Mobile Stroke: An Experience of Intravenous Thrombolysis Guided by Teleconsultation Based on Google Glass

摘要

Telestroke is a success story of the telemedicine service after the introduction of teleradiology 1. Evidence suggests that telestroke may help to resolve the shortage of neurological expertise in underserved areas, shorten the time to treatment and improve the use of intravenous (IV) recombinant tissue-type plasminogen activator (rt-PA), thus preventing permanent neurological impairment 2, 3. China is currently facing the problem of geographical disparity in the neurological expertise between urban and rural areas, and the rate of IV rt-PA treatment is extremely low 4. Due to this situation, the Chinese government and agencies are making efforts to develop telemedicine. Here, we report the experience of IV thrombolysis guided by a teleconsultation system based on Google Glass for an acute ischemic stroke patient. The teleconsultation system used in this case is a real-time two-way audio/one-way video interactive system consisting of two clients: a Google Glass (generation 2.0) device worn by a local physician and a smartphone (Android) held by a neurologist in the hub hospital (teleneurohospitalist). A software company was delegated to develop the applications (apps) installed on the devices. The expert's smartphone rings when the local physician initiates a consultation with a specified expert on his or her Google Glass contact list. The local physician can perform examinations that are guided by the expert, and the teleneurohospitalist can observe the local patient on his or her smartphone with a first-person perspective. Under the current system, the patient is not charged for the teleconsultation. A 58-year-old woman suffered right-sided dysphagia and asthenia while resting at home at 21:35 on December 10, 2014 and presented to the emergency department with a suspected stroke at 22:38. After swift assessment by a local physician, cerebral infarction was suspected, and the National Institutes of Health Stroke Scale (NIHSS) score was 5. At 22:58, noncontrast brain computed tomography (CT) images indicated no signs of edema, infarction, intracerebral hemorrhage, or tumor (Figure 1A). However, the local physicians were uncertain whether IV rt-PA should be injected. After consent was received from the patient, a teleconsultation using Google Glass was established with a teleneurohospitalist at 23:36 (Figure 2). The teleneurohospitalist swiftly evaluated the patient's neurological impairment by guiding the local physician. At this time, the myodynamia of the patient's right upper and lower limbs weakened, and the NIHSS score increased to 7. After reviewing the CT images and other tests, the teleneurohospitalist reviewed the inclusion and exclusion characteristics of the patient and suggested that IV thrombolysis should be initiated as soon as possible. At 00:15 the following day, IV rt-PA injection was initiated. Thirty minutes later, the dysphasia resolved. At 01:35, the myodynamia of the right upper and lower limbs recovered from grade III to grade IV. At 11:00, the neurological function had completely recovered, although an infarction spot was noted on brain CT scans on December 12 (Figure 1B). Solutions for interactive audiovisual telemedicine have evolved from traditional teleconference rooms to telemedicine robots to wireless telecommunications networks and portable devices. Telemedicine apps on portable devices ensure that expertise can be provided 24/7 5. Remote evaluation of CT images and NIHSS scores, which are the two crucial elements in telestroke, can be made using smartphone apps, and are reliable relative to bedside assessments 6, 7. We have established a telestroke network based on smartphones in Shaanxi Province in China (ClinicalTrials.gov, NCT02088346). However, local physicians found that holding a smartphone was inconvenient during teleconsultation, especially when physical examinations were needed. Furthermore, teleneurohospitalists felt that this system did not possess the capability of evaluating patient