Background Stroke is a leading cause of morbidity and mortality in Brazil, where there are significant imbalances in access to specialized stroke care. Telemedicine networks allow patients to receive neurological evaluation and intravenous thrombolysis in underserved areas, where performance measures are challenging. Aims To describe the impact caused by adequate stroke care training, using realistic simulation, in a developing country telestroke network. Methods Retrospective observational study comparing the number of all stroke diagnoses, thrombolysis rate, door-to-needle time and symptomatic intracranial hemorrhage after intravenous thrombolysis, during one year providing just algorithms and orientation in stroke care to spoke facilities (phase 1), with the results achieved along one year after the beginning of ongoing live training sessions (phase 2). Results The mean number of patients diagnosed with stroke increased from 7.5 to 16.58 per month ( P = 0.019) rising from 90 patients during phase 1 to 199 in phase 2. There was a reduction in the mean door-to-needle time from 137.1 to 95.5 min (-41.58; 95% CI -62.77 to -20.40). The thrombolysis and symptomatic intracranial hemorrhage rates had a non-significant decrease from 21.31% to 18.18% (OR 0.82; 95% CI 0.39 to 1.71) and 12.5% to 7.69% (OR 0.58; 95% CI 0.046 to 7.425), respectively. Conclusions Realistic simulation stroke care training provided by stroke centers to spoke facilities seems to significantly reduce door-to-needle time and enhance adherence in a telestroke network.

A 67-year-old man with 45-minute onset left hemiparesis underwent 3.0T gadolinium-enhanced MRI (reported iodine contrast allergy) with right frontoparietal small infarcts on diffusionweighted images without vascular obstruction. No reperfusion therapy was given due to complete spontaneous symptoms regression. Twenty-four hours later, a second MRI showed right parietal CSF space enhancement on fluid-attenuated inversion recovery. Neither MRI nor CT had sign of hemorrhage ( figure).The hyperintense acute reperfusion marker is an early and transient blood-brain barrier disruption sign caused by leakage of gadolinium-based

A 67-year-old man with 45-minute onset left hemiparesis underwent 3.0T gadolinium-enhanced MRI (reported iodine contrast allergy) with right frontoparietal small infarcts on diffusion-weighted images without vascular obstruction. No reperfusion therapy was given due to complete spontaneous symptoms regression. Twenty-four hours later, a second MRI showed right parietal CSF space enhancement on fluid-attenuated inversion recovery. Neither MRI nor CT had sign of hemorrhage (figure).