebertHJ. Barriers, legal issues, limitations and ongoing questions in telemedicine applied to stroke. Cerebrovasc Dis. 2009;27(suppl 4):36–39.
55.
MoskowitzAChanYFBrunsJLevineSR. Emergency physician and stroke specialist beliefs and expectations regarding telestroke. Stroke. 2010;41(4):805–809.
56.
LaMonteMPBahouthMNHuPTelemedicine for acute stroke: triumphs and pitfalls. Stroke. 2003;34(3):725–728.
57.
de BustosEMVuillierFChavotDMoulinT. Telemedicine in stroke: organizing a network--rationale and baseline principles. Cerebrovasc Dis. 2009;27(suppl 4):1–8.
58.
DemaerschalkBM. Telemedicine or telephone consultation in patients with acute stroke. Curr Neurol Neurosci Rep. 2011;11(1):42–51.
59.
DemaerschalkBMBobrowBJRamanRStroke team remote evaluation using a digital observation camera in Arizona: the initial mayo clinic experience trial. Stroke. 2010;41(6):1251–1258.
60.
DemaerschalkBMMileyMLKiernanTEStroke telemedicine. Mayo Clin Proc. 2009;84(1):53–64.
61.
AndersonERSmithBIdoMFrankelM. Remote assessment of stroke using the iPhone 4. J Stroke Cerebrovasc Dis. 2011. [Epub ahead of print].
62.
LaiF. Stroke networks based on robotic telepresence. J Telemed Telecare. 2009;15(3):135–136.
ShafqatSKvedarJCGuanciMMChangYSchwammLH. Role for telemedicine in acute stroke. Feasibility and reliability of remote administration of the NIH stroke scale. Stroke. 1999;30(10):2141–2145.
65.
PervezMASilvaGMasrurSRemote supervision of IV-tPA for acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe. Stroke. 2010;41(1):e18–e24.
66.
LevineSR, Gorman M. "Telestroke": the application of telemedicine for stroke. Stroke. 1999;30(2):464–469.
67.
LevineSRMcConnochieKM. Telemedicine for acute stroke: when virtual is as good as reality. Neurology. 2007;69(9):819–820.
68.
AudebertHJKuklaCClarmann von ClaranauSTelemedicine for safe and extended use of thrombolysis in stroke: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria. Stroke. 2005;36(2):287–291.
69.
AudebertHJSchenkelJHeuschmannPUBogdahnUHaberlRL. Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany. Lancet Neurol .2006;5(9):742–748.
70.
AudebertHJSchultesKTietzVLong-term effects of specialized stroke care with telemedicine support in community hospitals on behalf of the Telemedical Project for Integrative Stroke Care (TEMPiS). Stroke. 2009;40(3):902–908.
71.
KhanKShuaibAWhittakerTTelestroke in northern alberta: a two year experience with remote hospitals. Can J Neurol Sci. 2010;37(6):808–813.
72.
LaMonteMPCullenJGaglianoDMTeleBAT: mobile telemedicine for the Brain Attack Team. J Stroke Cerebrovasc Dis. 2000;9(3):128–135.
73.
MeyerBCLydenPDAl-KhouryLProspective reliability of the STRokE DOC wireless/site independent telemedicine system. Neurology. 2005;64(6):1058–1060.
74.
MeyerBCRamanRHemmenTEfficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study. Lancet Neurol. 2008;7(9):787–795.
75.
LaMonteMPBahouthMNXiaoYHuPBaquetCRMackenzieCF. Outcomes from a comprehensive stroke telemedicine program. Telemed J E Health. 2008;14(4):339–344.
SchwabSVatankhahBKuklaCLong-term outcome after thrombolysis in telemedical stroke care. Neurology. 2007;69(9):898–903.
80.
NelsonRESaltzmanGMSkalabrinEJDemaerschalkBMMajersikJJ. The cost-effectiveness of telestroke in the treatment of acute ischemic stroke. Neurology. 2011;77(17):1590–1598.
81.
SmithEEDreyerPPrvu-BettgerJStroke center designation can be achieved by small hospitals: the Massachusetts experience. Crit Pathw Cardiol. 2008;7(3):173–177.
82.
