Telemedicine-assisted Treatment of Patients With ICH
Telemedicine-assisted Treatment of Patients With ICH
Results suggested that the care of patients with ICH through a telemedicine system is safe and effective. The telemedicine network allowed prompt selection of a subgroup of patients who were the best candidates for direct neurosurgical or neurointensive care. This group consisted of 24% of all patients with ICH who had been admitted to the peripheral hospitals and included those (13%) in whom the surgical control of ICP was readily necessary or decidedly predictable and those (11%) in whom bleeding due to vascular malformations, tumors, or sinus thrombosis had to be ruled out in the acute setting. The interpretation of images and clinical data was correct in 96.5% of cases.
The selection of patients as candidates for direct neurosurgical care is controversial, and the practice in ICH care continues to be arbitrary. This attitude is in part a consequence of the misinterpretation of the results of the largest trial on spontaneous ICH management, the International Surgical Trial in Intracerebral Haemorrhage (STICH). Evidence of the poor efficacy of surgical management for spontaneous ICH persuaded many surgeons that there is no need to perform surgery in patients with ICH. However, it is evident that early relief of elevated ICP is effective in all other clinical settings. Furthermore, a detailed post hoc analysis of the data in the STICH showed that 42% of patients had an associated IVH, and the prognosis in most of these cases is dismal. Removing these patients from the analysis and focusing on superficial ICHs, the data presented a more encouraging picture for surgery, with 49% of patients gaining a favorable outcome versus 37% of the conservatively treated patients (p = 0.080).
Beyond the data mentioned above, there are specific categories of patients with spontaneous ICH who remain reasonably suitable candidates for surgery, such as those with acute hydrocephalus due to intraventricular bleeding and those with a large (> 3 cm) cerebellar hemorrhage who are neurologically deteriorating or have brainstem compression and/or hydrocephalus. Furthermore, seemingly spontaneous ICHs may hide vascular abnormalities (aneurysm, arteriovenous malformation, dural arteriovenous fistula, and cavernous malformation), tumors, or venous thrombosis, which require specific surgical treatments, or vasculitis and coagulopathy, which require specific medical treatments. A qualified judgment of the combined clinical status of the patients and the neuroradiological picture is therefore essential to avoid inappropriate management.
Telemedicine networks represent a new approach to improve stroke care in community settings. Since the first 1999 description by Levine and Gorman of a telemedicine network for the treatment of patients with ischemic stroke (Telestroke), several studies have been conducted to demonstrate the efficacy of telemedicine in providing specialist care to patients with ischemic stroke in rural communities. Telemedicine clearly showed its efficacy in providing hospitals in rural communities with the expertise of established stroke centers on demand and within minutes. Moreover, it has been demonstrated that, embedded in a comprehensive stroke network, the teletransfer of clinical information and brain images yields medical results similar to those following treatment at experienced stroke centers.
In particular, it has been shown that Telestroke improves the care of patients with ischemic stroke by limiting the number of interhospital referrals, allowing one to choose or exclude candidates for thrombolytic therapy with intravenous tissue plasminogen activator and eventually improve neurological outcome in these patients. Actually, using the Telestroke approach, intravenous thrombolysis with tissue plasminogen activator has been shown to be safe and has been applied more frequently than without teleneurological consultation. Nonetheless, studies focused on the role of telemedicine in the treatment of patients with ICH in acute settings are lacking. Only 1 study demonstrated that telemedicine might enhance enrollment of patients with ICH into time-sensitive stroke trials, such as FAST (Factor Seven for Acute Hemorrhagic Stroke), a multicenter randomized trial to study the role of recombinant factor VIIa in ICH.
Our telemedicine network (RESPECT) considerably improved the rapidity of a second opinion consultation, making it more efficient in acute settings. The possibility of directly viewing neuroradiological images and doing postprocessing analysis made neurosurgical consultation easier and faster, allowing us to choose patients who needed transfer to the academic hub and making their transfer more rapid. Indeed, our data confirm that telemedicine allows one to effectively organize selected and timely interhospital transfers to specialized institutions.
