Telestroke Strategies to Enhance Acute Stroke Management in Rural Settings: A Systematic Review and Meta-analysis

Background: The potential of telestroke implementation in resource-limited areas has yet to be systematically evaluated. This study aims to investigate the implementation of telestroke on acute stroke care in rural areas.

Methods: Eligible studies published up to November 2019 were included in this study. Randomized trials were further evaluated for risk of bias with Cochrane RoB 2, while nonrandomized studies with ROBINS-I tool. Random effects model was utilized to estimate effect sizes, and the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool.

Results: The search yielded 19 studies involving a total of 28,496 subjects, comprising of prehospital and in-hospital telestroke interventions in the form of mobile stroke units and hub-and-spoke hospitals network, respectively. Telestroke successfully increased the proportion of patients treated ≤3 hr (OR 2.15; 95% CI 1.37-3.40; I  = 0%) and better three-month functional outcome (OR 1.29; 95% CI 1.01-1.63; I  = 44%) without increasing symptomatic intracranial hemorrhage rate (OR 1.27; 0.65-2.49; I  = 0%). Furthermore, telestroke was also associated with shorter onset-to-treatment time (mean difference -27.97 min; 95% CI -35.51, -20.42; I  = 63%) and lower in-hospital mortality rate (OR 0.67; 95% CI 0.52-0.87; I  = 0%). GRADE assessments yielded low-to-moderate certainty of body evidences.

Conclusion: Telestroke implementation in rural areas was associated with better clinical outcomes as compared to usual care. Its integration in both prehospital and in-hospital settings could help optimize emergency stroke approach. Further studies with higher-level evidence are needed to confirm these findings.