The global incidence of stroke keeps rising. In Colombia, the stroke incidence lays between 85–87 cases per 100,000 people.1,2 It represents one of the most important causes of overall mortality and disability.3,4 Further treatments are needed to modify the natural course of the disease.

Tissue plasminogen activator thrombolysis (IV-tPA) is the most important treatment for systemic reperfusion approved for stroke patients.5 Its administration should be supervised by a vascular neurologist or a stroke specialist. Nonetheless, the lack of neurologists and the geographic barriers pose an important challenge that precludes rural areas from receiving adequate stroke care.5,6 Considering this, the American Heart Association (AHA) has endorsed the use of telemedicine for Stroke workup and treatment; such strategy is also known as Teleictus or Telestroke.7

While some centers are able to perform thrombolysis and keep these patients in observation after receiving tPA (on-site thrombolysis or Face-to-face thrombolysis), others need the advice and expertise from a specialized team that remotely directs and sets up IV thrombolysis and then sends the patients to a concentration stroke center (Telestroke strategy). In our study, we used the experience from the San Rafael Tunja University Hospital (HUSRT), which works as a regional reference center (face-to-face thrombolysis center).

Considering this, we decided to conduct a study with the aim of comparing the outcomes of stroke treatment using the Telestroke versus the Face-to-face thrombolysis models of care.

We performed a retrospective, analytic, observational study using 2 cohort groups comparing the clinical evolution and outcomes of adult patients that underwent stroke treatment using either the Face-to-face thrombolysis or the Telestroke strategies between June 2019 and April 2021. Sociodemographic, clinical, protocol thrombolysis related and clinical evolution variables were analyzed in all patients.

Our main goal was to evaluate the National Instituted of Health Stroke Scale (NIHSS) score at discharge. Other secondary outcomes that were studied were hospital length of stay, in-hospital mortality, and mortality after 3 months. We also studied the intracerebral hemorrhage (ICH) incidence during the first 24 h after thrombolysis, using non contrast CT scan (NCCT), as a variable to assess the safety of the thrombolytic therapy in both scenarios. CT scan studies were evaluated using appropriate classifications8 by two members of the research team. This study was approved by the ethics committee of the HUSRT.

During the study period, 65 stroke patients were treated using the Face-to-face thrombolysis model and 35 were intervened using the Telestroke model in the HUSRT. Median age was 69 and 67 for each group. Women outnumbered men in both groups; 52.3% were women in the Face-to-face thrombolysis group and 62.8% in the Telestroke group.

Regarding attention times, a median onset-of-symptoms to door time was calculated at 136 min (IQR 81–180) for the Face-to-face thrombolysis group and 81 min (IQR 44–155) for the Telestroke group p = 0.0083. In the case of the door-to-CT and door-to-needle times, their respective median was 4, 6 and 49, 50 min; neither were statistically significant between both groups (p > 0.05) Table 1.

When comparing clinical characteristics of the stroke patients in the face-to-face thrombolysis and telestroke groups, we found an initial NIHSS score of 11 and 12 points respectively. 80% of the patients had an anterior circulation stroke and more than 50% of patients had a left stroke, slightly higher than right stroke. The most compromised arteries were the Middle Cerebral Artery (MCA) (76.9% for the Face-to-face thrombolysis group and 82.8% for the Telestroke group), followed by the Posterior Cerebral Artery (PCA) (13.8% in the Face-to-face thrombolysis group) and the Anterior Cerebral Artery (5.7% in the Telestroke group). No statistically significant differences were observed between the NIHSS scores, stroke territories, side and affected arteries of the study groups Table 2.

When analyzing the etiologies of the strokes included in the study, we found an auricular fibrillation frequency of 21.5% in the Face-to-face thrombolysis group and 40% in the Telestroke group (p = 0.04986). The percentage of carotid stenosis lower than 50% was 93.8% for the Face-to-face thrombolysis group and 88.5% for the Telestroke group. The Left Ventricle Ejection Fractions (LVEFs) reported for the patients were non-significant between the groups. The most common hemorrhagic complications were the Hemorrhagic Infarction type 1 and the Hemorrhagic Infarction type 2; intraparenchymal hemorrhage was observed at a lower percentage.

