Original Article
Remote Assessment of Stroke Using the iPhone 4

https://doi.org/10.1016/j.jstrokecerebrovasdis.2011.09.013Get rights and content

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.

Section snippets

Subjects and Methods

The study protocol was approved by Emory University’s Institutional Review Board and Grady Memorial Hospital’s Research Oversight Committee. Each patient or a family member who could serve as a legal representative gave consent for participation in this study. The study included 20 patients (9 males and 11 females) admitted to the neurology inpatient service at Grady Memorial Hospital for acute stroke. Patients who were clinically unstable were not included in the study.

Twenty patients with

Results

The average NIHSS scores were similar for the bedside and remote raters (6.05 and 6.30, respectively, with a range of 0-22 for both groups). Distributions of the values assigned to each NIHSS component are presented in Table 1. The mean remote evaluation time was 8.45 minutes.

Ten components of the NIHSS showed quasi-perfect agreement between the bedside and remote rates: level of consciousness, month and age, visual fields, right motor arm, left motor arm, right motor leg, left motor leg,

Discussion

In the event of an acute stroke where there is no vascular neurologist on site, using telemedicine to provide such expertise is a class I, level A recommendation.8 Telemedicine has been available for use in the assessment and management of acute stroke patients for more than a decade. Unfortunately, the startup costs associated with currently available systems is substantial, potentially upwards of several thousands of dollars.20, 21, 23 These costs are prohibitive for small rural hospitals and

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