Vascular Aphasias

*Dragoș Cătălin Jianu, Silviana Nina Jianu, Ligia Petrica, Traian Flavius Dan and Georgiana Munteanu*

## **Abstract**

Aphasia represents an acquired central disorder of language that impairs a person's ability to understand and/or produce spoken and written language, caused by lesions situated usually in the dominant (left) cerebral hemisphere, in right-handed persons. Aphasia has a prevalence of 25–30% in acute ischemic stroke (vascular aphasia). It is considered as an important stroke severity marker, being associated with a higher risk of mortality, poor functional prognosis, and augmented risk of vascular dementia. The assessment of aphasias in clinical practice is based on classical analysis of oral production and comprehension. The language disturbances are frequently combined into aphasic syndromes which are components of different vascular syndromes that may evolve/involve rapidly at the acute stage of ischemic stroke. The main determinant of the type of vascular aphasia is the infarct location (especially left middle cerebral artery territory). Recent studies at the hyperacute stage of ischemic stroke have observed features of aphasia, have reanalyzed its neuroanatomy using new imaging techniques, and have shown that aphasias have a parallel course to that of cortico-subcortical hypoperfusion. Thus, the reversal of hypoperfusion, following recanalization (spontaneous or secondary to thrombolysis or thrombectomy), is associated with resolution of aphasia. Speech therapy is needed as soon as permitted by clinical condition.

**Keywords:** language, speech, aphasia, vascular aphasia, hyperacute stage of ischemic stroke, language therapy

## **1. Introduction**

Aphasia is one of the most common and also frustrating disabilities secondary to stroke; over 25% of the patients who suffer an acute ischemic stroke are dealing with this complex syndrome in their evolution. It is also considered an important stroke severity marker, being associated with a higher risk of mortality, poor functional prognosis, and augmented risk of vascular dementia. This syndrome is a real challenge not only for the patients or their relatives but also for the specialists (neurologists, speech therapists, psychologists, and physiotherapists) involved in the diagnosis and treatment of those patients.

The assessment of aphasias in clinical practice is based on classical analysis of oral production and comprehension. The language disturbances are frequently combined into aphasic syndromes (nonfluent/fluent aphasias), which are constituents of different vascular syndromes, being accompanied by motor deficit of the right limbs or visual deficit (hemianopia). The main determinant of the type of vascular aphasia is the infarct location (especially left middle cerebral artery territory). Recent studies at the hyperacute stage of ischemic stroke have observed features of aphasia, have reanalyzed its neuroanatomy using new imaging techniques, and have shown that aphasias have a parallel course to that of cortico-subcortical hypoperfusion. Thus, the reversal of hypoperfusion, following recanalization (spontaneous or secondary to thrombolysis or thrombectomy), is associated with resolution of aphasia. Speech therapy is needed as soon as permitted by clinical condition. Unfortunately, pharmacotherapy remains to be evaluated. Other studies examined the potential interest of new treatment, such as transcranial magnetic stimulation.

This chapter is meant to clarify different aspects regarding the definition, classification, diagnosis criteria, and therapeutically strategies for the most common vascular aphasic syndromes due to ischemic stroke.

## **2. Language and speech**

In the field of neurolinguistics, there are two words, often misused as synonyms: "language" and "speech," although each one of these terms describes different functions regarding distinct processes and involving distinct neural networks [1].

*Language* is a noninstinctive, culturally driven system of voluntarily produced symbols, involving receptive and expressive skills enabling understanding and expression of information or emotion. It represents a complex interaction between sensory-motor abilities and symbolic combinations, so that people can communicate [1].

The language system consists of five domains [1]:


**39**

*Vascular Aphasias*

*DOI: http://dx.doi.org/10.5772/intechopen.92691*

and respiratory muscles [1].

**3. Definition of aphasia**

**4. Language localization**

result in similar deficits [1].

and meanings of words [1].

(b) *posterior areas* [1–5]:

come apparent ambiguity in a peculiar context.

5.*Pragmatics*: The rules for maintaining a conversation in terms of responsiveness and relevance. It defines the way people produce and comprehend intended meanings through language, in actual situations. Unlike semantics, which defines meaning that is conventional (grammar and lexicon) in a given language, pragmatics explains how the speaker and listener are capable to over-

Speech results from the extremely coordinated rapid motor functions, thereby requiring the combination of phonation (voicing), resonance (nasality), articulation, fluency, and prosody. It is responsible for the actual act of vocal expression of language. The most important neural structures involved in the regulation of speech are represented by the cortical systems, the basal ganglia, the cerebellum, and the corticobulbar tracts, via the nuclei of the trigeminal, facial, glossopharyngeal, vagal, accessory (spinal), hypoglossal, and phrenic nerves. All these structures maintain the control and coordination between all the muscles involved in speaking: oral, lingual, palatal, pharyngeal, laryngeal,

Aphasia represents an acquired central disorder of language that impairs a person's ability to understand or/and produce spoken language, often associated with impairment in reading (alexia) and writing (agraphia). Aphasia may supplementary affect the person's ability to use musical notation, mathematical operations, etc.; in consequence, the aphasic may present difficulties to generate and use symbol systems. Aphasia is different from a peripheral (sensory-motor) disorder of language that may mimic aphasia (such as weakness of the muscles of articulation). In the same time, it is an acquired phenomenon that appears after the language has already been learned [1–4].

Nowadays, in the era of functional neuroimaging, using a variety of complex techniques, organization of the language network has been partially understood. The outward production of language is the effect of neural activation in huge network including different regions in the cortex, basal ganglia, cerebellum, and brainstem. An overlap in that network or with other networks of specialization determines the huge clinical spectrum following an acquired injury. One lesion in an area can produce numerous signs, and injuries concerning distinct areas can

Functional neuroimaging studies mentioned that the "language network" is strikingly similar across different language tasks and across different healthy people: *the dorsal frontoparietal pathway*—for articulatory and syntactic processes and *the ventral temporal pathway*—for mapping sounds to lexical representations

Aphasia is caused by a localized brain damage. Using a combination of different neuroimaging techniques, it has been suggested that *core language functions are perisylvian left*—*lateralized regions* in the majority of patients (95% right-handers and 75% left-handers, respectively) [1]. These regions include (a) *anterior areas* and *Ischemic Stroke*

magnetic stimulation.

**2. Language and speech**

networks [1].

communicate [1].

sounds of speech.

produce a word).

sequence SVO or SOV.

flecting content and utterance intent.

vascular aphasic syndromes due to ischemic stroke.

