The history and future of telestroke


This Review focuses on the application of telemedicine to the care of patients with acute stroke (telestroke), from the prehospital setting through hospitalization. Telestroke has grown remarkably in the past decade and has entered mainstream care for patients with acute stroke. Telestroke enables such patients to be remotely evaluated, thereby allowing optimal treatment and management even in clinically underserved areas and removing geographical disparities in access to expert care. Telestroke systems enable thrombolytic treatment to be administered in community and rural hospitals, and facilitate the appropriate transfer of patients with complex conditions (who require critical care services and neurosurgical or intra-arterial interventions) to a comprehensive stroke centre. Decision-analytic models show that telestroke is cost-effective from both a societal and a hospital perspective. Limitations to the use of telestroke in the USA include the need for state licensing and credentialling of physicians, and the technical requirements of a minimum network bandwidth (which is still lacking in some regions). However, the opportunity exists for telestroke to become the backbone of an electronic stroke unit and to be used to identify and enrol patients in clinical trials of acute stroke treatment. The use of telestroke in the prehospital setting has been hampered by limited telecommunication availability, but these problems might be mitigated by fourth-generation cellular data networks.

Key Points

  • Telestroke networks have expanded in the past decade, enabling rural and community hospitals to administer tissue plasminogen activator to patients intravenously in a timely, safe and effective manner

  • Telestroke systems can also facilitate an electronic stroke unit, with ongoing follow-up and consultation by stroke specialists and nurse practitioners during the patient's hospitalization

  • Telestroke could improve the rate of recruitment and enrolment of under-represented populations of patients into clinical trials of acute stroke treatment

  • Telestroke is cost-effective from both societal and individual hospital perspectives

  • Barriers to telestroke implementation in the USA include the lack of nationwide credentialling and licensing programmes; the Center for Medicare Services has streamlined the credentialling process, but national licences are lacking

  • Telestroke is starting to move into the prehospital setting, but there are still technical barriers that might be mitigated by new fourth-generation cellular data networks

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Figure 1: Hub and spoke design for a telestroke network.
Figure 2: Role of telestroke in acute stroke treatment.
Figure 3: Different approaches to use of telestroke in prehospital stroke care.
Figure 4: Role of telestroke in clinical trials.


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H. J. Audebert acknowledges funding for the Telemedicine Project for Integrative Stroke Care (TEMPiS) network from Bavarian Health Insurance, Bavarian Ministry for Social Affairs, the German Foundation for Stroke Aid and the German Federal Ministry of Education and Research (BMBF), as well as funding for the Stroke Emergency Unit Mobile (STEMO) project from Zukunftsfonds Berlin and the Federal Ministry of Education and Research, via grant number 01 EO 0801 from the Center for Stroke Research, Berlin, Germany.

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D. C. Hess and H. J. Audebert contributed equally to discussion of content for the article, researching data to include in the manuscript, and writing, reviewing and editing of the manuscript before submission.

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Correspondence to David C. Hess.

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Competing interests

D. C. Hess is a co-founder of and equity holder in REACH Health, a telestroke and telemedicine company. He is a member of the Board of Directors of REACH Health, but does not receive compensation for this role and does not receive compensation from the company. H. J. Audebert has received honoraria for acting as a speaker and/or consultant from Bayer Vital, Boehringer Ingelheim, Bristol–Myers Squibb, Lundbeck, Pfizer, Sanofi–Synthélabo, Takeda Pharmaceuticals, and UCB.

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Hess, D., Audebert, H. The history and future of telestroke. Nat Rev Neurol 9, 340–350 (2013).

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