AudebertHJWimmerMLHahnRCan telemedicine contribute to fulfill WHO Helsingborg Declaration of specialized stroke care?Cerebrovasc Dis. 2005;20(5):362–369.
83.
MileyMLDemaerschalkBMOlmsteadNLThe state of emergency stroke resources and care in rural Arizona: a platform for telemedicine. Telemed J E Health. 2009;15(7):691–699.
84.
AmoryCFLevineSR. Is telemedicine the answer for delivering stroke care to rural areas?Nat Clin Pract Neurol. 2007;3(4):192–193.
85.
VatankhahBSchenkelJFurstAHaberlRLAudebertHJ. Telemedically provided stroke expertise beyond normal working hours. The Telemedical Project for Integrative Stroke Care. Cerebrovasc Dis. 2008;25(4):332–337.
86.
WalterSKostpopoulosPHaassABringing the hospital to the patient: first treatment of stroke patients at the emergency site. PLoS One. 2010;5(10):e13758.
87.
SchwammLHRosenthalESHirshbergAVirtual TeleStroke support for the emergency department evaluation of acute stroke. Acad Emerg Med. 2004;11(11):1193–1197.
88.
WangDZ. Editorial comment-- telemedicine: the solution to provide rural stroke coverage and the answer to the shortage of stroke neurologists and radiologists. Stroke. 2003;34(12):2957.
89.
WangSGrossHLeeSBRemote evaluation of acute ischemic stroke in rural community hospitals in Georgia. Stroke. 2004;35(7):1763–1768.
90.
WiborgAWidderB.Teleneurology to improve stroke care in rural areas: The Telemedicine in Stroke in Swabia (TESS) Project. Stroke. 2003;34(12):2951–2956.
91.
WangSLeeSBPardueCRemote evaluation of acute ischemic stroke: reliability of National Institutes of Health Stroke Scale via telestroke. Stroke. 2003;34(10):e188–e191.
92.
MeyerBCRamanRChaconMRJensenMWernerJD. Reliability of site-independent telemedicine when assessed by telemedicine-naive stroke practitioners. J Stroke Cerebrovasc Dis. 2008;17(4):181–186.
93.
RubinM. Teleneurology report card: proof of concept. Pract Neurol. 2011:32–34.
CraigJPattersonVRussellCWoottonR. Interactive videoconsultation is a feasible method for neurological in-patient assessment. Eur J Neurol. 2000;7(6):699–702.
96.
BrownSW. Will teleneurology hit the big time?Lancet Neurol. 2004;3(9):517–518.
97.
CraigJChuaRRussellCWoottonRChantDPattersonV. A cohort study of early neurological consultation by telemedicine on the care of neurological inpatients. J Neurol Neurosurg Psychiatry. 2004;75(7):1031–1035.
98.
GanapathyK. Role of telemedicine in neurosciences. Stud Health Technol Inform. 2004;104:116–124.
99.
GanapathyK. Telemedicine and neurosciences. J Clin Neurosci. 2005;12(8):851–862.
100.
GanapathyK. Telemedicine in neurology. Neurol India. 2005;53(2):242; author reply.
101.
GarciaEGuyennetHLapayreJCMoulinT. Adaptive tele-application for remote neurology diagnosis. Telemed J E Health. 2005;11(6):692–702.
102.
SinghRNgWHLeeKEWangENgILeeWL. Telemedicine in emergency neurological service provision in Singapore: using technology to overcome limitations. Telemed J E Health. 2009;15(6):560–565.
103.
MisraUKKalitaJMishraSKYadavRK. Telemedicine in neurology: underutilized potential. Neurol India. 2005;53(1):27–31.
104.
PattersonVWoottonR. How can teleneurology improve patient care?Nat Clin Pract Neurol. 2006;2(7):346–347.
105.
CraigJChuaRRussellCPattersonVWoottonR.The cost-effectiveness of teleneurology consultations for patients admitted to hospitals without neurologists on site. 1: A retrospective comparison of the case-mix and management at two rural hospitals. J Telemed Telecare. 2000;6(suppl 1):S46–S49.
106.
PattersonV. How best to organise acute hospital services? Realtime teleneurology can help small hospitals. BMJ .2001;323(7324):1306.
107.
