The phrase “time is brain” represents the recognition that a stroke is a time sensitive neurological emergency.
But many patients, particularly those who live in remote and medically underserved areas, have limited access to neurologists. Although telemedicine is a possible solution in those situations, neurologists are still tied to a desktop or laptop computer that require a reliable Internet connection.
A recent study by Bart Demaerschalk, M.D., and colleagues from the Mayo Clinic in Phoenix, has determined that telemedicine can, as Dr. Demaerschalk puts it, “fit in our pockets.” The study, published in the September 2012 issue of Stroke, found that the U.S. Food and Drug Administration (FDA)-approved ResolutionMD™ Mobile smartphone app, from Calgary Scientific, can be used successfully to evaluate medical images during the course of a complete telestroke evaluation.
“Every second that elapses between the onset of stroke and diagnosis, management and institution of treatment means that more neurons die and patients have a greater possibility of neurological deficit, disability or death,” said Dr. Demaerschalk, a professor of neurology and medical director of Mayo Clinic Telestroke, a network connecting the Mayo Clinic Hospital in Phoenix to a dozen rural hospitals, most of which are in Arizona. “But with existing technology, as sophisticated as it is, there are still instances when there can be delays.”
Smartphones, however, give neurologists immediate access to patients’ brain imaging. Dr. Demaerschalk and colleagues evaluated 53 patients who presented at Yuma Regional Medical Center with acute stroke and underwent a CT brain scan. Each scan was simultaneously interpreted by radiologists in Yuma and telestroke doctors with smartphones, and then by an independent adjudication panel of stroke neurologists whose determinations were considered to be the gold standard.
Researchers determined that smartphones were “not perfect” when it came to evaluating the more subtle features of CT brain scans. “In some cases, it wasn’t as good as the traditional radiologist interpretation at a PACS workstation,” Dr. Demaerschalk said.
But as far as the most important aspects of the CT scan interpretation for purposes of this study—its usefulness in making treatment recommendations for patients with acute stroke—the smartphone worked quite well. “In excluding hemorrhage in the brain, tumor, and any other contraindications to recommendations for clot-busting medications, it was very good,” Dr. Demaerschalk said, pointing out that the level of agreement among reviewers was 92 to 100 percent.
Results show that telemedicine can be used anywhere and at anytime, which is particularly important in a state like Arizona where a substantial part of the population doesn’t have immediate access to neurological care.
“We’ve also learned that it’s not just remote rural hospitals that are underserved,” Dr. Demaerschalk said. “There are a number of urban hospitals that are underserved as well.” He pointed out that his own institution in Phoenix provides telestroke care to the Maricopa Medical Center, a busy urban hospital that has neurologists on staff but is still challenged when it comes to finding emergency neurological care.
Dr. Demaerschalk and colleagues also conducted a companion study, published in Stroke, in which they determined that high-quality video teleconferencing using smartphones to conduct neurological exams for stroke are “reliable, easy to use, affordable...and [yield] high physician satisfaction.”
Ultimately, Dr. Demaerschalk would like to test the validity of the two studies in one combined study, to determine whether smartphones remain a reliable and safe tool, before the technology is adopted for routine clinical practice. q
Smartphones were used by neurologists at Jikei University School of Medicine (JUSM) in Tokyo to develop a system for exchanging diagnostic images and clinical and management information to rapidly diagnose and treat stroke victims.
In their pilot study, co-inventors and authors Hiroyuki Takao, M.D., an instructor at JUSM, and Yuichi Murayama, M.D., director for the Center of Endovascular Surgery at JUSM, developed the “i-Stroke” system to transfer hospital-generated patient, clinical and imaging information from a hospital “stroke server” to a physician’s smartphone. The system, since renamed SYNAPSE ERm, is able to transfer clinical data, CT, MR, angiographic, intraoperative images and expert opinion in real time. The consultation occurs via Twitter direct messages seen only by the recipient.
The study was published in the October 2011 issue Stroke and presented at the 2012 Society of NeuroInterventional Surgery annual meeting.
Dr. Takao sees smartphones as part of the solution in continuing efforts to rapidly diagnose and treat stroke victims. “We can’t use a personal computer anytime and anywhere, but we can use smartphone devices for stroke on anyone, anytime anywhere.”
In addition to delivering images, the system can alert hospital staff to the imminent arrival of stroke patients and the amount of time elapsed after the stroke and patient’s condition on arrival. By allowing physicians to view imaging results and other tests in real time, SYNAPSE ERm encourages swift reaction and saves precious time.
The system also allows neurologists outside the hospital to view surgical and other procedures in real time, making them available for guidance and expert assessment of treatment progress.
“The system may become useful for acute patient management in neurology and neurosurgery,” said Dr. Takao, adding that the system can improve the outcome in many patients by facilitating diagnosis and treatment of stroke. He also believes SYNAPSE ERm can help cut healthcare costs by improving physician efficiency and reducing misdiagnosis and the unnecessary transfer of patients.
SYNAPSE ERm is available for free download at the Apple store in Japan. Licensed by FUJIFILM Corp., the system is now in place in approximately 25 hospitals in Japan, Dr. Takao said. Trials are underway in the U.S. and Europe to evaluate the technology and pave the way for possible regulatory approval.
To view an abstract of the study, “Smartphone Teleradiology Application Is Successfully Incorporated Into a Telestroke Network Environment,” go to stroke.ahajournals.org/content/43/11/3098.
To view an abstract of the study, “A New Support System Using a Mobile Device (Smartphone) for Diagnostic Image Display and Treatment of Stroke,” go to stroke.ahajournals.org/content/43/1/236.abstract.
To access SYNAPSE ERm at the Apple store in iTunes, go to itunes.apple.com/jp/app/i-stroke-med/id412362802?l=en&mt=8.
To view a video of Bart Demaerschalk, M.D., demonstrating the ResolutionMD smartphone application, go to http://youtu.be/trxsCPOkfN4.
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