The language system consists of five domains [1]:

the right limbs or visual deficit (hemianopia). The main determinant of the type of vascular aphasia is the infarct location (especially left middle cerebral artery territory). Recent studies at the hyperacute stage of ischemic stroke have observed features of aphasia, have reanalyzed its neuroanatomy using new imaging techniques, and have shown that aphasias have a parallel course to that of cortico-subcortical hypoperfusion. Thus, the reversal of hypoperfusion, following recanalization (spontaneous or secondary to thrombolysis or thrombectomy), is associated with resolution of aphasia. Speech therapy is needed as soon as permitted by clinical condition. Unfortunately, pharmacotherapy remains to be evaluated. Other studies examined the potential interest of new treatment, such as transcranial

This chapter is meant to clarify different aspects regarding the definition, classification, diagnosis criteria, and therapeutically strategies for the most common

In the field of neurolinguistics, there are two words, often misused as synonyms: "language" and "speech," although each one of these terms describes different functions regarding distinct processes and involving distinct neural

symbols, involving receptive and expressive skills enabling understanding and expression of information or emotion. It represents a complex interaction between sensory-motor abilities and symbolic combinations, so that people can

*Language* is a noninstinctive, culturally driven system of voluntarily produced

1.*Phonology*: The systematic organization of different sounds in spoken languages and linguistic rules of their pronunciation and perception. It is different from phonetics. While phonology reveals the modality sounds come together within a certain language to encode meaning (to form words), phonetics describes the physical production, acoustic transmission, and perception of the

2.*Morphology*: The study of the internal structure of words, how they are formed, and their relationship to other words in the same language. Morphemes represent the minimal units of words that have meaning and, in the same time, cannot be subdivided further (free morphemes can appear alone: example: "good," but bound morphemes: example: "ly" must be added to a free morpheme to

3.*Semantics*: The systematic meaning of words represents the study of relations between words and what they denote; it means the signification of words re-

4.*Syntax*: The set of linguistic principles that define the way in which words order ("arrange together") to convey a complete thought, and to form correct sentences or phrases in a given language: example: the sequence in which the subject (S), verb (V), and object (O) combine in sentences: usually in the

**38**

5.*Pragmatics*: The rules for maintaining a conversation in terms of responsiveness and relevance. It defines the way people produce and comprehend intended meanings through language, in actual situations. Unlike semantics, which defines meaning that is conventional (grammar and lexicon) in a given language, pragmatics explains how the speaker and listener are capable to overcome apparent ambiguity in a peculiar context.

Speech results from the extremely coordinated rapid motor functions, thereby requiring the combination of phonation (voicing), resonance (nasality), articulation, fluency, and prosody. It is responsible for the actual act of vocal expression of language. The most important neural structures involved in the regulation of speech are represented by the cortical systems, the basal ganglia, the cerebellum, and the corticobulbar tracts, via the nuclei of the trigeminal, facial, glossopharyngeal, vagal, accessory (spinal), hypoglossal, and phrenic nerves. All these structures maintain the control and coordination between all the muscles involved in speaking: oral, lingual, palatal, pharyngeal, laryngeal, and respiratory muscles [1].

## **3. Definition of aphasia**

Aphasia represents an acquired central disorder of language that impairs a person's ability to understand or/and produce spoken language, often associated with impairment in reading (alexia) and writing (agraphia). Aphasia may supplementary affect the person's ability to use musical notation, mathematical operations, etc.; in consequence, the aphasic may present difficulties to generate and use symbol systems. Aphasia is different from a peripheral (sensory-motor) disorder of language that may mimic aphasia (such as weakness of the muscles of articulation). In the same time, it is an acquired phenomenon that appears after the language has already been learned [1–4].

## **4. Language localization**

Nowadays, in the era of functional neuroimaging, using a variety of complex techniques, organization of the language network has been partially understood. The outward production of language is the effect of neural activation in huge network including different regions in the cortex, basal ganglia, cerebellum, and brainstem. An overlap in that network or with other networks of specialization determines the huge clinical spectrum following an acquired injury. One lesion in an area can produce numerous signs, and injuries concerning distinct areas can result in similar deficits [1].

Functional neuroimaging studies mentioned that the "language network" is strikingly similar across different language tasks and across different healthy people: *the dorsal frontoparietal pathway*—for articulatory and syntactic processes and *the ventral temporal pathway*—for mapping sounds to lexical representations and meanings of words [1].

Aphasia is caused by a localized brain damage. Using a combination of different neuroimaging techniques, it has been suggested that *core language functions are perisylvian left*—*lateralized regions* in the majority of patients (95% right-handers and 75% left-handers, respectively) [1]. These regions include (a) *anterior areas* and (b) *posterior areas* [1–5]:


Recent studies [2], using MRI, noted the following correlations between different linguistic disturbances and cerebral lesions due to ischemic strokes:


## **5. The evaluation of language disturbances**

The assessment of aphasias in clinical practice is based on the analysis of six different language domains, which are represented by oral production (expressive language), comprehension (language understanding), repetition, naming, reading, and writing (**Figure 1**) [1–6].

## **5.1 Assessment of oral production (expressive language/spontaneous speech)**

It refers to modifications of fluency, prosody and volume, and presence of deviations at various linguistic levels [1–7].

Fluency is represented by the flow of speech (number of words per minute: wpm) and effort (smoothness).

The main deviations at different linguistic levels of oral production are as follows:


**41**

*Vascular Aphasias*

*DOI: http://dx.doi.org/10.5772/intechopen.92691*

(in Wernicke's aphasia)

*comprehension, and repetition.*

**Figure 1.**

successive approximations).

**5.2 Assessment of oral comprehension**

d.*Syntactic level* (grammar): agrammatism characterized by a severe diminution in the use of grammatical elements in language (in Broca's aphasia), and paragrammatism with an overuse of wrongly selected grammatical elements

*The assessment of aphasias in clinical practice is based on the classical analysis of oral production (fluency),* 

Other deviations are represented by oral production restricted to a few stereotyped utterances (e.g., "tan tan"), jargon aphasia (associating frequently multiple phonemic and verbal deviations leading to neologisms), echolalia, and the "conduit d'approche" (i.e., numerous attempts to correct phonemic deformations by

There are two types of aphasias: nonfluent (Broca's aphasia, transcortical motor aphasia, and global aphasia) and fluent (Wernicke's aphasia, transcortical sensory aphasia, and conduction aphasia). On the one hand, a nonfluent spontaneous speech presents less than 50 wpm, augmented effort, dysprosodia, sometimes hypophonia, dysarthria, few paraphasias (especially phonological paraphasias), substantive words in excess, and short sentences. On the other hand, a fluent speech presents a normal of words per minute (100–200 wpm), with a normal effort, normal prosody and volume, no deviation at sound level (correct articulation of a sound), many paraphasias (including verbal paraphasias), relatively lack of sub-

It analyses comprehension at the linguistic levels of word and syntax [1–7]. Oral comprehension is formally examined by (a) asking the aphasic to point an object, a body part, etc. and (b) presenting different verbal commands with augmenting complexity. Impaired oral comprehension is usually underdiagnosed in clinical practice. We should think at this language disturbance when a patient does not behave according to the examiner's tasks, especially during object pointing on verbal command and

stantive words, and normal sentences (including 5–8 wps) [1–7].