As a second step, we evaluated the role of telemedicine in optimizing the care of patients with ICH at peripheral hospitals in the acute setting. Five hundred forty-nine patients (74.9%) could be directly treated at the spoke hospitals. They underwent clinical, neurological, and neuroradiological monitoring based on neurosurgical indications; they also underwent more CT studies than the patients admitted to the hub, despite similar clinical conditions. We did not address the safety and efficacy of the procedure by measuring the long-term outcome. Actually, in general it is possible that patients treated at the peripheral hospitals received different levels of care. Nevertheless, our experience suggests that in the acute and subacute settings, telemedicine allows the treatment of patients with ICH directly at the peripheral hospitals with the opportunity for online neurosurgical evaluation. This may contribute to increase competence in ICH management among health system professionals and optimization of resources, avoiding unnecessary transfers. Patients treated at the spokes were those who needed standard care or those in whom supportive care was indicated. Nonetheless, 8 patients (1.4%) treated at the spoke hospitals presented with a rapid and unpredicted worsening of neurological status and/or a neuroradiological picture that made secondary transfer to the referring neurosurgical department necessary. In 5 of 8 patients, the worsening was a result of treatment with oral anticoagulants. As demonstrated already, the use of such drugs can increase the risk of spontaneous ICH or hemorrhagic evolution in patients with ICH. There are lessons to be learned from these cases. To avoid secondary transfer, history and clinical/neurological examination by emergency physicians at the peripheral hospitals should be as accurate as possible to make neurosurgical consultation easier and more precise. Moreover, one must strictly follow neurosurgical indications, respecting time intervals between radiological examinations and repeatedly using the telemedicine system for a second opinion. Even if those needing secondary transfer were a small proportion, the patients in a deep coma or moribund status were not centralized and were only given supportive care. Thus, the rate of secondary transfer may underestimate the patient deterioration that occurred at the spoke hospitals.
Discussion
Results suggested that the care of patients with ICH through a telemedicine system is safe and effective. The telemedicine network allowed prompt selection of a subgroup of patients who were the best candidates for direct neurosurgical or neurointensive care. This group consisted of 24% of all patients with ICH who had been admitted to the peripheral hospitals and included those (13%) in whom the surgical control of ICP was readily necessary or decidedly predictable and those (11%) in whom bleeding due to vascular malformations, tumors, or sinus thrombosis had to be ruled out in the acute setting. The interpretation of images and clinical data was correct in 96.5% of cases.
The selection of patients as candidates for direct neurosurgical care is controversial, and the practice in ICH care continues to be arbitrary. This attitude is in part a consequence of the misinterpretation of the results of the largest trial on spontaneous ICH management, the International Surgical Trial in Intracerebral Haemorrhage (STICH). Evidence of the poor efficacy of surgical management for spontaneous ICH persuaded many surgeons that there is no need to perform surgery in patients with ICH. However, it is evident that early relief of elevated ICP is effective in all other clinical settings. Furthermore, a detailed post hoc analysis of the data in the STICH showed that 42% of patients had an associated IVH, and the prognosis in most of these cases is dismal. Removing these patients from the analysis and focusing on superficial ICHs, the data presented a more encouraging picture for surgery, with 49% of patients gaining a favorable outcome versus 37% of the conservatively treated patients (p = 0.080).
Beyond the data mentioned above, there are specific categories of patients with spontaneous ICH who remain reasonably suitable candidates for surgery, such as those with acute hydrocephalus due to intraventricular bleeding and those with a large (> 3 cm) cerebellar hemorrhage who are neurologically deteriorating or have brainstem compression and/or hydrocephalus. Furthermore, seemingly spontaneous ICHs may hide vascular abnormalities (aneurysm, arteriovenous malformation, dural arteriovenous fistula, and cavernous malformation), tumors, or venous thrombosis, which require specific surgical treatments, or vasculitis and coagulopathy, which require specific medical treatments. A qualified judgment of the combined clinical status of the patients and the neuroradiological picture is therefore essential to avoid inappropriate management.
