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Inicio Neurología (English Edition) Code stroke. Can we improve stroke times? A reply
Journal Information
Vol. 34. Issue 4.
Pages 281-282 (May 2019)
Vol. 34. Issue 4.
Pages 281-282 (May 2019)
Letter to the Editor
DOI: 10.1016/j.nrleng.2016.08.002
Open Access
Code stroke. Can we improve stroke times? A reply
Código ictus. ¿Podríamos mejorar los tiempos? Réplica
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L. Benavente
Corresponding author
lbf.benfer@gmail.com

Corresponding author.
, S. Calleja
Servicio de Neurología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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Dear Editor:

We appreciate the interest in our article “Code stroke in Asturias,”1 as it presents us an opportunity to offer more detail on the code stroke strategy being implemented in our region, and to make improvements based on other authors’ contributions.

We entirely concur with the authors of the letter that transport times from more remote areas constitute a challenge for the treatment of acute stroke in many patients who are more distant from the 2 reference hospitals. This can be observed in the small number of patients from the most remote areas among those who receive treatment, despite increases in code stroke activation and in the administration of reperfusion therapy since the latest update to our region's code stroke policy.2

We plan to apply research and communications technologies to address the obstacles of time and our region's topography. Telemedicine has long been used in the treatment of acute stroke; fibrinolysis administered at remote centres by a specialist at the reference hospital has been shown to be safe and effective, and is associated with good long-term progression.3–5 The technique is less well-established in some other areas of Spain, but has achieved similar results.6,7 Various clinical practice guidelines attest to the effectiveness of telemedicine, recommending its use for stroke treatment.8,9 Telestroke has also been associated with improvements in rural settings10; NIHSS scores established in examinations performed over videoconference have been shown to be valid and reliable.11 Other studies have demonstrated good results for the identification of candidates by teleradiology, with specialists viewing scans remotely.12 In our region, this function is provided via an internet connection between public hospitals, allowing radiological imagery to be sent and viewed.

The Public Health System of Asturias is currently working to implement a specific telemedicine system for the treatment of acute stroke. We hope that once the system is live, acute-phase stroke treatment will become available to patients who are currently outside the treatment window for fibrinolysis, or who are excluded from the code stroke system itself due to long transport times.

The telestroke system is intended to enable neurologists at reference centres to collaborate with local on-call physicians to simultaneously examine patients from more remote areas without on-call neurology services or stroke units, and to assess neuroimaging findings and share clinical history data in real time, jointly deciding whether to administer fibrinolysis. The only aspect on which we disagree with the authors of the letter is whether patients should be transported to reference hospitals once perfusion is underway. Some studies have demonstrated the safety and effectiveness of transporting patients during administration of fibrinolysis.13,14 This approach offers the benefits of admission to a stroke unit (which is not possible in remote hospitals) and the associated protocols, care, management of complications, and diagnostic and therapeutic procedures. It also minimises treatment delays for patients requiring endovascular treatment: invaluable time is wasted if we wait for fibrinolysis to be completed at the local hospital.

References
[1]
L. Benavente, M.J. Villanueva, P. Vega, I. Casado, J.A. Vidal, B. Castaño, et al.
El código ictus de Asturias.
Neurologia, 31 (2016), pp. 143-148
[2]
C. García-Cabo, L. Benavente, J. Martínez-Ramos, A. Pérez-Álvarez, A. Trigo, S. Calleja.
Análisis del primer año del nuevo protocolo de código ictus en Asturias. Experiencia de un único centro.
[3]
S.R. Levine, M. Gorman.
“Telestroke”: the application or telemedicine for stroke.
Stroke, 30 (1999), pp. 464-469
[4]
H.J. Audebert, C. Kukla, S. Clarmann von Claranau, J. Kühn, B. Vatankhah, J. Schenkel, TEMPiS Group.
Telemedicine for safe and extended use of thrombolysis in stroke: The Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria.
Stroke, 36 (2005), pp. 287-291
[5]
S. Schwab, B. Vatankhah, C. Kukla, M. Hauchwitz, U. Bogdahn, A. Fürst, TEMPiS Group, et al.
Long-term outcome after thrombolysis in telemedical stroke care.
[6]
M. Jiménez, S. Tar, I. Legarda, A. Gorospe, M. Torres, P. Merino, et al.
Telemedicina aplicada al ictus en las Islas Baleares: el proyecto Teleictus balear.
Rev Neurol, 54 (2012), pp. 31-40
[7]
A. Pedregosa, J. Álvarez-Sabín, C. Molina, J. Bregués, M. Ribó.
Trombólisis endovenosa en un hospital comarca mediante el sistema teleictus.
Rev Neurol, 53 (2011), pp. 139-144
[8]
L.H. Schwamm, R.G. Holloway, P. Amarenco, H.J. Audebert, T. Bakas, N.R. Chumbler, American Heart Association Stroke Council, Interdisciplinary Council on Peripheral Vascular Disease, et al.
A 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, 40 (2009), pp. 2616-2634
[9]
European Stroke Organisation (ESO) Executive Committee, ESO Writing Committee.
Guidelines for management of ischaemic stroke and transient ischaemic attack 2008.
Cerebrovasc Dis, 25 (2008), pp. 457-507
[10]
A. Wiborg, B. Widder, for the TESS Study Group.
Tele neurology to improve stroke care in rural areas. The Telemedicine in stroke in Swabia (TESS) Project.
Stroke, 34 (2003), pp. 2951-2957
[11]
R. Handschu, R. Littmann, U. Reulbach, C. Gaul, J.G. Heckmann, B. Neundörfer, et al.
Telemedicine in emergency evaluation of acute stroke. Interrupter agreement in remote video examination with a novel multimedia system.
[12]
K.C. Johnston, B.B. Worrall, Teleradiology Assessment of Computerized Tomographs Online Reliability Study.
Teleradiology Assessment of Computerized Tomographs Online Reliability Study (TRACTORS) for acute stroke evaluation.
Telemed J E Health, 9 (2003), pp. 227-233
[13]
M.A. Pervez, G. Silva, S. Masrur, R.A. Betensky, K.L. Furie, R. Hidalgo, et al.
Remote Supervision of IV-tPA for Acute ischemic stroke by telemedicine or telephone before transfer to a regional stroke center is feasible and safe.
Stroke, 41 (2010), pp. e18-e24
[14]
I.E. Silverman, D.K. Beland, J. Chhabra, L.D. McCullough.
The drip-and-ship approach: starting IV t-PA for acute ischemic stroke at outside hospitals prior to transfer to a regional stroke center.
Conn Med, 69 (2005), pp. 613-620

Please cite this article as: Benavente L, Calleja S. Código ictus. ¿Podríamos mejorar los tiempos? Réplica. Neurología. 2019;34:280–281.

Copyright © 2016. Sociedad Española de Neurología
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