Validation of a Smartphone Application in the Evaluation and Treatment of Acute Stroke in a Comprehensive Stroke Center

Abstract

Background and Purpose— The increasing demand and shortage of experts to evaluate and treat acute stroke patients has led to the development of remote communication tools to aid stroke management. We aimed to evaluate the JOIN App smartphone system—a low-cost tool for rapid clinical and neuroimaging data sharing to expedite decision-making in stroke. Methods— Consecutive acute ischemic stroke patients treated at a University Hospital in Brazil from December 2014 to December 2015 were evaluated. The analysis included all patients presenting with acute ischemic stroke who underwent initial evaluation by neurology residents followed by JOIN teleconsultation with a stroke neurologist on call for management decisions. An expert panel of stroke neurologists and neuroradiologists revised all cases using a standard Picture Archiving and Communication System imaging workstation within 24 hours and analyzed the decision made with remote assistance during the emergency setting. Results— A total of 720 stroke codes were evaluated with 442 acute ischemic stroke qualifying. Seventy-eight (18%) patients were treated with intravenous thrombolysis. The main reasons for tPA (tissue-type plasminogen activator) exclusion were symptom onset >4.5 hours (n=295; 67%) and hypodense middle cerebral artery territory area >1/3 (n=31; 7%). The agreement rates between Picture Archiving and Communication System versus JOIN-based thrombolysis decisions were 100% for the stroke (unblinded) and 99.3% for the neuroradiologist (blinded) experts. The use of the application resulted in a significant reduction in the door-to-needle times across the pre- versus postimplementation periods (median, 90 [interquartile range, 75–106] versus 63 [interquartile range, 61–117] minutes; P =0.03). The rates of 90-day excellent outcomes (modified Rankin Scale, 0–1) were 51.3%; 90-day mortality, 2.6%; and symptomatic intracranial hemorrhage, 3.8%. Conclusions— The JOIN smartphone system allows rapid sharing of clinical and imaging data to facilitate decisions for stroke treatment. The remote application-based decisions seem to be as accurate as the physical presence of stroke experts and might lead to faster times to treatment. This system represents an easily implementable low-cost telemedicine solution for centers that cannot afford the full-time presence of stroke specialists.

Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel

“…23,24 Use of the lowcost smartphone application system is another option for the rapid clinical assessment in acute stroke care. 25 Conclusion and practice implications…”

Practice Implications for Acute Ischemic Stroke during the COVID-19 Pandemic for the Indian Scenario: Realistic and Achievable Recommendations by the Society of Neurocritical Care (SNCC), India

“…Telemetry or telestroke as an integral part of stroke systems of care telestroke has demonstrated equivalence to that of a bedside assessment for immediate assessment of stroke severity using National Institutes of Health Stroke Scale (NIHSS) and to determine intravenous recombinant tissue plasminogen activator (rt-PA) and/or thrombectomy eligibility. 7 , 17 Use of the low-cost smartphone application system is another option for the rapid clinical assessment in acute stroke care. 17 The use of telestroke must be maximized in the current situation because all aspects of acute stroke evaluation can be performed.…”

“… 7 , 17 Use of the low-cost smartphone application system is another option for the rapid clinical assessment in acute stroke care. 17 The use of telestroke must be maximized in the current situation because all aspects of acute stroke evaluation can be performed. Institutions may explore with the ethics committee or Institutional Review Board whether commercially available low-cost smartphone application systems can substitute when telestroke networks are not available.…”

A Smartphone Application as a Telemedicine Tool for Stroke Care Management

“…7) Compared to the existing concept of "telemedicine"-connectivity between two hospitals (a hub-and-spoke model), where a specialized doctor from the "hub" hospital consults regarding a patient in the "spoke" hospital-a smartphone application envisions connections between multiple doctors within a hospital (in-hospital) or between hospitals (inter-hospital), potentially improving diagnostic and treatment capabilities. JOIN [8][9][10][11] (Fig. 1) is a communication application for new-generation smartphones that works through current high-speed networks (LTE, 4G).…”