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CASE STUDY

Mr. Taylor is a 45-year-old man enjoying a summer vacation camping in rural southwest Virginia. He has been enjoying hiking and swimming with his wife and two young daughters for the last two days. Today at 5:25 P.M., his wife finds him in their tent “slumped over” with incomprehensible speech. She had just talked to him no more than 10 minutes prior and he seemed fine. She sees that his right side is paralyzed and immediately knows he needs emergency help. Emergency medical services (EMS) are summoned by the clerk at the park entrance. Mr. Taylor is lifted into the ambulance to be transported to the nearest hospital, which is a small 16-bed critical access hospital serving the surrounding rural area. During ambulance transport, the EMS provider identifies the patient as having a potential “stroke” using a validated prehospital stroke scale. Under a new protocol, the EMS provider connects with a telestroke neurologist at a regional academic medical center using a mounted tablet with 4G LTE connectivity. The neurologist reviews the history, medications, and vital signs with EMS and performs the NIH Stroke Scale (NIHSS). The neurologist's assessment suggests a severe stroke that may be eligible for thrombolytic treatment and perhaps a large vessel occlusion that may warrant endovascular therapy with clot retrieval. This information is relayed to the local emergency department physicians.

Upon arrival to the hospital, Mr. Taylor is rapidly taken to the computed tomography (CT) scanner, and the images are digitally transferred to the hub hospital's radiology server. A videoconference telemedicine cart is placed at the foot of the bed, and the telestroke consulting neurologist rapidly repeats the NIHSS to confirm the deficits. She discusses her findings with the patient's wife, explaining that he is a good candidate for the clot-busting drug, intravenous tissue plasminogen activator (tPA), and recommends immediate treatment. The tPA is administered at 6:35 P.M., 80 minutes since Mr. Taylor was last seen normal. The neurologist has notified the on-call interventional neuroradiologist at the hub hospital. Using multipoint videoconferencing, they discuss the patient's neurovascular imaging, including a CT angiogram that demonstrates an abrupt “cut-off” sign indicating an embolus in the left middle cerebral artery. The emergency department (ED) physician, the neurologist, and the interventionalist discuss with the patient's family by live videoconferencing and recommend that Mr. Taylor be air-lifted to the hub stroke center for immediate clot retrieval. Mr. Taylor successfully undergoes the procedure and is able to discharge to home with minimal neurological deficits several days later. He is independent and back to work at 3 months.

INTRODUCTION

The paradigm of acute stroke care shifted in the 1990s with the approval of intravenous (IV) tPA, rendering stroke a time-sensitive condition requiring rapid availability of neurological expertise. 1 For many hospitals and communities unable to provide continual stroke expertise, particularly in rural and underserved areas, 2,3 the emerging practice of telemedicine ...

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