Telemedicine networks represent a new approach to improve stroke care in community settings. Since the first 1999 description by Levine and Gorman of a telemedicine network for the treatment of patients with ischemic stroke (Telestroke), several studies have been conducted to demonstrate the efficacy of telemedicine in providing specialist care to patients with ischemic stroke in rural communities. Telemedicine clearly showed its efficacy in providing hospitals in rural communities with the expertise of established stroke centers on demand and within minutes. Moreover, it has been demonstrated that, embedded in a comprehensive stroke network, the teletransfer of clinical information and brain images yields medical results similar to those following treatment at experienced stroke centers.
In particular, it has been shown that Telestroke improves the care of patients with ischemic stroke by limiting the number of interhospital referrals, allowing one to choose or exclude candidates for thrombolytic therapy with intravenous tissue plasminogen activator and eventually improve neurological outcome in these patients. Actually, using the Telestroke approach, intravenous thrombolysis with tissue plasminogen activator has been shown to be safe and has been applied more frequently than without teleneurological consultation. Nonetheless, studies focused on the role of telemedicine in the treatment of patients with ICH in acute settings are lacking. Only 1 study demonstrated that telemedicine might enhance enrollment of patients with ICH into time-sensitive stroke trials, such as FAST (Factor Seven for Acute Hemorrhagic Stroke), a multicenter randomized trial to study the role of recombinant factor VIIa in ICH.
Our telemedicine network (RESPECT) considerably improved the rapidity of a second opinion consultation, making it more efficient in acute settings. The possibility of directly viewing neuroradiological images and doing postprocessing analysis made neurosurgical consultation easier and faster, allowing us to choose patients who needed transfer to the academic hub and making their transfer more rapid. Indeed, our data confirm that telemedicine allows one to effectively organize selected and timely interhospital transfers to specialized institutions.
As a second step, we evaluated the role of telemedicine in optimizing the care of patients with ICH at peripheral hospitals in the acute setting. Five hundred forty-nine patients (74.9%) could be directly treated at the spoke hospitals. They underwent clinical, neurological, and neuroradiological monitoring based on neurosurgical indications; they also underwent more CT studies than the patients admitted to the hub, despite similar clinical conditions. We did not address the safety and efficacy of the procedure by measuring the long-term outcome. Actually, in general it is possible that patients treated at the peripheral hospitals received different levels of care. Nevertheless, our experience suggests that in the acute and subacute settings, telemedicine allows the treatment of patients with ICH directly at the peripheral hospitals with the opportunity for online neurosurgical evaluation. This may contribute to increase competence in ICH management among health system professionals and optimization of resources, avoiding unnecessary transfers. Patients treated at the spokes were those who needed standard care or those in whom supportive care was indicated. Nonetheless, 8 patients (1.4%) treated at the spoke hospitals presented with a rapid and unpredicted worsening of neurological status and/or a neuroradiological picture that made secondary transfer to the referring neurosurgical department necessary. In 5 of 8 patients, the worsening was a result of treatment with oral anticoagulants. As demonstrated already, the use of such drugs can increase the risk of spontaneous ICH or hemorrhagic evolution in patients with ICH. There are lessons to be learned from these cases. To avoid secondary transfer, history and clinical/neurological examination by emergency physicians at the peripheral hospitals should be as accurate as possible to make neurosurgical consultation easier and more precise. Moreover, one must strictly follow neurosurgical indications, respecting time intervals between radiological examinations and repeatedly using the telemedicine system for a second opinion. Even if those needing secondary transfer were a small proportion, the patients in a deep coma or moribund status were not centralized and were only given supportive care. Thus, the rate of secondary transfer may underestimate the patient deterioration that occurred at the spoke hospitals.