**Figure 1.**

*Ischemic Stroke*

area: Fa)

speech

• Impaired repetition • Oral comprehension • Anomia (naming deficits)

Recent studies [2], using MRI, noted the following correlations between different

• Putamen

gyri

• Inferior frontal gyrus

• The external capsule

• Insula and external capsule • Posterior subcortical • Head of caudate nucleus

genu of internal capsule

• Anterior subcortical lesions

• Insular and external and posterior internal lesions • The posterior part of the superior and middle temporal

• The Wernicke's area: the posterior part of the first two temporal gyri-T1/T2 (BA 22) • The inferior parietal lobes: the angular gyrus (BA 39), and the supramarginal gyrus (BA 40)

• The anterior part of the temporal lobe

• Medial temporal, middle and inferior frontal gyri, and

• The insula and the inferior frontal gyrus

The assessment of aphasias in clinical practice is based on the analysis of six different language domains, which are represented by oral production (expressive language), comprehension (language understanding), repetition, naming, reading,

**5.1 Assessment of oral production (expressive language/spontaneous speech)**

Fluency is represented by the flow of speech (number of words per minute:

a.*Sound/articulation level* (incorrect articulation of a sound): dysarthria

It refers to modifications of fluency, prosody and volume, and presence of devia-

The main deviations at different linguistic levels of oral production are as follows:

b.*Phonemic level* (addition, omission, substitution, or inversion of a phoneme):

c.*Verbal level* (word-selection/lexicon): word-finding difficulties (anomia), are the core symptom of aphasias, usually associated with verbal (semantic)

paraphasias, perseveration, circumlocutions, or, even, neologisms

linguistic disturbances and cerebral lesions due to ischemic strokes:

**Anterior areas Posterior areas**

• The Broca's area: the posterior part of the third frontal gyrus-F3 (Brodmann areas: BA 44 and 45) • The Rolandic operculum (lower part of the motor

• The insular cortex and the subjacent white matter • The left premotor and prefrontal regions (situated

**5. The evaluation of language disturbances**

and writing (**Figure 1**) [1–6].

• Reduction in fluency of spontaneous

anterior and superior of Broca's area) • The supplementary motor area

tions at various linguistic levels [1–7].

wpm) and effort (smoothness).

phonological paraphasias

**40**

*The assessment of aphasias in clinical practice is based on the classical analysis of oral production (fluency), comprehension, and repetition.*

d.*Syntactic level* (grammar): agrammatism characterized by a severe diminution in the use of grammatical elements in language (in Broca's aphasia), and paragrammatism with an overuse of wrongly selected grammatical elements (in Wernicke's aphasia)

Other deviations are represented by oral production restricted to a few stereotyped utterances (e.g., "tan tan"), jargon aphasia (associating frequently multiple phonemic and verbal deviations leading to neologisms), echolalia, and the "conduit d'approche" (i.e., numerous attempts to correct phonemic deformations by successive approximations).

There are two types of aphasias: nonfluent (Broca's aphasia, transcortical motor aphasia, and global aphasia) and fluent (Wernicke's aphasia, transcortical sensory aphasia, and conduction aphasia). On the one hand, a nonfluent spontaneous speech presents less than 50 wpm, augmented effort, dysprosodia, sometimes hypophonia, dysarthria, few paraphasias (especially phonological paraphasias), substantive words in excess, and short sentences. On the other hand, a fluent speech presents a normal of words per minute (100–200 wpm), with a normal effort, normal prosody and volume, no deviation at sound level (correct articulation of a sound), many paraphasias (including verbal paraphasias), relatively lack of substantive words, and normal sentences (including 5–8 wps) [1–7].

#### **5.2 Assessment of oral comprehension**

It analyses comprehension at the linguistic levels of word and syntax [1–7]. Oral comprehension is formally examined by (a) asking the aphasic to point an object, a body part, etc. and (b) presenting different verbal commands with augmenting complexity. Impaired oral comprehension is usually underdiagnosed in clinical practice. We should think at this language disturbance when a patient does not behave according to the examiner's tasks, especially during object pointing on verbal command and tasks using sentences of progressive complexity. The shortened Token Test is the test usually used to exam if the comprehension is impaired (adjusted score <29) and to differentiate Broca from global aphasia (adjusted score <17) [2, 6].

## **5.3 Assessment of repetition**

When testing repetition, it is essential to use different types of items (short-long verbal information and meaningful-meaningless utterances) [1–7].

Aphasias with impaired repetition ability (perisylvian aphasias) differ from this point of view from transcortical (extrasylvian) aphasias, with normal repetition (even if oral comprehension is severely impaired in transcortical sensory aphasia).

### **5.4 Naming**

While testing naming, different types should be included: objects, body parts, actions, and colors ("What is this?") [5–7]. If we want to assess the understanding ability of the patient, we have to exam pointing ("Show me, please, where the…is!"), which is the opposite of naming [5, 6].

## **5.5 Reading (lexia)**

While testing reading, we should focus on two aspects: (a) the mechanisms of reading (the conversion of visual signs-graphemes into phonemes) and (b) reading comprehension (using written commands, etc.) [5–7].

## **5.6 Writing (graphia)**

We should exam spontaneous writing, writing by dictation, and copying at different levels of the writing language: letters, syllables, words, sentences, and texts [5–7].

The different language disturbances observed are frequently combined into aphasic syndromes (nonfluent/fluent aphasias) [1, 2, 5, 7].

An experimented examiner can diagnose the aphasic syndrome based on analysis of six language domains (oral production, etc.).

However, clinical examination can produce two kinds of errors: (a) underestimation of oral comprehension deficit and (b) misdiagnose of verbal stereotypies with jargon aphasia.

These errors are not found in the case of assessment of aphasias using an aphasia battery test:


Each test provides well-defined cut-off scores, so the description of the aphasic syndrome is more precise than that obtained on clinical grounds [2].

**43**

*Vascular Aphasias*

equivalent tests [6].

1.Broca's aphasia

2.Wernicke's aphasia

3.Conduction aphasia

5.Global aphasias

are rare [1, 2, 5].

**6.1 Broca's aphasia**

*6.1.1 Clinical aspects*

1.Fluency

6.Anomic plus aphasias

capsulo-striatal aphasias) [2, 12–14].

4.Transcortical aphasias:

a.Transcortical motor aphasia

b.Transcortical sensory aphasia

c.Mixed transcortical aphasia

*DOI: http://dx.doi.org/10.5772/intechopen.92691*

**6. Types of aphasic syndromes**

Bilingual Aphasia Test (BAT) [6] was realized to exam each of the languages of a bilingual or polyglot aphasic in an equivalent way. The test is available in dozens of different pairs of languages. Thus, the various versions of the BAT are linguistically

The main determinants of the type of aphasias are *the site* and *size of the lesion* [2]. In the same time, *age* (with a higher frequency of nonfluent aphasias in young patients) and *sex* (with a higher frequency of nonfluent aphasias in men) are two other determinants. This aspect has been observed only in aphasics with ischemic

The global aphasia (24–38%) and anomic plus aphasia (20%) are more frequent

When there is no aphasic mutism or when mutism has regressed, the patient presents a nonfluent, arduous verbal output, characterized by difficulties to initiate spontaneous speech, effortful with hesitations and slow output (10–15 words/minute), and interrupted by word-finding pauses. Sometimes, he presents dysprosody (oral expression is monotonously, melodic modulation being absent) [1–5, 15–18].

in acute ischemic stroke; Broca (10–15%), Wernicke (15%), and transcortical motor aphasias (15–20%) present an intermediate frequency, and other aphasias

About 10% of aphasias remain unclassifiable, especially in patients with a previous ischemic stroke (atypical aphasias: mixed aphasias, thalamic aphasias, and

**A.** Assessment of oral production (spontaneous speech)

stroke, but not in those with hemorrhagic stroke or tumors [2, 11].

