What is the problem?
Stroke is common in Australia, with 60,000 new or recurrent strokes yearly. Studies show these numbers are disproportionately distributed across Australia, with stroke rates 17% higher in rural areas.
Stroke is most commonly caused by blockage of an artery in the brain resulting in brain injury. Fast treatment with ‘clot busting’ drugs (thrombolysis with intravenous tissue plasminogen activator –tPA) and/or endovascular clot removal (ECR) can save brain function.
Stroke reperfusion therapies are highly effective treatments producing major reductions in disability.
However patients in rural and regional Australia have had limited opportunity to receive ECR. Use of tPA in rural and regional patients has also been much lower than it should be.
Recent pivotal trials have shown that ECR can be undertaken up to 24 hours post stroke onset in advanced imaging selected patients, with significant benefit. This increases the scope for ECR for rural and regional patients previously excluded by the six-hour window.
Rapid treatment of stroke is critical. Having a well-designed and streamlined process to deliver tPA and identify patients for ECR is crucial, and has been shown to have a large impact on patient outcome.
About the research translation program
The research project implemented an acute 24/7 telestroke service in 7 district hospitals in northern NSW.
The service provided (and continues to provide) neurologist videoconferencing and advanced CT imaging-supported stroke treatment. This enables ECR eligible patients to be accurately identified and quickly transferred from rural and regional areas to major hospitals.
Paramedics were trained to identify potential candidates, so that eligible patients could immediately be taken to the most appropriate centre. Out-of-area transfers could therefore be restricted to those most likely to benefit.
The advanced imaging and stroke neurologist-supported decision-making available through this service also facilitated the appropriate use of tPA in rural and regional centres.
What were the findings?
Before the rollout of the telestroke project, the majority of participating rural sites had no access to reperfusion therapies (thrombolysis locally or referral pathway to endovascular clot retrieval).
From January 2020 to June 2021, over 1800 patients were assessed and more than 300 patients received reperfusion therapies as a result of this project.
The direct benefit to these patients and the community was enormous.
Based on the success of the pilot project, a NSW state-wide telestroke service was established in March 2020, combining federal and NSW state funding.
It is currently providing services to 16 rural sites across NSW, with a plan to provide stroke services to 23 sites by the end of 2022.
Lillicrap T, Pinheiro A, Miteff F, Garcia-Bermejo P, Gangadharan S, Wellings T, O’Brien B, Evans J, Alanati K, Bivard A, Parsons M, Levi C, Garcia-Esperon C and Spratt N (2020) No Evidence of the “Weekend Effect” in the Northern New South Wales Telestroke Network. Front. Neurol. 11:130. doi: 10.3389/fneur.2020.00130
Gangadharan S, Lillicrap T, Miteff F, Garcia-Bermejo P, Wellings T, O’Brien B, Evans J, Alanati K, Levi C, Parsons MW, Bivard A, Garcia-Esperon C and Spratt NJ (2020) Air vs. Road Decision for Endovascular Clot Retrieval in a Rural Telestroke Network. Front. Neurol. 11:628. doi: 10.3389/fneur.2020.00628
Kashida YT, Garcia-Esperon C, Lillicrap T, Miteff F, Garcia-Bermejo P, Gangadharan S, Chew BLA, O’Brien W, Evans J, Alanati K, Bivard A, Parsons M, Majersik JJ, Spratt NJ, Levi C; members of Northern NSW Telestroke investigators for this project. The Need for Structured Strategies to Improve Stroke Care in a Rural Telestroke Network in Northern New South Wales, Australia: An Observational Study. Front Neurol. 2021 Apr 9;12:645088. doi: 10.3389/fneur.2021.645088. PMID: 33897601; PMCID: PMC8064411.
Hood RJ, Maltby S, Keynes A, Kluge MG, Nalivaiko E, Ryan A, Cox M, Parsons MW, Paul CL, Garcia-Esperon C, Spratt NJ, Levi CR and Walker FR (2021) Development and Pilot Implementation of TACTICS VR: A Virtual Reality-Based Stroke Management Workflow Training Application and Training Framework. Front. Neurol. 12:665808. doi: 10.3389/fneur.2021.665808
Garcia-Esperon, C. (2020). Multimodal Computed Tomography: Future Applications in Acute Ischaemic Stroke (Doctoral dissertation, The University of Newcastle).
Tran, L., Lin, L., Spratt, N., Bivard, A., Chew, B. L. A., Evans, J. W., O’Brien, W., Levi, C., Ang, T., Alanati, K., Pepper, E., Garcia-Esperon, C. & Parsons, M. (2021). Telestroke Assessment With Perfusion CT Improves the Diagnostic Accuracy of Stroke vs. Mimic. FRONTIERS IN NEUROLOGY, 12. doi: 10.3389/fneur.2021.745673.
Ostman, C., Garcia-Esperon, C., Lillicrap, T., Alanati, K., Chew, B. L. A., Pedler, J., … & Spratt, N. (2022). Comparison of two pre-hospital stroke scales to detect large vessel occlusion strokes in Australia: A prospective observational study. Australasian Journal of Paramedicine, 19. doi: 10.33151/ajp.19.989