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Acute vision loss related to cerebral or retinal ischemia is a time-sensitive emergency with potential treatment options including IV or intra-arterial thrombolysis and mechanical thrombectomy. However, patients either present in a delayed fashion or present to an emergency department that lacks the subspecialty expertise to recognize and treat these conditions in a timely fashion. Moreover, health care systems in the United States are becoming increasingly reliant on telestroke and teleneurology services for acute neurologic care, making the accurate diagnosis of acute vision loss even more challenging due to critical limitations to the remote video evaluation, including the inability to perform routine ophthalmoscopy. The COVID-19 pandemic has led to a greater reliance on telemedicine services and helped to accelerate the development of novel tools and care pathways to improve remote ophthalmologic evaluation, but these tools have yet to be adapted for use in the remote evaluation of acute vision loss. Permanent vision loss can be disabling for patients, and efforts must be made to increase and improve early diagnosis and management. Herein, the authors outline the importance of improving acute ophthalmologic diagnosis, outline key limitations and barriers to the current video-based teleneurology assessments, highlight opportunities to leverage new tools to enhance the remote assessment of vision loss, and propose new avenues to improve access to emergent ophthalmology subspecialty.

Globally, to date, there have been nearly 125 million confirmed cases of coronavirus disease 2019 (COVID-19) during this pandemic, including >2.7 million deaths, as reported to World Health Organization. Although the common symptoms of COVID-19 are cough, dyspnea, fever, chills, myalgia, anosmia, and ageusia, an increase in several neurologic manifestations, specifically ischemic and hemorrhagic stroke syndromes, has been recognized. Ischemic stroke related to COVID-19 may be secondary to thrombotic microangiopathy, vascular endotheliopathy, arterial dissection, or leukoencephalopathy of the posterior reversible encephalopathy type.1 Hemorrhagic stroke associated with COVID-19 may also be due to intracerebral hemorrhage, subarachnoid hemorrhage, or microbleeds.1 The incidence of stroke during the pandemic was predicted to increase due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus link to both thrombotic and hemorrhagic risk potential.2 Paradoxically, stroke admissions to hospital appeared to decline during the pandemic, speculated to be due to a fear of infection, leading to patients with stroke refusing to call for emergency medical services.2 Scientists called for epidemiologic data to characterize and more clearly understand the effect of the COVID-19 pandemic on stroke care.2,3

Objective: To review current literature on neurology telemedicine and to discuss its application to patient care, neurology practice, military medicine, and current federal policy. Methods: Review of practice models and published literature on primary studies of the efficacy of neurology telemedicine. Results: Teleneurology is of greatest benefit to populations with restricted access to general and subspecialty neurologic care in rural areas, those with limited mobility, and those deployed by the military. Through the use of real-time audio-visual interaction, imaging, and store-and-forward systems, a greater proportion of neurologists are able to meet the demand for specialty care in underserved communities, decrease the response time for acute stroke assessment, and expand the collaboration between primary care physicians, neurologists, and other disciplines. The American Stroke Association has developed a defined policy on teleneurology, and the American Academy of Neurology and federal health care policy are beginning to follow suit. Conclusions: Teleneurology is an effective tool for the rapid evaluation of patients in remote locations requiring neurologic care. These underserved locations include geographically isolated rural areas as well as urban cores with insufficient available neurology specialists. With this technology, neurologists will be better able to meet the burgeoning demand for access to neurologic care in an era of declining availability. An increase in physician awareness and support at the federal and state level is necessary to facilitate expansion of telemedicine into further areas of neurology.

IV recombinant tissue plasminogen activator (rtPA) within 4.5 hours of symptom onset has been established as an effective therapy for acute ischemic stroke.1 Over the past 2 decades, systems of care and quality assurance teams have developed to ensure that all potentially eligible patients receive IV rtPA in a timely and effective manner.2 Many neurologists cannot arrive rapidly to the emergency department for in-person acute stroke assessment, and many rural areas lack 24/7 coverage by neurologists. Telemedicine has brought neurologic expertise through real-time audiovisual technical link to the emergency department for assessment of patients within the narrow treatment window.3 Studies have shown that telemedicine (telestroke) is superior to a telephone (only) for acute stroke consultation and decision-making.4 Patient outcomes from telestroke administration of IV rtPA can rival outcomes from an in-person stroke team treatment.5 Multiple health economic analyses have demonstrated high cost-effectiveness for telestroke practice and likely cost savings from both the societal and hospital perspectives.6,7