Types of aphasic syndromes (nonfluent/fluent aphasias) [1, 2, 8] are:

*Vascular Aphasias DOI: http://dx.doi.org/10.5772/intechopen.92691*

*Ischemic Stroke*

**5.4 Naming**

**5.5 Reading (lexia)**

**5.6 Writing (graphia)**

with jargon aphasia.

battery test:

**5.3 Assessment of repetition**

which is the opposite of naming [5, 6].

comprehension (using written commands, etc.) [5–7].

aphasic syndromes (nonfluent/fluent aphasias) [1, 2, 5, 7].

• Boston Diagnostic Aphasia Examination (BDAE) [8]

• Montreal-Toulouse Language Assessment Battery [10]

• Minnesota Test for Differential Diagnosis of Aphasia [6]

syndrome is more precise than that obtained on clinical grounds [2].

sis of six language domains (oral production, etc.).

• Western Aphasia Battery (WAB) [9]

• Multilingual Aphasia Examination [6]

• Bilingual Aphasia Test [6]

tasks using sentences of progressive complexity. The shortened Token Test is the test usually used to exam if the comprehension is impaired (adjusted score <29) and to

When testing repetition, it is essential to use different types of items (short-long

Aphasias with impaired repetition ability (perisylvian aphasias) differ from this point of view from transcortical (extrasylvian) aphasias, with normal repetition (even if oral comprehension is severely impaired in transcortical sensory aphasia).

While testing naming, different types should be included: objects, body parts, actions, and colors ("What is this?") [5–7]. If we want to assess the understanding ability of the patient, we have to exam pointing ("Show me, please, where the…is!"),

While testing reading, we should focus on two aspects: (a) the mechanisms of reading (the conversion of visual signs-graphemes into phonemes) and (b) reading

We should exam spontaneous writing, writing by dictation, and copying at different levels of the writing language: letters, syllables, words, sentences, and texts [5–7]. The different language disturbances observed are frequently combined into

An experimented examiner can diagnose the aphasic syndrome based on analy-

However, clinical examination can produce two kinds of errors: (a) underestimation of oral comprehension deficit and (b) misdiagnose of verbal stereotypies

These errors are not found in the case of assessment of aphasias using an aphasia

Each test provides well-defined cut-off scores, so the description of the aphasic

differentiate Broca from global aphasia (adjusted score <17) [2, 6].

verbal information and meaningful-meaningless utterances) [1–7].

**42**

Bilingual Aphasia Test (BAT) [6] was realized to exam each of the languages of a bilingual or polyglot aphasic in an equivalent way. The test is available in dozens of different pairs of languages. Thus, the various versions of the BAT are linguistically equivalent tests [6].

## **6. Types of aphasic syndromes**

The main determinants of the type of aphasias are *the site* and *size of the lesion* [2]. In the same time, *age* (with a higher frequency of nonfluent aphasias in young patients) and *sex* (with a higher frequency of nonfluent aphasias in men) are two other determinants. This aspect has been observed only in aphasics with ischemic stroke, but not in those with hemorrhagic stroke or tumors [2, 11].

Types of aphasic syndromes (nonfluent/fluent aphasias) [1, 2, 8] are:

	- a.Transcortical motor aphasia
	- b.Transcortical sensory aphasia
	- c.Mixed transcortical aphasia

The global aphasia (24–38%) and anomic plus aphasia (20%) are more frequent in acute ischemic stroke; Broca (10–15%), Wernicke (15%), and transcortical motor aphasias (15–20%) present an intermediate frequency, and other aphasias are rare [1, 2, 5].

About 10% of aphasias remain unclassifiable, especially in patients with a previous ischemic stroke (atypical aphasias: mixed aphasias, thalamic aphasias, and capsulo-striatal aphasias) [2, 12–14].

#### **6.1 Broca's aphasia**

*6.1.1 Clinical aspects*

#### **A.** Assessment of oral production (spontaneous speech)

1.Fluency

When there is no aphasic mutism or when mutism has regressed, the patient presents a nonfluent, arduous verbal output, characterized by difficulties to initiate spontaneous speech, effortful with hesitations and slow output (10–15 words/minute), and interrupted by word-finding pauses. Sometimes, he presents dysprosody (oral expression is monotonously, melodic modulation being absent) [1–5, 15–18].

	- a.Sound/arthric level (incorrect articulation of a sound)—dysarthria.
	- b.Phonemic level (omission, substitution, addition, or inversion of a phoneme)—phonemic paraphasias.
	- c.Verbal level (naming): semantic (verbal) paraphasias; word-finding difficulty (anomia), especially in spontaneous speech; deficits in action naming are more severe than deficits in object naming.
	- d.Syntactic level: agrammatism, usually more apparent after the acute phase: omission of functional/grammatical words (prepositions, conjunctions, articles, auxiliary verbs/e.g. "the," "an," and inflections), while conceptual words (nouns, verbs, and adverbs) are used in a greater proportion— "telegraphic speech." Sometimes, the oral production can be restricted to a few stereotyped utterances (e.g., "tan tan") [4, 5, 17, 19].

#### **B.** Assessment of repetition

*Poor repetition*—The patient will find difficult to repeat operational words and flexional endings, resulting phonemic and verbal paraphasias (e.g., "The boy eats an apple"/"Boy-eat-apple"). Repetition and naming are impaired, although this is less marked than spontaneous speech.

*Automatic speech*—Enumerating the days of the week, the months of the year, numbering from 1 to 10, repeating a poem, and so on, can ameliorate the verbal output [17, 20, 21].

#### **C.** Assessment of oral comprehension

Usually, good oral comprehension, at least for commands, is needed to permit clinical exam. In some cases, syntactic comprehension can be affected as requested to understand complex sentences and multiple instructions [2]:

a.The patient is unable to distinguish between different operational words like "on" or "in."

b.Comprehension of passive reversible sentences can be affected [18, 22].

Example: (Q ): "The girl was kissed by the boy. Who kissed whom? (A): Girl kiss boy."

#### **D.** Assessment of reading and writing

Reading (frontal alexia-literal alexia) and writing (frontal agraphia) are also impaired [20].

In conclusion, three characteristics represent the core of Broca's aphasia: dysarthria, agrammatism, and preserved comprehension [1–5].

#### *6.1.2 Associated signs and symptoms*

1.Contralateral hemiparesis—lesions that cause Broca's aphasia also interrupt adjacent cortical motor fibers and deep fiber tracts.

**45**

**Figure 2.**

*Vascular Aphasias*

2.Facial weakness.

same utterance.

individuals (**Figure 2**):

and 45.

object naming.

*6.1.3 Anatomo-clinical correlations*

*DOI: http://dx.doi.org/10.5772/intechopen.92691*

sequently, he can develop depression [1–3].

b.Rolandic operculum: lower part of motor area: Fa.

of the superior division of the left MCA [1, 2, 5, 23–25].

