Code stroke. Can we improve stroke times? A reply

Dear Editor:

We appreciate the interest in our article “Code stroke in Asturias,”¹ as it presents us an opportunity to offer more detail on the code stroke strategy being implemented in our region, and to make improvements based on other authors’ contributions.

We entirely concur with the authors of the letter that transport times from more remote areas constitute a challenge for the treatment of acute stroke in many patients who are more distant from the 2 reference hospitals. This can be observed in the small number of patients from the most remote areas among those who receive treatment, despite increases in code stroke activation and in the administration of reperfusion therapy since the latest update to our region's code stroke policy.²

We plan to apply research and communications technologies to address the obstacles of time and our region's topography. Telemedicine has long been used in the treatment of acute stroke; fibrinolysis administered at remote centres by a specialist at the reference hospital has been shown to be safe and effective, and is associated with good long-term progression.^3–5 The technique is less well-established in some other areas of Spain, but has achieved similar results.^6,7 Various clinical practice guidelines attest to the effectiveness of telemedicine, recommending its use for stroke treatment.^8,9 Telestroke has also been associated with improvements in rural settings¹⁰; NIHSS scores established in examinations performed over videoconference have been shown to be valid and reliable.¹¹ Other studies have demonstrated good results for the identification of candidates by teleradiology, with specialists viewing scans remotely.¹² In our region, this function is provided via an internet connection between public hospitals, allowing radiological imagery to be sent and viewed.

The Public Health System of Asturias is currently working to implement a specific telemedicine system for the treatment of acute stroke. We hope that once the system is live, acute-phase stroke treatment will become available to patients who are currently outside the treatment window for fibrinolysis, or who are excluded from the code stroke system itself due to long transport times.

The telestroke system is intended to enable neurologists at reference centres to collaborate with local on-call physicians to simultaneously examine patients from more remote areas without on-call neurology services or stroke units, and to assess neuroimaging findings and share clinical history data in real time, jointly deciding whether to administer fibrinolysis. The only aspect on which we disagree with the authors of the letter is whether patients should be transported to reference hospitals once perfusion is underway. Some studies have demonstrated the safety and effectiveness of transporting patients during administration of fibrinolysis.^13,14 This approach offers the benefits of admission to a stroke unit (which is not possible in remote hospitals) and the associated protocols, care, management of complications, and diagnostic and therapeutic procedures. It also minimises treatment delays for patients requiring endovascular treatment: invaluable time is wasted if we wait for fibrinolysis to be completed at the local hospital.