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-2 = 0%) and better three-month functional outcome (OR 1.29; 95% CI 1.01-1.63;I-2 = 44%) without increasing symptomatic intracranial hemorrhage rate (OR 1.27; 0.65-2.49;I-2 = 0%). Furthermore, telestroke was also associated with shorter onset-to-treatment time (mean difference -27.97 min; 95% CI -35.51, -20.42;I-2 = 63%) and lower in-hospital mortality rate (OR 0.67; 95% CI 0.52-0.87;I-2 = 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.