*Different types of aphasias: anatomo-clinical correlations.*

3.Buccofacial apraxia/apraxia of speech, which represents a disturbance in motor programming of speech articulation. The patient is aware of his deficit, so he tries unsuccessfully to correct his disturbance by trial and error. Instead, he presents difficulty in initiating utterances, groping articulatory movements, and articulatory inconsistency on repeated attempts of the

4.The patient with Broca's aphasia is aware of his oral expression disorders; con-

Lesions or dysfunctions usually involves on the left side in right-handed

a.Broca's area: the posterior part of the third frontal gyrus-Brodmann areas 44

Lesions in this area determine transitory apraxia of speech. Larger lesions, involving Broca's area and its subjacent white matter, produce transitory mutism, which is replaced by a rapidly improving syndrome with prominent arthric deformations and deficits in action naming that are more severe than deficits in

c.Lesions can extend or separately affect insular cortex, and subjacent white matter, centrum semiovale, capsulostriatum (caudate nucleus head and putamen), and periventricular areas. Infarctions involving together these structures and Broca's area can produce the complete syndrome of Broca's aphasia.

Broca's aphasia is produced by infarcts/severe hypoperfusion (MRI of the brain)

## 2.Facial weakness.

*Ischemic Stroke*

2.Presence of deviations at various levels

phoneme)—phonemic paraphasias.

**B.** Assessment of repetition

output [17, 20, 21].

"on" or "in."

(A): Girl kiss boy."

Example:

impaired [20].

less marked than spontaneous speech.

**C.** Assessment of oral comprehension

**D.** Assessment of reading and writing

*6.1.2 Associated signs and symptoms*

a.Sound/arthric level (incorrect articulation of a sound)—dysarthria.

b.Phonemic level (omission, substitution, addition, or inversion of a

c.Verbal level (naming): semantic (verbal) paraphasias; word-finding difficulty (anomia), especially in spontaneous speech; deficits in action

*Poor repetition*—The patient will find difficult to repeat operational words and flexional endings, resulting phonemic and verbal paraphasias (e.g., "The boy eats an apple"/"Boy-eat-apple"). Repetition and naming are impaired, although this is

*Automatic speech*—Enumerating the days of the week, the months of the year, numbering from 1 to 10, repeating a poem, and so on, can ameliorate the verbal

Usually, good oral comprehension, at least for commands, is needed to permit clinical exam. In some cases, syntactic comprehension can be affected as requested

a.The patient is unable to distinguish between different operational words like

Reading (frontal alexia-literal alexia) and writing (frontal agraphia) are also

In conclusion, three characteristics represent the core of Broca's aphasia: dysar-

1.Contralateral hemiparesis—lesions that cause Broca's aphasia also interrupt

b.Comprehension of passive reversible sentences can be affected [18, 22].

to understand complex sentences and multiple instructions [2]:

(Q ): "The girl was kissed by the boy. Who kissed whom?

thria, agrammatism, and preserved comprehension [1–5].

adjacent cortical motor fibers and deep fiber tracts.

d.Syntactic level: agrammatism, usually more apparent after the acute phase: omission of functional/grammatical words (prepositions, conjunctions, articles, auxiliary verbs/e.g. "the," "an," and inflections), while conceptual words (nouns, verbs, and adverbs) are used in a greater proportion— "telegraphic speech." Sometimes, the oral production can be restricted to a

naming are more severe than deficits in object naming.

few stereotyped utterances (e.g., "tan tan") [4, 5, 17, 19].

**44**


## *6.1.3 Anatomo-clinical correlations*

Lesions or dysfunctions usually involves on the left side in right-handed individuals (**Figure 2**):

a.Broca's area: the posterior part of the third frontal gyrus-Brodmann areas 44 and 45.

Lesions in this area determine transitory apraxia of speech. Larger lesions, involving Broca's area and its subjacent white matter, produce transitory mutism, which is replaced by a rapidly improving syndrome with prominent arthric deformations and deficits in action naming that are more severe than deficits in object naming.

b.Rolandic operculum: lower part of motor area: Fa.

c.Lesions can extend or separately affect insular cortex, and subjacent white matter, centrum semiovale, capsulostriatum (caudate nucleus head and putamen), and periventricular areas. Infarctions involving together these structures and Broca's area can produce the complete syndrome of Broca's aphasia.

Broca's aphasia is produced by infarcts/severe hypoperfusion (MRI of the brain) of the superior division of the left MCA [1, 2, 5, 23–25].

**Figure 2.** *Different types of aphasias: anatomo-clinical correlations.*

## **6.2 Wernicke's aphasia**

## *6.2.1 Clinical aspects*

	- 1.Fluency

The verbal output is fluent, with easy initialization of speech, plentiful output (100–200 words/minute), the phrase length is normal (~5–8 words/ phrase), with normal prosody. There is no quantitative reduction of spontaneous speech. In some cases, the oral production may be augmented (logorrhea), concerning patients with jargon aphasia and anosognosia (differential diagnosis with acute delirium) [1, 2, 5, 26–28].

	- a.Sound/arthric level: good articulation of sounds, well-articulated speech
	- b.Phonemic level: verbal paraphasias (semantically related word substitutions), phonemic paraphasias (phonologically related word or nonword substitutions), and jargon aphasia (associating frequently multiple paraphasias leading to neologisms)
	- c.Verbal level (naming): word-finding difficulty anomia (naming is severely affected), frequently associated circumlocutions, perseveration, and occasional neologisms
	- d.Syntactic level: paragrammatism: nouns replaced by pronouns ("that" and "those") or by unspecific words ("thing" and "something") [1, 2, 5, 26–28]

Repetition is severely impaired [1, 2, 5, 26–28].

**C.** Assessment of oral comprehension

Oral comprehension is severe impaired, due to disturbances in language sounds perception (repetition is impossible); incapacity of accessing the meaning of the word (repetition is normal); decrease in verbal memory (repetition may be disturbed depending on the length of the verbal output of the speaker); perturbation in comprehension of the lexicosemantic relations of the phrase or utterance [1, 2, 5, 26–28].

Sometimes, comprehension is more difficult for isolated words; on the other hand, verbal reception of some lexicosemantic categories may be partially or totally preserved. Syntactic comprehension is significant affected [1, 2, 5, 26–28].

**D.** Assessment of reading and writing

Reading is frequently impaired (alexia).

Writing (agraphia): spontaneous and dictated writing are fully of paragraphia and paragrammatism; copying a text is easier than writing after hearing one [1, 2, 5, 26–28].

**47**

*Vascular Aphasias*

3.Limb apraxia.

(**Figure** 2).

thrombotic [1, 2, 5, 23–25].

**6.3 Conduction aphasia**

*6.3.1 Clinical aspects*

29–32].

*DOI: http://dx.doi.org/10.5772/intechopen.92691*

1.Homonymous hemianopia—frequently associated.

his disorders and seems unconcerned [1, 2, 5, 26–28].

subjacent white matter can be also affected.

**A.** Assessment of oral production (spontaneous speech)

the cardinal feature of conduction aphasia.

tion aphasia than in other fluent types of aphasia.

2.Presence of deviations at various levels

2.Complete/dissociated Gerstmann syndrome (agraphia, acalculia, finger agnosia, and inability to distinguish between the right and left sides of one's body).

