Keywords
Stroke
Intravenous thrombolysis
How to Cite
Abstract
Cerebrovascular diseases are the leading cause of death and disability in Brazil, playing a significant public health challenge. In 2012, the Brazilian Ministry of Health approved a protocol for thrombolysis in acute ischemic stroke (AIS). It established national guidelines for stroke care, including telemedicine for neurological support. However, the effectiveness of this strategy within the Brazilian Unified Health System (SUS) had not yet been proven. This study evaluated the effectiveness and safety of telemedicine through
the JOIN application (Allm Inc.) for the triage, diagnosis, and treatment of acute stroke in the XIII Regional Health Department (DRS XIII) of the state of São Paulo. The tool enabled real-time image sharing and case discussions between local services and the Emergency Unit of the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto (EU/HCFMRP), which provided comprehensive consultation for decisions regarding intravenous thrombolysis and combined therapy. One hundred forty-three patients were admitted, including 74 AIS cases, of which 30 (40.5%) underwent thrombolysis. No symptomatic hemorrhagic
transformation was observed. Response times, door-to-imaging, and door-to-needle times were within the recommended targets. These findings highlight the pivotal role of telemedicine in expanding access to reperfusion therapies, reducing regional disparities, and ensuring timely and safe treatment for AIS patients in the public health system.
References
1. Feigin VL, Owolabi MO. The Lancet Neurology Commissions Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission. Lancet Neurol [internet]. 2023 [acesso em 10 jan 2025];22: 1160–206. Disponível em:
https://www.thelancet.com/action/showPdf?pii=S1474-4422%2823%2900277-6
2. Kim J, Olaiya MT, Silva DA, Norrving B, Bosch J, Aguiar de Sousa D, et al. Global Stroke Statistics 2023: Availability of reperfusion
services around the world. Int J Stroke [internet]. 2024 [acesso em 16 jun 2024];19(3):253-270. Doi: 10.1177/17474930231210448
3. Minelli C, Fen LF, Minelli DPC. Stroke incidence, prognosis, 30-day, and 1-year case fatality rates in Matão, Brazil: A population-based
prospective study. Stroke. 2007;38(11):2906–11.
4. Lange MC, Cabral NL, Moro CHC, Longo AL, Gonçalves AR, Zétola VF, et al. Incidence and mortality of ischemic stroke subtypes in Joinville, Brazil: a population-based study. Arq Neuropsiquiatr [internet]. 2015 [acesso em 22 jan 2024];73(8):648–54. Disponível em:
https://pubmed.ncbi.nlm.nih.gov/26222354/
5. Cabral NL, Nagel V, Conforto AB, Amaral CH, Venancio VG, Safanelli J, et al. Five-year survival , disability , and recurrence after first-ever stroke in a middle-income country : A population- based study in Joinvile, Brazil. 2018;0(0):1–9.
6. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute
ischemic stroke. N Engl J Med [internet]. 2008 [acesso em 17 set 2024];359(13):1317–29. Disponível em: https://pubmed.ncbi.nlm. nih.gov/18815396/
7. Fiehler J, Gerloff C. Mechanical Thrombectomy in Stroke. 2015.
8. Kim J, Olaiya MT, De Silva DA, Norrving B, Bosch J, De Sousa DA, et al. Global stroke statistics 2023: availability of reperfusion services
around the world. Int J Stroke [internet]. 2024 [acesso em 10 set 2024];19(3):253. Disponível em: /pmc/articles/PMC10903148/
9. Ouriques Martins SC, Sacks C, Hacke W, Brainin M, Figueiredo FA, Pontes-Neto OM, et al. Priorities to reduce the burden of stroke in
Latin American countries. Lancet Neurol [internet]. 2019 [acesso em 20 fev 2024];18(7):674–83. Disponível em: http://www.thelancet.
com/article/S1474442219300687/fulltext
10. Ministério da Saúde (BR). Portaria no 664, de 12 de abril de 2012. Aprova o Protocolo Clínico e Diretrizes Terapêuticas - Trombólise
no Acidente Vascular Cerebral Isquêmico Agudo [internet]. Diário Oficial da União. 2012 [acesso em 15 jul 2023]. Disponível em: https://
bvsms.saude.gov.br/bvs/saudelegis/gm/2012/PRT0664_12_04_2012.html
11. Rocha LJA, Melo MTB, Piva RG, Rafani SM, Pontes-Neto OM, Rocha E, et al. Conceito leigo sobre o acidente vascular cerebral (AVC)
em uma capital do Nordeste brasileiro e o impacto da pandemia de COVID-19. Arq Neuropsiquiatr. 2024;82(8):1–6.