PattersonV. Teleneurology in Northern Ireland: a success. J Telemed Telecare. 2002;8(suppl 3):S3:46–47.
108.
PattersonVConneallyP. Intercontinental telemedicine for acute neurology. J Telemed Telecare. 2005;11(6):320–322.
YozbatiranNHarnessETLeVLuuDLopesCVCramerSC. A tele-assessment system for monitoring treatment effects in subjects with spinal cord injury. J Telemed Telecare. 2010;16(3):152–157.
111.
PattersonVHCraigJJWoottonR. Effective diagnosis of spinal cord compression using telemedicine. Br J Neurosurg. 2000;14(6):552–554.
112.
PattersonVBinghamE. Telemedicine for epilepsy: a useful contribution. Epilepsia. 2005;46(5):614–615.
113.
VespaPMMillerCHuXNenovVBuxeyFMartinNA. Intensive care unit robotic telepresence facilitates rapid physician response to unstable patients and decreased cost in neurointensive care. Surg Neurol. 2007;67(4):331–337.
114.
VespaPM. Multimodality monitoring and telemonitoring in neurocritical care: from microdialysis to robotic telepresence. Curr Opin Crit Care. 2005;11(2):133–138.
115.
PattersonVCraigJPangKAWoottonR. Successful management of unexplained coma by telemedicine. J Telemed Telecare. 1999;5(2):134–136.
116.
MeekerMDuRBacchettiPPupil examination: validity and clinical utility of an automated pupillometer. J Neurosci Nurs. 2005;37(1):34–40.
117.
ChenJWGombartZJRogersSGardinerSKCecilSBullockRM. Pupillary reactivity as an early indicator of increased intracranial pressure: the introduction of the neurological pupil index. Surg Neurol Int. 2011;2:82.
118.
TaylorWRChenJWMeltzerHQuantitative pupillometry, a new technology: normative data and preliminary observations in patients with acute head injury. Technical note. J Neurosurg .2003;98(1):205–213.
119.
Panoptic Device used with personal digital assistant (PDA), iPhone and iExamine software to examine the retina by local examiner. iExamine—intuitive medtechhttp://www.youtube.com/user/IntuitiveMedTech.
120.
PascoeDA. A pupil gauge. Anaesthesia. 1980;35(10):1021.
121.
BradleyWGJrMR-guided focused ultrasound: a potentially disruptive technologyJ Am Coll Radiol. 2009;6(7):510–513.
122.
SchererKBedlackRSSimel DL. Does this patient have myasthenia gravis?JAMA. 2005;293(15):1906–1914.
YousemDMBeauchampNJJr. Clinical input into designing a PACS. J Digit Imaging. 2000;13(1):19–24.
126.
VassalloDJHoqueFRobertsMFPattersonVSwinfenPSwinfenR. An evaluation of the first year's experience with a low-cost telemedicine link in Bangladesh. J Telemed Telecare. 2001;7(3):125–138.
127.
ChemakCBouhlelMSLapayreJC. Neurology diagnostics security and terminal adaptation for PocketNeuro project. Telemed J E Health. 2008;14(7):671–678.
128.
BusisN. Mobile phones to improve the practice of neurology. Neurol Clin. 2010;28(2):395–410.
129.
TakaoHMurayamaYIshibashiTKaragiozovKLA new support system using a mobile device (Smartphone) for diagnostic image display and treatment of stroke. Stroke. 2012;43(1):236–239.
130.
WeintraubMI. Thrombolysis (tissue plasminogen activator) in stroke: a medicolegal quagmire. Stroke. 2006;37(7):1917–1922.
131.
SwitzerJALevineSRHessDC. Telestroke 10 years later—‘telestroke 2.0'. Cerebrovasc Dis. 2009;28(4):323–330.
132.
DemaerschalkBMKiernanTESTARRInvestigators. Vascular neurology nurse practitioner provision of telemedicine consultations. Int J Telemed Appl. 2010;2010.
133.
MisraUKKalitaJMishraSKYadavRK. Telemedicine for distance education in neurology: preliminary experience in India. J Telemed Telecare. 2004;10(6):363–365.
134.
About remote evaluation of stroke patients. Patient page. Neurology. 2010;74(21):e95–e96.
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