Code stroke: can we improve response times?

Dear Editor,

It was with great interest that we read the recently published article “Code stroke in Asturias.”¹ We congratulate the authors and promoters of code stroke implementation in the region of Asturias on this excellent initiative. Stroke is associated with high morbidity and mortality, and prognosis is time-dependent; emergency services therefore play an essential role in early detection, transport, and access to neuroimaging studies.²

Several studies have highlighted the importance of good implementation of these processes in order to reduce morbidity and mortality in stroke patients.³ The importance of this resides in reducing the time between symptom onset and definitive treatment, which has a definitive impact on prognosis: “Time is brain.”^4,5

Transport times frequently exceed 90 minutes due to the locations of the administrative areas assigned to the 2 reference centres providing reperfusion therapy (HUCA and Hospital de Cabueñes) and the time required for an ambulance to transport a patient from a given healthcare centre to the reference hospital. To transport time we should add the typical delays in seeking medical care, the time required for code stroke activation, the time necessary for the emergency services to reach the patient, and the time required for activating the in-hospital code stroke protocol (CT scan). Cumulative delay poses a threat for treatment within the therapeutic window (4 h 30 min). This is especially problematic given that delays in administering fibrinolysis reduce the effectiveness of the treatment.⁶

We decided to explore the possibility of using new technologies to treat stroke patients at the closest regional hospital equipped with a CT scanner. Treatment would be administered by specialised stroke teams and monitored by a specialist neurologist⁷ from the reference centre. Telemedicine for stroke treatment is currently in use in several areas of Spain, obtaining similar results to those reported in the literature and those observed for treatment administered in stroke units.^8,9 Current telemedicine systems not only enable video conferences and joint examinations by clinicians at both centres, but also real-time sharing of the patient's relevant medical history and CT images.¹⁰ Our experience with this system over the past 7 years has been very positive, with patients treated in a regional hospital using telemedicine systems and patients treated at the reference hospital's stroke unit displaying similar modified Rankin Scale scores at 3 months. In fact, symptom onset–CT scan times, symptom onset–treatment times, and door-to-needle times were shorter in local hospitals with telemedicine systems than in the reference hospital.¹¹

Telemedicine may help to significantly reduce time to reperfusion therapy. Once IV fibrinolysis is administered at the regional hospital, patients may be transferred to the reference hospital's stroke unit for re-evaluation and, where necessary, endovascular treatment with techniques only available at reference hospitals (intra-arterial thrombolysis, thrombectomy, or other techniques). In our health district,¹² regional hospitals with telemedicine systems transfer patients to the reference hospital's stroke unit after completing IV fibrinolysis (1 hour) locally; when symptoms do not improve or large vessel occlusion is suspected, the patient is transferred to the reference centre while receiving IV fibrinolytics, as agreed by the neurologists at the regional and reference centres (telestroke).