To determine differences in intravenous rt-PA exclusion criteria (EC) between emergency department (ED) stroke code activations evaluated at bedside versus telemedicine.

Telemedicine allows for rapid acute stroke evaluations. It is unclear whether reasons for rt-PA exclusion differs in bedside and telemedicine assessments. 

We retrospectively reviewed prospectively collected data from an IRB-approved registry. The sample included consecutive stroke code activations at an academic, Comprehensive Stroke Center evaluated at bedside (BG) versus aggregate telemedicine sites (TG) from 10/1/2013-6/30/2020. Patients treated with acute therapies were excluded. Exclusion criteria (EC) were categorized into stroke-related (sEC) and stroke mimic criteria (mEC). Providers were the same in both groups. Groups were compared for frequency and distribution of sEC and mEC. Age was not available in the TG sample, therefore it was not included in the analysis. Groups were compared via chi-squared, logistic regression, and Pairwise Wilcoxon. Analyses were done unadjusted and adjusted for NIHSS, as appropriate.

In total, 5352 patients (BG: n=2369; TG: n=2983) were included in the analysis. The BG was significantly more likely to be excluded due to recent stroke (p=0.01), CT findings (p=0.01), last known well (LKW) time [>3 hours (p<0.001); >4.5 hours (p<0.001); unknown (p<0.001)]. The TG were significantly more likely to refuse tPA when recommended (p=0.01). For mEC, the TG was significantly less likely to be excluded for intoxication (p<0.001), somatization (p<0.001), syncope (p<0.001), or metabolic encephalopathy (p<0.001). The TG was significantly more likely to have transient ischemic attack (p<0.001) and other mimics (p<0.001) compared to the BG. 

There were significant differences in reasons for exclusion from rt-PA in this study of in-person versus telemedicine stroke code evaluations. This may result from stroke code activation protocols dictated by agreements between the Hub and Spoke site. A further evaluation of patent demographics and other characteristics are warranted.