{#article-title-2} In their editorial, Drs. Marquardt and Barnett1 contend that because the CREST trial2 grouped symptomatic and asymptomatic patients together, the trial denied information about the benefit of endarterectomy (CEA) and stenting (CAS) in these separate conditions. We respectfully disagree. In CREST, 2 a …

A colleague once challenged grand rounds attendants to identify any pharmacologic treatment for stroke, other than recombinant tissue plasminogen activator (rtPA), which, 15 years after Food and Drug Administration approval, still evoked a mental checklist of eligibility criteria, with numerous contraindications, yet the audience was mute. Are all IV thrombolysis exclusion criteria really necessary? The Simplified Management of Acute Stroke Using Revised Treatment (SMART) protocol considers all ischemic stroke patients for thrombolysis regardless of common rtPA exclusion criteria, contending that such criteria are consensus-based, not evidence-based; nearly 20% of all ischemic stroke patients received IV rtPA without an increase in adverse events.1 SMART proposed that exclusion criteria be critically reevaluated,1 with many investigators adopting an empirical approach to this challenge.2,3 Concerns over poorer post-thrombolysis outcomes in patients with a history of prior stroke and diabetes prompted trialists to exclude these patients for the European Cooperative Acute Stroke Study (ECASS)–3.4 Prior stroke reduces the benefits from thrombolysis.5 Furthermore, there is a clear association of hyperglycemia with worse outcomes in ischemic stroke, through multiple possible mechanisms6: increased plasminogen activator inhibitor-1 activity, resistance to antithrombotic agents, and …

Objective: Our objective is to characterize mentorship in vascular neurology and provide recommendations to prepare future leaders. We assess the hypothesis that there is a consensus among neurologists regarding the importance of mentorship in vascular neurology and mechanisms for its enhancement. Background Vascular neurology is an evolving area of medicine that requires specialty-trained clinicians committed to the field. A conduit for this endeavor is mentorship. Many sources cite mentorship as an integral role in clinician development, but information specific to mentorship in vascular neurology is limited. Design/Methods: North American vascular neurologists were surveyed to assess mentorship. Email invitations to participate in an IRB approved, confidential, anonymous survey were sent to American Board of Psychiatry and Neurology Vascular Neurology Diplomates and Canadian Stroke Consortium registered vascular neurologists. The survey included demographic, reflective, and satisfaction questions. Results: The response rates were 123/591 (21%) and 25/95 (26%) among American and Canadian respondents, respectively. All neurologists surveyed received mentorship in their careers, and 57% had served as mentors. Eighty percent (95%CI,72-85%) strongly agreed that mentorship is critical to the training of vascular neurologists. One-third (95%CI,22-41%) cited the opportunity to foster research skills and 23% (95%CI,15-32%) named clinical skill development as the most valuable aspects of mentorship. While 83% (95%CI,76-89%) expressed satisfaction with their mentorship experience, 92% (95%CI,83-96%) felt that the experience could have been enhanced. Sixty-nine percent (95%CI,57-78%) called for formalization of mentorship programs. The most frequently named recommendations for future mentorship experiences were a well-defined curriculum and career-planning services, 28% (95%CI,22-41%) and 13% (95%CI,15-33%), respectively. Conclusions: The allocation of protected time for clinical and research endeavors, as well as career advising are vital to successful mentorship experiences. As evidenced, there is a need for formalization (e.g. mentor-mentee pairing), in addition to developed curricula. Although the value of mentorship in vascular neurology is clear, a more formal analysis is needed. Supported by: Funding for this study was provided by Vladimir Hachinski9s Paul Morley Mentorship Award of the Canadian Stroke Network. Disclosure: Dr. Minzer has nothing to disclose. Dr. Miley has nothing to disclose. Dr. Hachinski has received personal compensation for activities with Boehringer Ingelheim Pharmaceuticals, Inc., Servier, Uriach as a participant in Symposia.Dr. Hachinski has received personal compensation in an editorial capacity for Lippincott Williams & Wilkins for serving as Editor-in-Chief of the American Heart Association Journal STROKE. Dr. Kachroo has nothing to disclose.