4.Anosognosia—it can be observed at the initial stage and decreases gradually; high excitation: logorrhea and exaggeration of mimico-gestural language. The patient with Wernicke's aphasia, in contrast to a Broca's aphasic, is unaware of

a.Wernicke's area: posterior part of the first two temporal gyri-T1/T2 (BA 22)

b.Inferior parietal lobes: angular gyrus (BA 39) and supramarginal gyrus (BA 40).

c.Lesions can extend to the insular-external capsule region and anterior part of temporal gyri (BA22). Besides the cortical destructions from these areas,

Wernicke's aphasia is the result of an infarct/sever hypoperfusion (MRI of the brain) of the inferior division of the left MCA (supplies the posterior part of the temporal lobe and inferior parietal lobule), usually an embolic occlusion/athero-

Wernicke's aphasia is more current in elderly women, due to a higher frequency of infarct in the inferior-posterior territory of the MCA in these patients [1, 2, 5].

1.Fluency: verbal output (spontaneous speech) is fluent, although some hesitations and self-correction attempts to interrupt the flow are noted [1, 2, 5,

a.Sound/arthric level: normal articulation (speech well-articulated).

b.Phonemic level: phonemic paraphasias are typically for conduction aphasia. The production of phonemic paraphasias across verbal tasks represents

• Semantic/verbal paraphasias or neologisms are less frequent in conduc-

*6.2.2 Associated signs and symptoms*

*6.2.3 Anatomo-clinical correlations*

	- 1.Homonymous hemianopia—frequently associated.
	- 2.Complete/dissociated Gerstmann syndrome (agraphia, acalculia, finger agnosia, and inability to distinguish between the right and left sides of one's body).
	- 3.Limb apraxia.

*Ischemic Stroke*

**6.2 Wernicke's aphasia**

**A.** Assessment of oral production (spontaneous speech)

sis with acute delirium) [1, 2, 5, 26–28].

2.Presence of deviations at various levels:

phasias leading to neologisms)

Repetition is severely impaired [1, 2, 5, 26–28].

occasional neologisms

**C.** Assessment of oral comprehension

**D.** Assessment of reading and writing

Reading is frequently impaired (alexia).

**B.** Assessment of repetition

The verbal output is fluent, with easy initialization of speech, plentiful output (100–200 words/minute), the phrase length is normal (~5–8 words/ phrase), with normal prosody. There is no quantitative reduction of spontaneous speech. In some cases, the oral production may be augmented (logorrhea), concerning patients with jargon aphasia and anosognosia (differential diagno-

a.Sound/arthric level: good articulation of sounds, well-articulated speech

b.Phonemic level: verbal paraphasias (semantically related word substitutions), phonemic paraphasias (phonologically related word or nonword substitutions), and jargon aphasia (associating frequently multiple para-

c.Verbal level (naming): word-finding difficulty anomia (naming is severely affected), frequently associated circumlocutions, perseveration, and

d.Syntactic level: paragrammatism: nouns replaced by pronouns ("that" and "those") or by unspecific words ("thing" and "something") [1, 2, 5, 26–28]

Oral comprehension is severe impaired, due to disturbances in language sounds

perception (repetition is impossible); incapacity of accessing the meaning of the word (repetition is normal); decrease in verbal memory (repetition may be disturbed depending on the length of the verbal output of the speaker); perturbation in comprehension of the lexicosemantic relations of the phrase or utterance

Sometimes, comprehension is more difficult for isolated words; on the other hand, verbal reception of some lexicosemantic categories may be partially or totally

Writing (agraphia): spontaneous and dictated writing are fully of paragraphia and paragrammatism; copying a text is easier than writing after hearing

preserved. Syntactic comprehension is significant affected [1, 2, 5, 26–28].

*6.2.1 Clinical aspects*

1.Fluency

**46**

[1, 2, 5, 26–28].

one [1, 2, 5, 26–28].

	- a.Wernicke's area: posterior part of the first two temporal gyri-T1/T2 (BA 22) (**Figure** 2).
	- b.Inferior parietal lobes: angular gyrus (BA 39) and supramarginal gyrus (BA 40).
	- c.Lesions can extend to the insular-external capsule region and anterior part of temporal gyri (BA22). Besides the cortical destructions from these areas, subjacent white matter can be also affected.

Wernicke's aphasia is the result of an infarct/sever hypoperfusion (MRI of the brain) of the inferior division of the left MCA (supplies the posterior part of the temporal lobe and inferior parietal lobule), usually an embolic occlusion/atherothrombotic [1, 2, 5, 23–25].

Wernicke's aphasia is more current in elderly women, due to a higher frequency of infarct in the inferior-posterior territory of the MCA in these patients [1, 2, 5].

## **6.3 Conduction aphasia**

## *6.3.1 Clinical aspects*

**A.** Assessment of oral production (spontaneous speech)

	- a.Sound/arthric level: normal articulation (speech well-articulated).
	- b.Phonemic level: phonemic paraphasias are typically for conduction aphasia. The production of phonemic paraphasias across verbal tasks represents the cardinal feature of conduction aphasia.
		- Semantic/verbal paraphasias or neologisms are less frequent in conduction aphasia than in other fluent types of aphasia.

#### **B.** Assessment of repetition

Repetition is impaired, contrasting with the sparing of the oral comprehension. Repetition of monosyllabic or bisyllabic words can be normal, but repetition of polysyllabic words and of sentences is always incorrect. The patient often paraphrases the sentence rather than repeating it.

Repetitive self-corrections, word-finding difficulties, and paraphrasing are attempts to correct phonemic deformations by successive approximations, named "conduit d'approche" [2, 29–32].

#### **C.** Assessment of oral comprehension

It involves sparing of oral comprehension. The patient understands simple, active sentences, but guesses at comprehension of passive sentences [1, 2, 5, 29–32].

#### **D.** Assessment of reading and writing

It involves usually good reading comprehension, but paraphasic oral reading. More precisely, the patient has difficulties in spelling and reading unfamiliar words, but correctly reads and spells words.

In conclusion, conduction aphasia presents three major characteristics: a relatively fluent, though phonologically paraphasic speech; poor repetition; and relatively spared comprehension [1, 2, 5, 29–32].

#### *6.3.2 Associated signs and symptoms*


#### *6.3.3 Anatomo-clinical correlations*

The lesions affect the inferior parietal lobes, especially the supramarginal gyrus or/and the external capsule; they classically disrupt the arcuate fasciculus (a large bundle of fibers), although its role remains debated for the repetition impairments: probably disconnection between the superior temporal cortex and the inferior frontal gyri, respectively (**Figure 2**).

Other explanations for the repetition impairments have been noted, such as short-term memory syndrome (the repetition impairment due to limited working memory)—so, the associated lesions are situated in areas critical for working memory: inferior parietal lobule (supramarginal and angular gyri), inferior frontal cortex, posterior temporal lobe, and/or their white matter connections (the external capsule).

Conduction aphasia is the result of an embolic infarct of the inferior division (posterior temporal or parietal) of the left MCA [1, 2, 5, 23–25].

It is rarely observed at the acute stage of stroke and more frequently affects younger patients.

