Advertisement

Remote Assessment of Stroke Using the iPhone 4

      Therapy with recombinant tissue plasminogen activator is underused in the treatment of ischemic stroke in rural hospitals, due to a lack of local stroke expertise. Telemedicine solutions for stroke are a level I, class A recommendation when a vascular neurologist is absent. However, current solutions require exorbitant startup costs, which are prohibitive for the rural hospitals in which they are needed most. This study demonstrates the efficacy of using the relatively inexpensive iPhone 4 in telestroke management. Twenty patients with stroke were assessed at the bedside using an iPhone 4, and each examination was directed remotely on another iPhone 4. Both the physician performing the bedside exam and the remote physician calculated a National Institutes of Health Stroke Scale (NIHSS) score for each patient. Each physician was blinded to the other’s NIHSS score. In the 20 patients assessed, NIHSS scores ranged from 0 to 22. Interrater reliability assessed using the κ statistic demonstrated excellent agreement in 10 items (level of consciousness, month and age, visual fields, right motor arm, left motor arm, right motor leg, left motor leg, sensation, language, and neglect), moderate agreement in 3 items (gaze, facial palsy, and dysarthria), and poor agreement in 1 item (ataxia). Total NIHSS scores obtained remotely and at bedside showed an excellent level of agreement (intraclass correlation coefficient, 0.98). Our findings indicate that the iPhone 4 is an economical mobile solution that can be used to assess stroke patients remotely with high fidelity and can be readily incorporated into a telestroke network.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kleindorfer D.
        • Xu Y.
        • Moomaw C.J.
        • et al.
        US geographic distribution of rt-PA utilization by hospital for acute ischemic stroke.
        Stroke. 2009; 40: 3580-3584
        • National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group
        Tissue plasminogen activator for acute ischemic stroke.
        N Engl J Med. 1995; 333: 1581-1587
        • Demaerschalk B.M.
        • Miley M.L.
        • Kiernan T.E.
        • et al.
        Stroke telemedicine.
        Mayo Clin Proc. 2009; 84: 53-64
        • Levine S.R.
        • McConnochie K.M.
        Telemedicine for acute stroke: When virtual is as good as reality.
        Neurology. 2007; 69: 819-820
        • Waite K.
        • Silver F.
        • Jaigobin C.
        • et al.
        Telestroke: a multi-site, emergency-based telemedicine service in Ontario.
        J Telemed Telecare. 2006; 12: 141-145
        • Kleindorfer D.
        • Lindsell C.J.
        • Brass L.
        • et al.
        National US estimates of recombinant tissue plasminogen activator use: ICD-9 codes substantially underestimate.
        Stroke. 2008; 39: 924-928
        • Heuschmann P.U.
        • Berger K.
        • Misselwitz B.
        • et al.
        Frequency of thrombolytic therapy in patients with acute ischemic stroke and the risk of in-hospital mortality: The German Stroke Registers Study Group.
        Stroke. 2003; 34: 1106-1113
        • Schwamm L.H.
        • Holloway R.G.
        • Amarenco P.
        • et al.
        A review of the evidence for the use of telemedicine within stroke systems of care: A scientific statement from the American Heart Association/American Stroke Association.
        Stroke. 2009; 40: 2616-2634
        • Demaerschalk B.M.
        • Bobrow B.J.
        • Raman R.
        • et al.
        Stroke team remote evaluation using a digital observation camera in Arizona: The initial Mayo Clinic experience trial.
        Stroke. 2010; 41: 1251-1258
        • Lawrence D.
        Wireless tech trends 2010. Trend: Telemedicine.
        Healthc Inform. 2010; 27 (28, 30, 58.)
        • Stradling D.A.
        Telestroke: State of the science and steps for implementation.
        Crit Care Nurs Clin North Am. 2009; 21: 541-548
        • Brott T.
        • Adams Jr., H.P.
        • Olinger C.P.
        • et al.
        Measurements of acute cerebral infarction: A clinical examination scale.
        Stroke. 1989; 20: 864-870
        • Goldstein L.B.
        • Bertels C.
        • Davis J.N.
        Interrater reliability of the NIH stroke scale.
        Arch Neurol. 1989; 46: 660-662
        • Lyden P.
        • Brott T.
        • Tilley B.
        • et al.
        • NINDS TPA Stroke Study Group
        Improved reliability of the NIH Stroke Scale using video training.
        Stroke. 1994; 25: 2220-2226
        • Spilker J.
        • Kongable G.
        • Barch C.
        • et al.
        • NINDS rt-PA Stroke Study Group
        Using the NIH Stroke Scale to assess stroke patients.
        J Neurosci Nurs. 1997; 29: 384-392
        • Wityk R.J.
        • Pessin M.S.
        • Kaplan R.F.
        • et al.
        Serial assessment of acute stroke using the NIH Stroke Scale.
        Stroke. 1994; 25: 362-365
        • Handschu R.
        • Littmann R.
        • Reulbach U.
        • et al.
        Telemedicine in emergency evaluation of acute stroke: Interrater agreement in remote video examination with a novel multimedia system.
        Stroke. 2003; 34: 2842-2846
        • Shafqat S.
        • Kvedar J.C.
        • Guanci M.M.
        • et al.
        Role for telemedicine in acute stroke: Feasibility and reliability of remote administration of the NIH Stroke Scale.
        Stroke. 1999; 30: 2141-2145
        • Wang S.
        • Lee S.B.
        • Pardue C.
        • et al.
        Remote evaluation of acute ischemic stroke: Reliability of National Institutes of Health Stroke Scale via telestroke.
        Stroke. 2003; 34: e188-e191
        • McCue M.J.
        • Palsbo S.E.
        Making the business case for telemedicine: An interactive spreadsheet.
        Telemed J E Health. 2006; 12: 99-106
        • Moskowitz A.
        • Chan Y.F.
        • Bruns J.
        • et al.
        Emergency physician and stroke specialist beliefs and expectations regarding telestroke.
        Stroke. 2010; 41: 805-809
        • McGraw K.O.
        • Wong S.P.
        Forming inferences about some intraclass correlation coefficients.
        Psychol Methods. 1996; 1: 30-46
        • Miley M.L.
        • Demaerschalk B.M.
        • Olmstead N.L.
        • et al.
        The state of emergency stroke resources and care in rural Arizona: A platform for telemedicine.
        Telemed J E Health. 2009; 15: 691-699
        • Mitchell J.R.
        • Sharma P.
        • Modi J.
        • et al.
        A smartphone client-server teleradiology system for primary diagnosis of acute stroke.
        J Med Internet Res. 2011; 13: e31