BackgroundThe majority of established telestroke services are based on “hub‐and‐spoke” models for providing acute clinical assessment and thrombolysis. We report results from the first year of the successful implementation of a locally based telemedicine network, without the need of 1 or more hub hospitals, across a largely rural landscape.Methods and ResultsFollowing a successful pilot phase that demonstrated safety and feasibility, the East of England telestroke project was rolled out across 7 regional hospitals, covering an area of 7500 square miles and a population of 5.6 million to enable out‐of‐hours access to thrombolysis. Between November 2010 and November 2011, 142 telemedicine consultations were recorded out‐of‐hours. Seventy‐four (52.11%) cases received thrombolysis. Median (IQR) onset‐to‐needle and door‐to‐needle times were 169 (141.5 to 201.5) minutes and 94 (72 to 113.5) minutes, respectively. Symptomatic hemorrhage rate was 7.3% and stroke mimic rate was 10.6%.ConclusionsWe demonstrate the safety and effectiveness of a horizontal networking approach for stroke telemedicine, which may be applicable to areas where traditional “hub‐and‐spoke” models may not be geographically feasible.

Recombinant tissue plasminogen activator (rtPA) is currently the only approved thrombolytic agent for treating acute ischaemic stroke that is widely used in clinical practice. However, it may cause haemorrhage and hypersensitivity reactions. Orolingual angioedema is an infrequent, usually mild but potentially life threatening, hypersensitivity reaction to rtPA. Our understanding of the basic biology of angioedema has increased in recent years. There is growing evidence that rtPA-induced orolingual angioedema is driven mainly by bradykinin generation rather than it being an anaphylactic response. Monitoring is important because orolingual angioedema may evolve and compromise airways and a small number do have angioedema as part of systemic anaphylaxis. There are no published guidelines for treating rtPA-induced orolingual angioedema, although some evidence suggests that those refractory to standard antianaphylactic agents may resolve with bradykinin B2 receptor antagonists. It is important that responses to orolingual angioedema are proportionate and that patients are closely monitored.

Left Atrial Ablation for Atrial Fibrillation is safe and effective for most patients. However a rare complication is thermal damage to the integrity of the normal physical barriers between the left atrium and the adjacent oesophagus due to the ablation process. This can lead to formation of an Atrial-Oesophageal fistula with sepsis, haemorrhage and systemic cardioembolism occurring even up to 2 months post procedure. The presentation is similar to endocarditis but localised instrumentation specifically Transoesophageal echocardiography (TOE) can provoke systemic cardioembolism. This is an important differential in those presenting acutely with a Pyrexia of Unknown Origin or endocarditis-like picture within 2 months of ablation therapy.

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‘End-of-life care in stroke’ examines the specific challenges in stroke, the challenges and difficulties of decision-making, identifiers of poor outcome, defining what is ‘good stroke death’, effective communication, role of resuscitation, clinically assisted hydration and nutrition, prepalliative care plans, personalized end-of-life care for the dying patient, symptom control, and issues concerning grieving and caring for the staff members. Over 80% of stroke deaths happen in those over 75. In most cases of life-threatening stroke, mental capacity is lost. Advanced care planning is rarely done and issues around decision-making are often challenging for those close to the patient. Families need an active communication process from day one with a realistic discussion of options. Where a poor outcome is feared, this needs communicating with reassurance and decisions made that would reflect the wishes and best interests of the person.