Objective: To assess the cost-utility of a telestroke network in the management of acute ischemic stroke (AIS) from the societal perspective. Background A hub-and-spoke telestroke network is an effective way to extend quality emergency stroke care to remote hospitals and improve patient outcomes. The economic consequences of these networks must be considered. Design/Methods: A lifetime Markov model was developed to compare the incremental costs and effectiveness with and without a telestroke network in AIS treatment. One-year transition probabilities between the three health states--minimal to no disability (modified Rankin scale [mRS] 0-2), disability (mRS 3-5), and death--were derived from the literature. Costs included telemedicine set-up and maintenance, treatment for initial and recurrent AIS (including inter-hospital transfers), rehabilitation, long-term care, and caregiver costs and were estimated in 2011 dollars. Effectiveness was defined as quality-adjusted life years (QALYs). Model inputs were obtained from the literature supplemented by data from Georgia Health Sciences University and Mayo Clinic telestroke networks. The base case used a network model with 1 hub and 7 spokes and assumed no survival benefits from acute treatment in a network. Costs and QALYs were discounted at 3% per year. One-way sensitivity analyses were conducted. Results: In the base case, an AIS patient treated in a network incurred $1,436 lower costs and gained 0.02 QALYs over a lifetime compared with one treated without a network. Incremental costs decreased over time from $444 for the first year to -$1,436 over a lifetime; incremental QALYs increased from 0.002 for the first year to 0.02 over a lifetime. Incremental costs increased with higher transfer rates and lower rates of endovascular stroke therapy usage. Conclusions: A telestroke network is cost-saving and more effective compared with no network from the societal perspective in most scenarios. Results may be sensitive to specific network features. Supported by: Genentech, Inc. Disclosure: Dr. Demaerschalk has received personal compensation for activities with Genentech and Otsuka. Dr. Switzer has nothing to disclose. Dr. Xie has received personal compensation for activities with Analysis Group, Inc. as an employee. Mr. Fan has received personal compensation for activities with Analysis Group, Inc., as an employee. Ms. Villa has received personal compensation for activites with Genentech, Inc. as an employee. Dr. Wu has received personal compensation for activities with Analysis Group, Inc. as an employee.

Objective: To assess the cost-effectiveness of a telestroke network in the management of acute ischemic stroke (AIS) from three perspectives: the network, hub, and spoke. Background A hub-and-spoke telestroke network is an effective way to extend quality emergency stroke care to remote hospitals and improve patient outcomes. The costs of these networks to the participating hospitals must be considered. Design/Methods: A decision analytic model was developed to compare cost and effectiveness with and without a telestroke network over a 5-year time horizon. The model considered changes in rates of teleconsultations, intravenous (IV) thrombolysis, endovascular stroke therapies, and spoke-to-hub transfers with and without the network. These inputs were estimated using data from Georgia Health Sciences University and Mayo Clinic telestroke networks. Costs included telemedicine set-up and maintenance costs, treatment costs, and reimbursement for AIS. Effectiveness was defined as discharges to home. Incremental effectiveness was assumed to result only from the increased number of patients treated with IV thrombolysis and/or endovascular stroke therapies. One-way sensitivity analyses were conducted. Results: Compared with no network, a network model with 1 hub and 7 spokes resulted in 45 more patients treated with IV thrombolysis and 20 more with endovascular stroke therapies per year, leading to 5.49 more home discharges per 1000 AIS patients. Across a span of transfer rates from 0% to 100%, incremental costs ranged from -$556,000 to -$6000 for the network, $1,485,000 to -$3,428,000 for the hub, and from -$292,000 to $489,000 for each spoke, with negative costs reflecting savings. Results were sensitive to rates of endovascular stroke therapies and transfers. Conclusions: In most scenarios, a telestroke network costs less and is more effective than no network from the network perspective. With increasing transfer rates, the hub experiences greater cost savings while spokes bear higher costs. Supported by: Genentech, Inc. Disclosure: Dr. Switzer has nothing to disclose. Dr. Demaerschalk has received personal compensation for activities with Genentech and Otsuka. Dr. Xie has received personal compensation for activities with Analysis Group, Inc. as an employee. Mr. Fan has received personal compensation for activities with Analysis Group, Inc., as an employee. Ms. Villa has received personal compensation for activites with Genentech, Inc. as an employee. Dr. Wu has received personal compensation for activities with Analysis Group, Inc. as an employee.

ACUTE STROKE: BENCH TO BEDSIDE edited by Anish Bhardwaj, Nabil J. Alkayed, Jeffrey R. Kirsch, and Richard J. Traystman, 515 pp., Informa Healthcare, 2006, $229.95 Acute Stroke: Bench to Bedside is an outstanding comprehensive textbook that accomplishes the stated goal of filling a recognized void in the stroke market by offering information about the continuum from basic science research to relevant patient care in the field. The common acute cerebrovascular conditions including intracerebral hemorrhage, subarachnoid hemorrhage, focal and global cerebral ischemia, and infarction are equally well represented in this textbook. Nearly …