Extended Window Thrombolytics for Ischemic Stroke: A Telestroke versus In-person Experience

Abstract

Background and purpose: Telestroke evaluation of patients with acute ischemic stroke is supported by American Heart and Stroke Association Guidelines. However, there is no data on outcomes or safety of administering IV thrombolytic stroke therapy using extended window criteria (>4.5 h since onset of symptoms with a hyperacute MRI diffusion T2/FLAIR mismatch) via telestroke. Here, we report adverse events and outcomes of extended-window thrombolysis by telestroke vs in-person care.

Methods: We performed a retrospective cohort review from 2020 to 2022 of prospectively collected multinstitutional databases from a large, not-for-profit health system with both in-person stroke and telestroke care. The primary outcome was frequency of symptomatic intracranial hemorrhage (sICH). Secondary outcomes were favorable functional outcome at hospital discharge (modified Rankin Scale, mRS, 0-3) and discharge disposition.

Results: A total of 33 patients were treated with extended-window thrombolysis (n = 20 in-person, n = 13 telestroke). The median NIH stroke scale was 6, and time since last known normal was similar (median [95% CI]: in-person 13 h [11-15 h] vs telestroke 12 h [9-16 h], P = .33). The sICH frequency was low and occurred in one patient (4.8% in-person vs 0% by telestroke). Favorable outcome at discharge was not different between in-person and telestroke care (median mRS [95% CI]: 2 [1-3] vs 1 [0-2], OR .0 [.0-1.8], P = .27), and discharge deposition was also similar.

Conclusions: In patients eligible for extended window acute stroke treatment with thrombolytics, there was no difference in adverse events between telestroke and in-person care.

Keywords: extended window thrombolysis; hyperacute stroke treatment; ischemic stroke; telemedicine; teleneurocritical care; telestroke; tissue plasminogen activator.

Figure 1.

Change in National Institute of Health Stroke Scale from initial hospital presentation to after administration of IV thrombolytics at the time of discharge. Consecutive patients represented. Positive change values indicate improvement of NIHSS, negative indicates worsening of the NIHSS.

Figure 2.

(A) Discharge modified rankin scale in patients treated with IV thrombolytics by MRI guided extended-window criteria, either by in-person neurology or telestroke. (B) Hospital discharge disposition categories. ARU, acute rehab unit; LTAC, long term acute care facility; MRS, modified rankin scale; SNF, skilled nursing facility.