The population of individuals aged 80 years and older in the US is expanding rapidly, projected to increase 2.5-fold over the next 3 decades, from 13.3 million in 2020 to 32.6 million in 2050.¹ Age is the most important nonmodifiable risk factor for stroke and stroke incidence increases exponentially with advancing years. Acute ischemic strokes in older patients present with more severe neurologic deficits and larger infarct volumes and yield more disabling and fatal outcomes.^2-4 Moreover, a greater proportion of ischemic strokes in individuals aged 80 years and older is due to large-vessel occlusion,^5,6 in part because atrial fibrillation, a major cause of large-vessel occlusion in acute ischemic strokes, is 4 times as prevalent among individuals older than 80 years.⁷

Background: Post-stroke depression (PSD) affects up to 50% of stroke survivors, reducing quality of life, and increasing adverse outcomes. Conventional therapies to treat PSD may not be effective for some patients. Repetitive transcranial magnetic stimulation (rTMS) is well-established as an effective treatment for Major Depressive Disorder (MDD) and some small trials have shown that rTMS may be effective for chronic PSD; however, no trials have evaluated an accelerated rTMS protocol in a subacute stroke population. We hypothesized that an accelerated rTMS protocol will be a safe and viable option to treat PSD symptoms. Methods: Patients (N = 6) with radiographic evidence of ischemic stroke within the last 2 weeks to 6 months with Hamilton Depression Rating Scale (HAMD-17) scores >7 were recruited for an open label study using an accelerated rTMS protocol as follows: High-frequency (20-Hz) rTMS at 110% resting motor threshold (RMT) was applied to the left dorsolateral prefrontal cortex (DLPFC) during five sessions per day over four consecutive days for a total of 20 sessions. Safety assessment and adverse events were documented based on the patients' responses following each day of stimulation. Before and after the 4-days neurostimulation protocol, outcome measures were obtained for the HAMD, modified Rankin Scale (mRS), functional independence measures (FIM), and National Institutes of Health Stroke Scales (NIHSS). These same measures were obtained at 3-months follow up. Results: HAMD significantly decreased (Wilcoxon p = 0.03) from M = 15.5 (2.81)−4.17 (0.98) following rTMS, a difference which persisted at the 3-months follow-up (p = 0.03). No statistically significant difference in FIM, mRS, or NIHSS were observed. No significant adverse events related to the treatment were observed and patients tolerated the stimulation protocol well overall. Conclusions: This pilot study indicates that an accelerated rTMS protocol is a safe and viable option, and may be an effective alternative or adjunctive therapy for patients suffering from PSD. Future randomized, controlled studies are needed to confirm these preliminary findings. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04093843.

Secondary prevention is a major priority for those living with stroke and may be improved through the use of mobile Health (mHealth) interventions. While evidence for the effectiveness of mHealth interventions for secondary prevention of stroke is growing, little attention has been given to the translation of these interventions into real-world use. In this review, we aimed to provide an update on the effectiveness of mHealth interventions for secondary prevention of stroke, and investigate their translation into real-world use. Four electronic databases and the gray literature were searched for randomized controlled trials of mHealth interventions for secondary prevention of stroke published between 2010 and 2023. Qualitative and mixed-methods evaluations of the trials were also included. Data were extracted regarding study design, population, mHealth technology involved, the intervention, and outcomes. Principal researchers from these trials were also contacted to obtain further translational information. From 1151 records, 13 randomized controlled trials and 4 evaluations were identified; sample sizes varied widely (median, 56; range, 24–4298). Short message service messages (9/13) and smartphone applications (6/13) were the main technologies used to deliver interventions. Primary outcomes of feasibility of the intervention were achieved in 4 trials, and primary outcomes of changes in risk factors, lifestyle behaviors, and adherence to medication improved in 6 trials. Only 1 trial had a hard end point (ie, stroke recurrence) as a primary outcome, and no significant differences were observed between groups. There was evidence for only 1 intervention being successfully translated into real-world use. Further evidence is required on the clinical effectiveness of mHealth interventions for preventing recurrent stroke, and the associated delivery costs and cost-effectiveness, before adoption into real-world settings.

Background:The state of West Virginia (WV) is often seen as a health care desert with a scarcity of hospitals and resources. The prevalence of cerebrovascular disease and associated comorbidities are also some of the highest in the nation. Introduction:Ischemic stroke is a time-sensitive diagnosis. Prompt treatment in WV is difficult due to limited and isolated stroke-ready hospitals. Adoption of telestroke has helped to bypass these obstacles and improve access to care. Materials and Methods:Retrospective analyses; using data from the American Heart Association's Get With The Guidelines Stroke Data Registry, and other statewide agencies, we looked for trends in the volume of patients treated with intravenous-tissue plasminogen activator (tPA) in WV. We also reviewed data from West Virginia University's (WVU) telestroke database to assess trends in consult volumes and quality metrics. Results:Since the establishment of WVU telestroke, the total number of stroke patients receiving tPA across the state increased by 173% from 2015 (259 patients) to 2018 (448 patients) (p < 0.0001). Telestroke consults made up 24% (107/448) of total statewide tPA administrations for 2018. Between 2016 and 2018, the total symptomatic hemorrhage rate for tPA treated patients through telestroke was 1% (3/292). Telestroke also facilitated local care by avoiding patient transfer on average 65% of the time. Conclusion:Not only has telestroke increased the quantity of treated acute ischemic strokes, but it has also done so safely and effectively even in resource-poor areas. These findings demonstrate that telestroke is a useful tool for treating strokes, particularly those that happen far from stroke centers.

Purpose: Telemedicine is increasingly utilized in the evaluation of critically ill patients, including those with decreased level of consciousness (LOC) or coma. Improving access to providers with neurologic expertise affords earlier triage and directed patient management. However, objective data regarding the reliability of using standardized coma scales, traditionally employed at the bedside for remote assessment, are largely lacking. Hypothesis: Bedside and remote assessments of patients with decreased LOC, using either the Glasgow Coma Scale (GCS) or Full scale Of UnResponsiveness (FOUR), score are equivalent. Methods: Prospective trial comparing the reliability of bedside and remote coma assessments using GCS or FOUR score clinical evaluation tools utilizing robotic telepresence technology. Total scores of the GCS and FOUR score were compared between bedside and remote physician assessors by paired t-test and Pearson correlation coefficient (PCC). Results: One hundred subjects were enrolled. Mean age was 70.8 (±15.9) years and the average examination time took 5.16 (±2.04) minutes. Mean GCS total score at bedside was 7.5 (±3.67) versus examination conducted remotely 7.23 (±3.85); difference in scores was 0.25 (±0.10); p = 0.01. Mean FOUR total score at bedside was 9.63 (±4.76) versus remote 9.21 (±4.74); difference in scores was 0.40 (±2.00); p = 0.05. PCC for GCS was 0.966; p < 0.001, and for FOUR score 0.912; p < 0.001. Ninety-five percent of remote providers rated GCS and 89% rated FOUR score as good (4/5) regarding overall satisfaction and ease of use. Conclusions: Differences between total bedside and remote GCS and FOUR scores were small. Furthermore, PCCs between remote and bedside assessments were excellent: 0.97 (GCS) and 0.91 (FOUR). These results suggest that LOC can be reliably assessed using existing robotic telemedicine technology. Telemedicine could be adopted to help evaluate critically ill patients in neurologically underserved areas.

MHealth impact on secondary stroke prevention: a scoping review of randomized controlled trials among stroke survivors between 2010–2020 Amelia K. Adcock, Treah Haggerty, Anna Crawford, Cristal Espinosa