The Asian Hospital Management Awards 2006

Bangkok Neuroscience Center : Telestroke
One of the first successful uses of Telemedicine in the Asia-Pacific Region

Chanpong Tangkanakul MD ¹ , Apirat Cheeppensuk MD ² , Yunyong Tongchaoroen MD ¹ , Surat Bunyakankul MD ¹ , Supol Jaroenjitkul MD ¹ , Dittapol Boonampol MD ¹ , Watcharawoot Siriarchawattana MD ¹

Neuroscience Center, Bangkok Hospital Medical Center, Bangkok, Thailand Bangkok Hospital Samui, Koh Samui, Surathani, Thailand

The Bangkok Hospital center team use distance communication tool diagnose and treat a stroke patient who was located on an island 696 kilometers from their main hospital in central Bangkok. The result were good for both the patient and the hospital.

Introduction : Stroke is a common disease and a main cause of death and disability worldwide. 1 For more than 10 years, two treatments have been effective : Stroke unit therapy and systemic thrombolysis, Because most stroke patients still do not have access to those therapeutic options, 2, 3 chances for stroke therapy are lost too. Two main causes for those unacceptable situations are that both stroke unit treatment and systemic thrombolysis need expertise and experience. This lack of stroke experts, especially in non-urban areas, could be compensated by the use of telemedicine.

Samui Island, we well-know as a beautiful island in south of Thailand. Each year, there are many tourists come to Samui. Located is far from Bangkok about 696 kilometers. Bangkok Hospital Samui hospital is a branch of Bangkok Hospital. In this case, a foreigner patient was admitted at Bangkok Hospital Samui, and the doctor contacted to the main Bangkok Hospital for teleconference.

The Telestroke Project of Bangkok Hospital.

Case presentation : A 25 year old lady with her profile, admit at Bangkok Hospital Samui

Chief complain Sudden left side weakness for 6 hours Present Illness During her breakfast in the morning (6 hours ago) she felt dizzy and black out for a few minutes. After that she developed left side weakness where mostly in the arm and face. Her husband took her to a hospital and at least 2 short episodes of generalized tonic clonic seizure were suspected by the physician there. She got Diazepam iv. 10 mg x 2 , Oxygen administration, blood tests, iv. infusion, EKG and CT brain (without contrast study), The blood test and CT brain could not find and abnormality so she was referred to Bangkok hospital Samui for further investigation and neurological consultation. She never found experiences like this problem before. The day before, she got minor motorcycle accident with a 2 degree burn on her right calf (without head injury). Immediately after the accident, she had fainted for a few minutes before she went to a hospital for wound dressing. There was no abnormal neurological symptom after the accident. She is using oral contraceptive pill. She has no medical problem and she does not smoke.

Impression Stroke in the young, Acute Lschemic Stroke

Investigation CT BRAIN and CT angiography (6 hours after onset of symptom) Non-contrast CT scans show no abnormal attenuation of the cerebral hemisphere. However, right caudate nucleus, basal ganglion and internal capsule are slighlty hypodense and loss of sharpness. Normal cortical sulci, gyri, cisterns and ventricles are noted.

CTA with vascular reformation images show short segment loss of deliniation of M1 segment of right MCA (white arrow). However, the peripheral MCA still noted. This may be due to collateral blood supply.

As retrospect to non contrast CT, the area that loss of non-opacified MCA on CTA is matched with hyperdense tubular structure (hyperdense artery sign) that suggestive of thrombus in right MCA (block arrow).

Diagnosis MCA Stenosis with cerebral Infarction

The BBC Telestroke System

The flow of this telestroke system combine clinical assessment via real-time teleconference and electronic transmission of cerebral imaging. This system uses dedicated integrated services digital network (ISDN) lines transmitting two way full motion, video and audio teleconferencing with the remote site. A remote control camera with rotation and zoom functions is needed in the remote site. Both sides need large monitors (eg 22 inches) with high resolution (minimum 1280 x 1024 pixel, polychrome). For adequate videoconferance quality (25-30 frames per second), telemedical networks should use connections with a stable bandwitdth of at least 300 kilobits/s.

BBC Telestroke between Bangkok Hospital and Bangkok Hospital Samui

Result : After the physician at Bangkok Hospital Samui activated telestroke, communicating the essential anamnestic and clinical data. During examination over remote video, the patient showed mild dysarthria, left facial palsy and mild left hemiparesis. Her National institute of Health Stroke Score (NIHSS) is 4. The CTA brain showed acute basal ganglion infarction with MCA stenosis. We have discussed in the conference and agreed with present medication. We advised to do some tests for evaluate the causes:- MRA brain, TCD and carotid duplex, transesophageal echocardiogram to exclude cardiogenic caused (such as patent foramen ovale) and 24 hour holter monitoring to exclude cardiac arrthymia. Due to limitation of the resource, we recommended that after one week without deterioration, she should be transferred to work up in Bangkok Hospital Medical Center.

Follow up of treatment : She has recovered from hemiparesis. The muscle power improved everyday by the first 4 days. Now only mild weakness gr.lll-/V of the left upper extremities and mild ataxia is still noticed. The blood pressure can be maintained around 90 / 60 without Dopamine. She has no dizziness and can take regular diet very well. The ambulation to wheel chair and transferring to wars was planned.

Conclusion : From the success of this pilot telestroke, we are developing a system where by the patient would visit their local hospital and the remote neurologist would be able to engage the patient and their attending physician via any location that has brosdband (high speed) internet access-such as their home, a hotel or other. In the future. Bangkok Brain Center will have plan to develop telestroke project by launch formal Bangkok Telehealth Center, expand to all network hospitals and the last, we will have the Neuro Ambulance with mobile telemetry and video conferencing.

Acknowledgements : The authors world like to acknowledge Dr Yingdao Krairiksh, CEO of Bangkok Eastern Hospital Group, Dr Narong Budhraja, Hospital Director of Bangkok Hospital Samui, Mr Brian De Francesca, Director of General Support and Medicine Ancillary Services and Health Audio Visual of Bangkok Hospital and Bangkok Hospital Samui.

References :

1. Murray CJ. Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 1997: 349: 1436-42.
2. Bogousslavsky J. Hennerici M. European stroke services: from evidence to practice. Cerebrovasc Dis 2003: 15: 4-32.
3. Arora S, Broderick JP, Frakel M, et al. Acute stroke care in the US: result from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry. Stroke 2005: 36: 1232-40.