Objective: Telemedicine for the management of acute ischemic stroke is being increasingly used to improve stroke care and deliver stroke expertise to physicians and patients in underserved areas. Recently, thrombectomy alone or after administration of rt-PA has proved effective for the treatment of mild to moderate stroke from large artery occlusion. Successful intra-arterial intervention depends on well-organized services at centers with quick and adequate expertise to perform thrombectomy. Though, studies have reported that telestroke increases the rate of administering thrombolytic therapy and providing expertise in thrombectomy to a larger number of stroke patients, there are relatively limited studies available to report the extent of stroke care achieved in this setting and needs to be elucidated further.  The objective of this analysis was to explore and compare the extent of stroke care achieved in moderate to severe stroke by a thrombolysis, thrombectomy and combination of both in telemedicine setting.    Methods: This retrospective study analyzed data from 517 patients hospitalized at Penn State College of Medicine from July 2015 to March 2018.  Data was abstracted from the institutional telestroke database after obtaining IRB approval. Subjects were divided into three groups. Group one: patients receiving thrombolysis only; Group two: patients receiving thrombectomy and Group three patients undergoing both thrombolysis and thrombectomy. Patients with NIH-SS score ≥ 10 were analyzed. A primary outcome measure was the difference in NIH-SS (at admission compared to discharge). Secondary outcome was discharge disposition (favorable, i.e. discharge to Home/Rehab or unfavorable; i.e. discharge to hospice/death). Furthermore, the final angiographic outcome recorded using Thrombolysis in Cerebral Infarction (TICI) Scale.                                                                                                                       Results: The change in NIH-SS (Mean ± SEM) was higher in the t-PA (7.57±0.87) and combination treatment (7.78±1.58) compared to thrombectomy alone group (4.73± 1.39) but did not reach at significance (p=0.09). There was no significant difference of discharge frequency among any of the groups. The discharge frequencies to home/ Rehab were: t-PA (76.61%), thrombectomy (80%) and combination therapy (75.9%). The rate of angiographic reperfusion (TICI 2B-3) was higher in the combination groups 26 (78.8%) of 33 patients compared to 21 (60%) of 35 patients in   thromectomy alone. Summary and Conclusion: The present study demonstrated good clinical outcomes for patient with moderate to severe strokes treated within in a tele-stroke network. The NIH-SS improved in all three groups following treatment. There was a trend towards best outcomes following combined treatment compared to thrombectomy, although the difference was not statistically significant. In addition reperfusion rates were higher in the combination group as compared to the thrombectomy group. The discharge frequency to home and Rehab were similar in all three groups. There was no significant difference in discharge disposition among any of the groups, possibly because of high stroke severity in this population. The Study stresses the benefits of early treatment with thrombolysis and thrombectomy after thrombolysis. Furthermore, thrombectomy alone can be an effective treatment modality in patients who are not a candidate for i.v. t-PA. Tele-stroke networks allow identifying and treating patients with moderate to severe strokes who will benefit from these therapies.

The Impact of Thrombolysis and Thrombectomy on Stroke Outcome in a Telemedicine Network