**49**

*Vascular Aphasias*

**6.4 Transcortical aphasias**

*6.4.1 Transcortical motor aphasia*

*6.4.1.1.1 Anatomo-clinical correlations*

*6.4.2 Transcortical sensory aphasia*

with semantic impairment [1, 2, 5, 33–36].

*6.4.2.2 Anatomo-clinical correlations*

*6.4.2.1 Clinical aspects*

*6.4.1.1 Clinical aspects*

quently preserved.

*DOI: http://dx.doi.org/10.5772/intechopen.92691*

Transcortical aphasias are the less common type of aphasias. They are character-

It is characterized by poor spontaneous speech (nonfluent, reduced oral output with possible initial mutism, loss of initiation, hypophonia, perseveration, and reduced phrase length). Minor dysarthria is noted in opposition with sever arthric deformation noted in Broca's aphasia. Sometimes, simplification of grammatical form is noted. Echolalia and perseveration are usually observed. Naming is fre-

1.Cortical frontal lesions of border areas (watershed area) between the left anterior cerebral artery (ACA) and middle cerebral artery (MCA); less frequently left premotor and prefrontal regions, situated anterior and superior of Broca's area (dorsolateral region-sparing Broca area), and supplementary motor area

2.Subcortical frontal lesions: thalamus, centrum semiovale with variable exten-

Spontaneous speech (oral output) is fluent, with verbal paraphasias, word-finding difficulty (especially by naming infrequent objects and animals), and circumlocutory speech (use of generic words such as "bird" for a hen and "furniture" for a showcase). Comprehension is severely impaired at the word level, especially for unusual nouns. This contrasts with repetition sparing (this is the key feature that distinguishes it from Wernicke's aphasia). The patient is incapable to describe accurately a name that is correctly repeated. The comprehension deficit is usually associated

1.Cortical lesions of border areas from MCA and posterior cerebral artery (PCA) territories: temporo-parieto-occipital junction region and inferotemporal

Repetition and oral comprehension are typically spared [1, 2, 5, 33–36].

(supero-medial area of the frontal lobe) (**Figure 2**)

region (second and third temporal gyri) (**Figure 2**)

sion into the striatum (hypophonia is noted) [1, 2, 5, 23–25]

ized by preservation of word repetition, even of those words without meaning. Repetition of words is mediated by the perisylvian cerebral region (fronto-temporoparietal region). Generally, in this type of aphasia, Broca's area, Wernicke's area, and the arcuate fasciculus are intact. In transcortical aphasia exists a disconnection between motor and/or sensory areas of language from hemispheric cortex, a process that occurs from lesions of border areas: (a) from ACA and MCA (transcortical motor aphasia) and (b) from MCA and PCA (transcortical sensory aphasia) [1, 2, 23–25].

## **6.4 Transcortical aphasias**

*Ischemic Stroke*

c.Verbal level (naming): anomia—naming may be mildly impaired.

simple syntax [1, 2, 5, 29–32].

paraphrases the sentence rather than repeating it.

**B.** Assessment of repetition

"conduit d'approche" [2, 29–32].

**C.** Assessment of oral comprehension

**D.** Assessment of reading and writing

relatively spared comprehension [1, 2, 5, 29–32].

1.Oral and limb apraxia; ideomotor apraxia

2.Right sensory impairment [1, 2, 5]

but correctly reads and spells words.

*6.3.2 Associated signs and symptoms*

*6.3.3 Anatomo-clinical correlations*

frontal gyri, respectively (**Figure 2**).

d.Syntactic level: the grammar is preserved. Sentences are short and have

Repetition is impaired, contrasting with the sparing of the oral comprehension. Repetition of monosyllabic or bisyllabic words can be normal, but repetition of polysyllabic words and of sentences is always incorrect. The patient often

Repetitive self-corrections, word-finding difficulties, and paraphrasing are attempts to correct phonemic deformations by successive approximations, named

It involves sparing of oral comprehension. The patient understands simple, active sentences, but guesses at comprehension of passive sentences [1, 2, 5, 29–32].

It involves usually good reading comprehension, but paraphasic oral reading. More precisely, the patient has difficulties in spelling and reading unfamiliar words,

The lesions affect the inferior parietal lobes, especially the supramarginal gyrus or/and the external capsule; they classically disrupt the arcuate fasciculus (a large bundle of fibers), although its role remains debated for the repetition impairments: probably disconnection between the superior temporal cortex and the inferior

Other explanations for the repetition impairments have been noted, such as short-term memory syndrome (the repetition impairment due to limited working memory)—so, the associated lesions are situated in areas critical for working memory: inferior parietal lobule (supramarginal and angular gyri), inferior frontal cortex, posterior temporal lobe, and/or their white matter connections (the

Conduction aphasia is the result of an embolic infarct of the inferior division

It is rarely observed at the acute stage of stroke and more frequently affects

(posterior temporal or parietal) of the left MCA [1, 2, 5, 23–25].

In conclusion, conduction aphasia presents three major characteristics: a relatively fluent, though phonologically paraphasic speech; poor repetition; and

**48**

external capsule).

younger patients.

Transcortical aphasias are the less common type of aphasias. They are characterized by preservation of word repetition, even of those words without meaning. Repetition of words is mediated by the perisylvian cerebral region (fronto-temporoparietal region). Generally, in this type of aphasia, Broca's area, Wernicke's area, and the arcuate fasciculus are intact. In transcortical aphasia exists a disconnection between motor and/or sensory areas of language from hemispheric cortex, a process that occurs from lesions of border areas: (a) from ACA and MCA (transcortical motor aphasia) and (b) from MCA and PCA (transcortical sensory aphasia) [1, 2, 23–25].

## *6.4.1 Transcortical motor aphasia*

## *6.4.1.1 Clinical aspects*

It is characterized by poor spontaneous speech (nonfluent, reduced oral output with possible initial mutism, loss of initiation, hypophonia, perseveration, and reduced phrase length). Minor dysarthria is noted in opposition with sever arthric deformation noted in Broca's aphasia. Sometimes, simplification of grammatical form is noted. Echolalia and perseveration are usually observed. Naming is frequently preserved.

Repetition and oral comprehension are typically spared [1, 2, 5, 33–36].

## *6.4.1.1.1 Anatomo-clinical correlations*


## *6.4.2 Transcortical sensory aphasia*

## *6.4.2.1 Clinical aspects*

Spontaneous speech (oral output) is fluent, with verbal paraphasias, word-finding difficulty (especially by naming infrequent objects and animals), and circumlocutory speech (use of generic words such as "bird" for a hen and "furniture" for a showcase).

Comprehension is severely impaired at the word level, especially for unusual nouns. This contrasts with repetition sparing (this is the key feature that distinguishes it from Wernicke's aphasia). The patient is incapable to describe accurately a name that is correctly repeated. The comprehension deficit is usually associated with semantic impairment [1, 2, 5, 33–36].

## *6.4.2.2 Anatomo-clinical correlations*

1.Cortical lesions of border areas from MCA and posterior cerebral artery (PCA) territories: temporo-parieto-occipital junction region and inferotemporal region (second and third temporal gyri) (**Figure 2**)

2.Subcortical lesions: anterolateral thalamus

Alzheimer's disease, semantic variant of primary progressive aphasia (PPA) or Creutzfeldt-Jakob disease can produce a similar syndrome [1, 2, 5, 23–25].