12. Rocha LJDA, Silva KAD, Chagas ADL, Veras ADO, Souto VGL, Valente MCMB, et al. Stroke in the state of Alagoas, Brazil: a descriptive
analysis of a northeastern scenario. Arq Neuropsiquiatr. 2022;80(6).
13. Levine SR, Gorman M. Telestroke: The Application of Telemedicine for Stroke [internet]. 1999 [acesso em 10 jan 2025]. Disponível
14. Subramaniam S, Chen J, Wilkerson TL, Stevenson L, Kincaid C, Firestone C, et al. Refining the Implementation of a Hub-and-Spoke
Model for TelePain Through Qualitative Inquiry. J Technol Behav Sci [internet]. 2023 [acesso em 10 fev 2024];8(3):295–305. Disponível
em: https://doi.org/10.1007/s41347-022-00288-w
15. Martins SCO, Pontes-Neto OM, Alves CV, Freitas GR, Filho JO, Tosta ED, et al. Past, Present, and Future of Stroke in Middle-Income
Countries: The Brazilian Experience [internet]. 2013 [acesso em 10 set 2024];8(100 A):106–11. Disponível em: https://journals.sagepub.
com. Doi:10.1111/ijs.12062
16. Martins SCO, Weiss G, Almeida AG, Brondani R, Carbonera LA, Souza AC, et al. Validation of a Smartphone Application in the
Evaluation and Treatment of Acute Stroke in a Comprehensive Stroke Center. Stroke [internet]. 2020 [acesso em 8 set 2023];51(1):240–6.
Disponível em: https://www.ahajournals.org/journal/str
17. Thrombolysis in Stroke Mimics: Comprehensive Stroke Centers vs Telestroke Sites. Enhanced Reader.
18. Poon JT, Tkach A, Havenon AH, Hoversten K, Johnson J, Hannon PM, et al. Telestroke consultation can accurately diagnose ischemic
stroke mimics. J Telemed Telecare. 2023;29(6):444–50.
19. Katzan IL, Hammer MD, Hixson ED, Furlan AJ, Abou-Chebl A, Nadzam DM. Utilization of Intravenous Tissue Plasminogen Activator
for Acute Ischemic Stroke. Arch Neurol [internet]. 2004;61(3):346-50. Disponível em: http://archneur.jamanetwork.com/ Doi: 10.1001/
archneur.61.3.346
20. Van Wijngaarden JDH, Dirks M, Huijsman R, Niessen LW, Fabbricotti IN, Dippel DWJ. Hospital rates of thrombolysis for acute ischemic
stroke: The influence of organizational culture. Stroke. 2009;40(10):3390–2.
21. Kleindorfer D, Xu Y, Moomaw CJ, Khatri P, Adeoye O, Hornung R. US geographic distribution of rt-PA utilization by hospital for acute
ischemic stroke. Stroke. 2009;40(11):3580–4.
22. Summers D, Leonard A, Wentworth D, Saver JL, Simpson J, Spilker JA, et al. Comprehensive overview of nursing and interdisciplinary
care of the acute ischemic stroke patient: A scientific statement from the American heart association. Stroke. 2009; 40: 2911–44.
23. Asimos AW, Norton HJ, Price MF, Cheek WM. Therapeutic Yield and Outcomes of a Community Teaching Hospital Code Stroke
Protocol. AEM, Academic Emergency Medicine. 2004;11(4):361–70.
24. Blech B, O’carroll CB, Zhang N, Demaerschalk BM. Telestroke Program Participation and Improvement in Door-To-Needle Times.
Telemed J E Health [internet]. 2020 [acesso em 11 set 2024];26(4):406–10. Disponível em: https://pubmed.ncbi.nlm.nih.gov/31287782/
25. Fonarow GC, Zhao X, Smith EE, Saver JL, Reeves MJ, Bhatt DL, et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA. 2014;311(16):1632–40.
26. Kepplinger J, Barlinn K, Deckert S, Scheibe M, Bodechtel U, Schmitt J. Safety and efficacy of thrombolysis in telestroke: A systematic
review and meta-analysis. Neurology [internet]. 2016 [acesso em 17 set 2024];87(13):1344–51. Disponível em: https://pubmed.ncbi.
nlm.nih.gov/27566746/
This work is licensed under a Creative Commons Attribution 4.0 International License.
Copyright (c) 2025 Letícia Januzi de Almeida Rocha, Rui Kleber do Vale Martins Filho, Francisco Antunes Dias, Frederico Fernandes Alessio Alves, Octávio Marques Pontes Neto