AcuteCare Telemedicine Blog

A Moment of Clarity

In order to make true progress in any industry, there must first be a clear vision, with goals and milestones laid out to define the path forwards. For telehealth, this vision must be extremely fluid, due to the constant introduction of new technologies and new research findings shaping best practices for successful implementation.

2012 was an important year, with new developments in government regulation shaping policy and procedure as well as a great deal of newsmedia coverage of the benefits of telehealth programs for healthcare systems and the patients they serve. Thanks to this progress, the vision for 2013 and beyond is becoming clearer.

First, 2012 helped us form a better understanding of the difference between telemedicine and telehealth. Whereas the power of telemedicine lies in its ability to connect doctors and extend care to new frontiers, telehealth places more emphasis on the role of patients. Traditionally, physicians and payers decided how healthcare was delivered. Today, consumers and employers have more say. Granting patients a voice in the dialogue has resulted in new avenues for improving the speed and quality of healthcare delivery – better home monitoring, non-emergency teleconsultation, and other services that reduce the use of valuable time and resources.

Going hand-in-hand with patient knowledge has been focused awareness of the steps that technology needs to take to enable better delivery. Generally speaking, usability is a major consideration. Improving infrastructure, particularly the availability and speed of broadband access will be pivotal to moving the needle on healthcare delivery. There is also a need for simpler, user-friendly hardware. Smartphones and tablets are far more likely to enter patient’s lexicon than diagnostics systems and more complex robotics.

Combining a more open dialogue with patients and giving them the tools they need and will bolster telehealth’s role in the healthcare ecosystem in 2013. Fortunately, hospitals have gained this clarity and are placing high priority on adopting telehealth programs. As this understanding becomes clearer, the impact will be greater.

Stroke Mimics in the Emergency Setting

The role of the neurologist in treatment of acute stroke often focuses on the decision to use clot busting medication (tissue plasminogen activator; tPA), recommending care setting (e.g. ICU vs routine admission) based on patient deficits and prognosis, and of course, patient education in the midst of this emotionally charged experience. However, an often overlooked mandate for the neurologist is the proper recognition of stroke itself. Dr. J. Stephen Huff, Associate Professor of Neurology at the University of Virginia, provides a clear and comprehensive review of what are termed stroke “mimics” – disorders which may appear to be a stroke, but are not.

Stroke, broadly defined, is any prolonged disruption of focal neurologic function due to decreased blood flow from blood clotting in a specific region of brain. If that disruption is transient or intermittent it is typically referred to as a transient ischemic attack (TIA). If brain function is disrupted by a cause other than a blood clot, treatment with tPA may not only lack benefit but expose the patient to unnecessary harm. Recognition of “stroke syndromes” that result from specific artery involvement is the bread and butter of neurology. The abrupt onset of aphasia (language deficit) and right sided weakness almost certainly indicates a patient has blocked their left middle cerebral artery. Blocking this same artery on the right results in the classic presentation of left sided weakness and “neglect,” an inability to recognize one’s own physical deficits. In either case, the immediate administration of tPA can be life-saving.

Other disorders may cause brain dysfunction unrelated to a blood clot. This is the case in approximately 13-20% of patients presenting with presumed stroke. If the duration of symptoms is unclear, this number may even be as high as 30%. The most common mimic is seizure. Excessive electrical and chemical brain activity may result in focal weakness (Todd’s paralysis) and other deficits. If the seizure was not witnessed (especially in patients with previous stroke as the cause of seizures), excluding an acute stroke can be difficult. Focal neurologic injury from brain tumor, inflammation (e.g. multiple sclerosis), or even peripheral nerve palsy may be mistaken for stroke.

Stroke can be mimicked without direct injury to the brain. The most common mimic in this category is a complex migraine in which visual disturbance, weakness, numbness and even aphasia can occur. Hypoglycemia or, less often, hyperglycemia (low and high blood sugar) can cause general symptoms of lethargy or coma, but focal brain dysfunction (particularly weakness) often occurs and can outlast normalization of blood glucose. Finally, 30% of patients presenting with psychiatric causes of physical illness (i.e. conversion disorder) exhibit neurologic deficits, typically weakness.

Determining the cause of a patient’s deficits can sometimes be accomplished in an emergency setting through the use of CT imaging and appropriate diagnostic tests. Often the results of serial examinations, detailed history and, increasingly, advances in MR imaging can eventually lead to the correct diagnosis. However, certain diagnoses, notably migraine and conversion, are diagnoses of exclusion, so repeated events and extensive negative testing may be required for confirmation.

Among patients presenting with neurologic deficits, emergency department physicians correctly identify stroke before applying diagnostic studies in about 75% of cases. This means as many as 1 in 4 cases are incorrectly diagnosed. It is the role of stroke experts, like those of AcuteCare Telemedicine, to quickly and accurately determine the likely cause of neurologic deficits, the risks and benefits of multiple treatment options and convey a plan of action simply yet fully to the patient and loved ones. It is a difficult but rewarding task.