When comparing the evolution data of the patients, both groups had a discharge NIHSS score of 4 p = 0.9091. Hospital length of stay show a median of 4 in both groups. At discharge, 89.2% of patients in the Face-to-face thrombolysis model were alive, compared to 77.1% in the Telestroke model. 3-month survival rate was calculated at 81.5% and 65.7% for the Face-to-face thrombolysis and Telestroke models respectively. Total of deceased patients was 13.8% in the Face-to-face thrombolysis group and 28.5% in the Telestroke model. No statistically relevant data was found for the hospital length of stay, survival at discharge and 3-month survival variables Table 3.

The adjusted association analysis showed that the Telestroke model has a OR of 3.49 (95% CI; 1.45–8.42) of having an onset-of-symptoms to door time equal or less than 81 min comparted to the Face-to-face thrombolysis model. Associations between survival at discharge, 3-month survival and mortality did not yield statistically significant differences.

The San Rafael Tunja University Hospital successfully performed the first telethrombolysis strategy in Colombia as an answer to the need to provide adequate care and thrombolysis to stroke patients from other counties away from Tunja, where the hospital is located.9 Stroke patients coming from up to 56.6 km away from our main institution were successfully treated, lowering the geographic coverage gap10 and allowing the creation of a virtual network covering the main hospitals in the region.

The clinical characteristics of the patients who underwent thrombolysis in both groups were similar.

Our study found that the age of presentation of stroke was similar in both groups, with a discrete higher prevalence in female patients; this is different from the findings published in the TEMPis and NINDS studies,11 as well as the Chilean experience,6 where the majority of patients were men, aged 68, 67 and 65.6 years respectively. A systematic analysis of the stroke burden of disease found that, when classified into age groups, stroke incidence is similar between men and women under 55 years, but significantly higher in men for ages between 55 and 75.1 Furthermore, some Colombian epidemiology studies report a higher incidence for men as well.12

Average initial NIHSS score was marginally lower than the ones reported in TEMPis and NINDS (13 and 14 points each)11 and in the Chilean study (8 points),6 but it still was higher than some studies that reported an average of 5 points.13 Compared to a previous systematic review published in Colombia, the initial NIHSS scores were similar to the ones observed in Bogotá (average 11.7 points), but higher than the ones found in an article in Barranquilla in 2017 (9 points) and lower than those in Cali in 2014 (12.9 points).14

The reported median onset-of symptoms-to-door, door-to-CT and door-to-needle times in our study were within the internationally standardized time frames according to the latest update in the Guidelines for the Early Management of Patients with Acute Ischemic Stroke by the AHA.15 In this guidelines and other documents, a shorter door-to-needle time is heavily emphasized, as stated in the phrase <>>.16

Among the comparison between the timeframes reported in our study and those reported externally, we observed a lower door-to-CT than the Chilean study (14 min),6 and a lower average door-to-needle time than what was reported in the TEMPis study in Bavaria (76 ± 24 min),11 as well as in the Sami Al Kasab cohort (57 min),13 the Mansilla et al. group (56.5 min)6 and the study in Catalonia (55 min).17

Our median door-to-needle time is remarkably lower than what was reported from on-site thrombolysis studies in Bogotá, Barranquilla, and Pasto (2017), each showing a median time of 98, 175 and 128.6 min respectively.14 Such reduction in time becomes crucial for countries and regions like ours, where geographic characteristics like mountain ranges become a burden for treatment and where the use of new technological tools can improve attention timeframes to access reperfusion therapies. Thus, telestroke becomes a major strategy to improve door-to-needle time in stroke patients.18

