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Neuro ICU/Surgical ICU
University of Minnesota Medical Center
500 Harvard St. SE
Minneapolis, MN 55455

Neurology and Neurosurgery Clinics
Clinics and Surgery Center
909 Fulton St. SE, Floor 3
Minneapolis, MN 55455

Stroke Center
Fairview Southdale Hospital
6401 France Ave. S, Unit 73
Edina, MN 55435

Telemedicine Extends Accessibility of Rapid, Advanced Stroke Care

Stroke affects ~ 800,000 individuals annually in the United States and results in approximately 140,000 deaths.1  Approximately 610,000 of these strokes are first or new strokes, and the remainder occur in individuals who have had a previous stroke.1  Stroke risk increases with age, but in 2009, 34% of those hospitalized for stroke were younger than age 65.2  Stroke accounts for an estimated $34 billion in health-related costs each year and is the leading cause of serious long-term disability.3  More than half of stroke survivors aged 65 or older experience reduced mobility, making initial therapy more critical for mitigating effects of stroke and reducing the likelihood of repeat strokes.3,4  

A telestroke cart in a clinic room. University of Minnesota Health neurologist Benjamin R. Miller, MD, appears on screen for a consultation.
A telestroke cart in a clinic room. 
Acute ischemic stroke accounts for about 85% of strokes in the United States, and rapid interventions through emergency department care provide the best opportunities for reversing neurologic deficits and restoring function.5  Time is critical for treatment. Every additional minute of ischemia is thought to lead to the death of 2 million neurons.5  Before 2014, treatment had been limited to intravenous tissue plasminogen activator given within 4.5 hours from the last time the patient was seen well, but clinical trials have demonstrated the effectiveness of minimally invasive endovascular clot removal, increasing the options for emergent stroke treatment and expanding the therapeutic time window.6,7 The 2 most recent endovascular stroke trials support extending the period of stroke intervention up to 24 hours from stroke onset for appropriately selected patients.8,9 What was most notable in these trials, however, was the marked impact of endovascular treatment in comparison with medical management: for every 2  patients treated with endovascular therapy, 1 additional patient had an improvement in functional outcome.9  Locally, the University of Minnesota played a pivotal role in this research effort, both as a DEFUSE-3 site and a coordinating hub for other DEFUSE-3 sites in the region.  

As a result of these new studies, increasing numbers of stroke patients can receive effective interventional therapy at Comprehensive Stroke Centers or when appropriately assessed and treated remotely. Toward this goal, telemedicine programs such as the University of Minnesota Health Stroke and Telestroke Program provide immediate around-the-clock clinical evaluation to remote hospitals with real-time interpretation of diagnostic testing and neuroimaging. (See Case Study for further discussion.) All University of Minnesota Health telestroke physicians are fellowship-trained specialists in stroke or neurocritical care. Telestroke enables them to rapidly determine whether emergent interventions would be beneficial or harmful and whether the patient should be transferred to a Comprehensive Stroke Center.  

References

  1. Centers for Disease Control and Prevention. Vital signs: recent trends in stroke death rates—United States, 2000-20015. MMWR. 2017:66. 
  2. Hall MJ, Levant S, DeFrances CJ. Hospitalization for stroke in US..hospitals, 1989-2009. NCHS data brief, No 95. Hyattsville, MD: National Center for Health Statistics; 2012 http://www.cdc.gov/nchs/products/databriefs/db95.htm [Accessed October 11, 2018]
  3. Benjamin EJ, Blaha MJ, Chieuve SE, et al, on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135:e229-e445.
  4. Zerna C, Thomalla G, Campbell BCV, Rha JH, Hill MD. Current practice and future directions in the diagnosis and acute treatment of ischaemic stroke. Lancet. 2018; Epub ahead of print, October 6, 2018. Accessed October 10, 2018.
  5. Saver JL. Time is brain-quantified. Stroke. 2006;37(1):263-266. doi:10.1161/01. STR.0000196957.55928.ab
  6. Goyal M, Menon BK, van Zwam WH, et al.; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a metaanalysis of individual patient data from five randomized trials. Lancet. 2016:387(10029):1723-1731. doi: 10.1016/S0140-6736(16)00163-X
  7. Saver JL, Goyal M, van der Lugt A, et al.; HERMES Collaborators. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA. 2016;316(12):1279-1288. doi: 10.1001/ jama.2016.13647
  8. Nogueira RG, Jadhav AP, Haussen DC, et al.; DAWN Trial Investigators. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378(1):11-21. doi: 10.1056/NEJMoa1706442 
  9. Albers GW, Marks MP, Kemp S, et al; DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378(8):708-718.

When to Refer

University of Minnesota Health specialists diagnose and treat a full range of cerebrovascular diseases, including stroke, cerebral aneurysm, arteriovenous malformations, and carotid disease. University of Minnesota Medical Center has received Advanced Certification for Comprehensive Stroke Centers. The Joint Commission designation recognizes excellence in patient outcomes; comprehensive services, including advanced imaging and specialized treatments; patient education; and research. We are among a small national cohort given this level of certification. Through our Comprehensive Stroke Centers, acute stroke care is available 24 hours a day, and patients have access to advanced, evidence-based therapies; a dedicated neuro-intensive care inpatient unit; and comprehensive after-care services and rehabilitation support. 

Our team includes neurosurgeons, neurologists, neurointensivists, interventional neuroradiologists, and advanced practice providers. This complete team approach coupled with rapid assessment and treatment offers patients the best opportunity for good outcomes.

University of Minnesota Health neurologists have implemented the telemedicine technology telestroke at Fairview Southdale Hospital, our second Comprehensive Stroke Center, in partnership with Fairview Health Services. They also operate telestroke at Fairview Ridges Hospital and Fairview Grand Itasca Hospital, with plans for further expansion underway. Telestroke technology allows many patients to be treated locally without the need for transfer to more specialized care, saving time, expediting recovery, and reducing expenses.

To learn more about participating in the University of Minnesota Health Stroke and Telestroke Program, contact Sarah Engkjer, MA, RN, Clinical Program Manager-Telestroke at sengkjer10@umphysicians.umn.edu or 612-626-6535.

For information and referrals to University of Minnesota Medical Center, call 612-672-7000. For the Fairview Southdale Stroke Center, call 952-924-5700. For physician referrals to the Fairview Acute Rehabilitation Center, call 612-273-4277.


To find current clinical trials available through M Health providers, visit studyfinder.umn.edu

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