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Re: Using tPA for acute stroke in a rural setting

The use of tPA in the rural setting described by Edwards is remarkably high.[1] This is likely because 16 of the 19 patients treated with tPA at the Hastings, Nebraska hospital were evaluated by neurologists. While we agree with Lyden’s [2] commentary that a dedicated stroke team is essential to optimize acute stroke care, we feel attempting to apply this on-site model in most settings in rural America is unrealistic. This statement may even endanger patients. Without specialist support, rural physicians may be coerced by threat of litigation to make unsound, acute stroke management decisions.

Our extensive experience in rural Georgia within a 100 mile radius of Augusta has documented that tPA was never given until the introduction of the REACH telestroke system (Remote Evaluation of Acute isCHemic stroke). [3] County hospitals, if present, range from 10 to 72 beds. The EDs are overwhelmingly staffed by non emergency physicians. Despite having older generation CT scanners, there is usually no available radiologist. The rural physician’s ability to read CT scans also varies. REACH has prevented administration of tPA to a missed subarachnoid hemorrhage. There are no neurologists on staff at these rural sites and long flight times historically precluded administration of tPA.

The REACH system at the Medical College of Georgia uses secure internet connections, a wireless computer cart, and a remotely driven camera to evaluate acute stroke patients in rural hospitals of north central Georgia in the nation’s “stroke belt.” Technical specifications have been previously detailed. [3,4] Dissemination of protocols and training in stroke response at all rural sites, along with mobile access to a stroke specialist 24/7 has resulted in a unique stroke team.

REACH was implemented in 2003 and has expanded to 9 rural sites. More than 450 consultations have been performed. Seventy-seven patients received tPA, many in under 2 hours from the onset of symptoms. Unpublished charted reviews at the REACH sites show 10% of acute stroke patients receive tPA. Reasons for not treating are similar to Edwards’ experience. Four tPA patients developed minimally symptomatic intracranial hemorrhages.

We absolutely concur that a strong stroke team is necessary. However, in the rural setting an on-site team is unrealistic. Our experience suggests that live consultation with stroke specialists via internet is presently the best answer to the shortage of physician specialists in rural America and the best hope for acute stroke patients.

References

1. Edwards LL. Using tPA for Acute Stroke in a Rural Setting, Neurology 2007; 648:292-294.

2. Lyden PD, Using tPA for Acute Stroke in a Rural Setting [Commentary], Neurology 2007; 648:247.

3. Wang S, Gross H, Lee SB et al. Remote Evaluation of Acute Ischemic Stroke in Rural Community Hospitals in Georgia. Stroke 2004;36:1763-1768.

4. Wang S, Lee SB., Pardue C et al. Remote Evaluation of Acute Ischemic Stroke – Reliability of National Institutes of Health Stroke Scale via Telestroke. Stroke 2003;34:e188-e192.

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Re: Reply from the Author

TPA is the only FDA approved treatment for acute stroke. [5] It makes a significant difference in the lives of many patients who receive it. There are clear parameters that must be followed when it is used. [5] An emergency room equipped with CT scanner and interpreting radiologist, clinical laboratory, physicians trained in the NIH stroke scale, and located within 2 hours of a neurosurgeon have the necessary components to consider implementing a stroke team approach that could safely incorporate the use of TPA in acute stroke.

Rural hospitals may be anything from a 10 to 100 bed institution. The implications for appropriate level of care will be different. There are several ways to improve the treatment of acute stroke in the United States. The REACH system [3,4] may be one of them, but I do not think we can suggest that our rural physicians are inept or subject to coercion in making sound medical decisions with regard to stroke.

The physicians who call me from smaller community hospitals exhibit extraordinary skills in discerning potential candidates for TPA. Our focus needs to be on how to facilitate the arrival of a potential stroke victim to a medical institution that has the advantage of providing TPA for acute stroke. This involves public education, education of EMT’s and paramedics, and cooperation with emergency department staff. We do not want to foster the attitude that it is too dangerous to use in the appropriate clinical situation.

Reference

5. NINDS t-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581-1587.