Regarding clinical characteristics, stroke was more common in anterior circulation than posterior, with a higher prevalence in the left side. The most affected arteries were the MCA, the PCA and the ACA. We found a patient in the Face-to-face thrombolysis group that did not show arterial occlusion in brain imaging and was then reclassified as a stroke mimic which represents from 5 to 30% of all patients who present cerebral ischemic symptoms in the emergency department. Even in stroke mimics, the thrombolysis safety profile is excellent, and the incidence of ICH is rare. Some of these cases may be ruled out using Magnetic Resonance Imaging (MRI).19,20

Median hospital length of stay was 4 days for both groups (Face-to-face thrombolysis and Telestroke). This value was lower than what was found in a previous publication from our own institution there we reported a median of 8 days,9 something still lower than what was reported in 2 Colombian articles that studied this variable (average of 10.6 days) (Bogotá 2017 and Bogotá 2014).14 After discharge, all patients were studied for stroke causes using Duplex Carotid Ultrasound, Echocardiogram and Holter electrocardiogram; this protocol marks an improvement in stroke care in our institution and has become an important intervention for secondary stroke prevention.

We found no statistically significant differences in discharge and 3-month mortality. We should stress that external studies have not reported relevant differences in the 90-day mortality rate between the 2 groups.21 We can then infer that the safety of tPA treatment does not change between on-site thrombolysis and telemedicine.

It should be stated that we could not identify whether the patients' primary cause of death was related to stroke, mostly because patient follow up is considerably hard in our health system, thus becoming a limitation in our study.

Our study had other limitations. Even though the telethrombolysis leg (telestroke) of the study was carried out prospectively, some of the data had to be gathered retrospectively. This is because initially we only used radiologic criteria to diagnose hemorrhagic transformation, without reporting clinical neurologic deterioration, as in the ECAS 1 study.8,22 However, we considered these data to be important since Type 2 parenchymal hematoma (PH2) has been associated to a devastating effect in early neurologic damage and 3-month mortality.22

Despite this, when compared to other relevant thrombolysis studies, we found these associations to be an expected result, given that the ECAS II reported a sICH incidence of 8.1%,23 TEMPis reported 8.5%11 and the Elena Lopez-Cacio group reported 4.1% for in-person thrombolysis and 6.1% for telethrombolysis patients.17 A recent metanalysis did not find significant differences in the thrombolysis safety data (sICH) between the telestroke patients in the Drip and Stay model and those in the Telestroke or Hub models (p = 0.942)24; furthermore, in a 2 year prospective telestroke experience, symptomatic intracranial hemorrhage was calculated at 6.7%,25 and a 2016 metanalysis from the American Academy of Neurology also found the sICH rate between the 2 previously stated groups to be similar (RR = 1.01, 95% IC 0.37–2.80; p = 0.978), effectively confirming the findings from the telestroke experience.

A final limitation was that we couldn't compare the disability in our patients against what is reported in other studies because the modified Rankin Scale assessment was not performed in our patients at discharge.

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  There are no statistically significant differences in the discharge NIHSS, the hospital length of stay, discharge mortality and 3-moth mortality between the Telestroke (telehealth) and the Face-to-face thrombolysis (on-site thrombolysis) models.

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  Thrombolytic therapy performed by a general practitioner guided by a certified neurologist from a telestroke team is as safe as those performed in a stroke center.

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  Our data show that patients who are distant from a stroke center may access thrombolytic therapy through the telestroke model, bypassing the geographic burdens and shortening the timeframes for acute stroke care.

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  First and second level institutions are vital to the telestroke and teleictus approach.

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  This experience ought to be replicated in other institutions around the country to further confirm the evidence the findings concerning these two approaches to stroke care.

Own resources.

Does not apply.

The authors declare that no experiments were performed on humans or animals for this study.

The authors declare that they have followed the protocols of their work center on the publication of patient data.

The authors declare that no patient data appear in this article.