## *6.4.3 Mixed transcortical aphasia (isolation aphasia)*

## *6.4.3.1 Clinical aspects*

Nonfluent reduced spontaneous speech (verbal output), palilalia, or even transitory mutism, combined with impaired comprehension, impaired reading (alexia), and impaired writing (agraphia), relatively spared repetition. It combines signs of both transcortical motor and sensory aphasia. It looks like a global aphasia with relatively normal repetition [1, 2, 5, 33–36].

## *6.4.3.1.1 Anatomo-clinical correlations*


## **6.5 Global aphasia**

## *6.5.1 Clinical aspects*

It is the most severe form of aphasia, which associates with the following:


## *6.5.1.1 Associated signs and symptoms*

Right hemiparesis/hemiplegia, right hemi-hypoesthesia, right homonym hemianopia, limbs apraxia, and facio-buccolingual apraxia [1, 2, 5, 37].

## *6.5.1.2 Anatomo-clinical correlations*

1.Extended lesions (including left perisylvian anterior and posterior language areas), which are the result of a left MCA/C1 occlusion (with a total left MCA infarct), produce global aphasia with hemiplegia, hemisensory deficits, and hemianopia (**Figure 2**) [2].

**51**

*Vascular Aphasias*

comprehension).

language network:

**6.6 Anomic aphasia**

*6.6.1 Clinical aspects*

mixed transcortical aphasia.

tions. Comprehension and repetition are spared.

the mildest aphasic syndrome [1, 2, 5, 39].

*6.6.2 Anatomo-clinical correlations*

**6.7 Peculiar aphasic syndromes**

(nondominant hemisphere).

*6.7.1 Crossed aphasias*

*DOI: http://dx.doi.org/10.5772/intechopen.92691*

2.Broca's and Wernicke's areas may be simultaneously hypoperfused in the acute

Early involution into Broca's aphasia (with early recovery of comprehension) may result from reperfusion of Wernicke's area. In this case, the patient presents only left frontal lobe, left basal ganglia, and left insula ischemic lesions (diffusion-weighted image shows infarct in superior division of left MCA territory, which includes Broca's area), sparing in the same time the left temporoparietal region (global aphasia with hemiplegia and early improvement of

Later recovery of comprehension may appear from the reorganization of the

4.Subcortical infarct extended into basal ganglia [1, 2, 5, 23–25, 38].

3.Frontal and temporoparietal lesions (two lesions) produce global aphasia without hemiplegia. When sensory-motor deficit is missing, we should search for

Typical anomic aphasia is a fluent aphasia with word-finding difficulty anomia (noted in spontaneous speech and naming), usually associated with circumlocu-

Acute anomic aphasia may be noted after stroke in many locations. It also represents a stage of all aphasic syndromes when they improve (**Figure 2**) [1, 2, 5, 23–25].

This is a very rare condition (1% of all acute ischemic stroke aphasias) [39], defined by an aphasic syndrome in a right-handed patient (free from developmental disorders and previous brain lesions, fully lateralized, which is demonstrated using a questionnaire like Edinburgh Inventory) [40], caused by a right hemisphere lesion

The anatomical determinants are similar to those observed in left hemisphere lesion, although a higher proportion of deviant cases are observed, particularly with mild aphasia contrasting with the large lesion. This fact is usually reported as

In the past, crossed aphasia was considered to be nonfluent, although today is reported that all aphasic syndromes can be registered (some cases of crossed Wernicke's aphasia in right-handed patients with lesions in the homologous area of

evidence for bilateral representation of the language [2].

the right cerebral hemisphere are noted [2].

Anomic plus aphasia presents additional minimal deficit of language (mild arthric deformation or mild impairment of oral comprehension or repetition). It is

period. Thus, global aphasia can be the initial aphasic syndrome.

*Ischemic Stroke*

*6.4.3.1 Clinical aspects*

[1, 2, 5, 23–25]

**6.5 Global aphasia**

*6.5.1 Clinical aspects*

[1, 2, 5, 37].

*6.5.1.1 Associated signs and symptoms*

*6.5.1.2 Anatomo-clinical correlations*

hemianopia (**Figure 2**) [2].

2.Subcortical lesions: anterolateral thalamus

*6.4.3 Mixed transcortical aphasia (isolation aphasia)*

relatively normal repetition [1, 2, 5, 33–36].

between the left MCA and PCA) (**Figure 2**)

*6.4.3.1.1 Anatomo-clinical correlations*

Alzheimer's disease, semantic variant of primary progressive aphasia (PPA) or Creutzfeldt-Jakob disease can produce a similar syndrome [1, 2, 5, 23–25].

Nonfluent reduced spontaneous speech (verbal output), palilalia, or even transitory mutism, combined with impaired comprehension, impaired reading (alexia), and impaired writing (agraphia), relatively spared repetition. It combines signs of both transcortical motor and sensory aphasia. It looks like a global aphasia with

1.Cortical lesions isolating the spared perisylvian language areas (watershed territory between the left ACA and MCA in addition to the watershed territory

2.Subcortical lesions: large thalamic hemorrhage interrupting the temporal isthmus; infarcts in the left thalamus, putamen, and periventricular white matter

It is the most severe form of aphasia, which associates with the following:

output, differing from mixed transcortical aphasia).

anopia, limbs apraxia, and facio-buccolingual apraxia [1, 2, 5, 37].

a.Major disorders of oral production, represented by aphasic mutism (oral output lost), or by a spontaneous speech restricted to some stereotyped utterances (with dysarthria). Repetition is severely affected (it does not improve oral

b.Major disorders of the oral and written comprehension. Global aphasia differs from Broca's aphasia by the severity of oral comprehension impairment

Right hemiparesis/hemiplegia, right hemi-hypoesthesia, right homonym hemi-

1.Extended lesions (including left perisylvian anterior and posterior language areas), which are the result of a left MCA/C1 occlusion (with a total left MCA infarct), produce global aphasia with hemiplegia, hemisensory deficits, and

**50**

2.Broca's and Wernicke's areas may be simultaneously hypoperfused in the acute period. Thus, global aphasia can be the initial aphasic syndrome.

Early involution into Broca's aphasia (with early recovery of comprehension) may result from reperfusion of Wernicke's area. In this case, the patient presents only left frontal lobe, left basal ganglia, and left insula ischemic lesions (diffusion-weighted image shows infarct in superior division of left MCA territory, which includes Broca's area), sparing in the same time the left temporoparietal region (global aphasia with hemiplegia and early improvement of comprehension).

Later recovery of comprehension may appear from the reorganization of the language network:


## **6.6 Anomic aphasia**

### *6.6.1 Clinical aspects*

Typical anomic aphasia is a fluent aphasia with word-finding difficulty anomia (noted in spontaneous speech and naming), usually associated with circumlocutions. Comprehension and repetition are spared.

Anomic plus aphasia presents additional minimal deficit of language (mild arthric deformation or mild impairment of oral comprehension or repetition). It is the mildest aphasic syndrome [1, 2, 5, 39].

## *6.6.2 Anatomo-clinical correlations*

Acute anomic aphasia may be noted after stroke in many locations. It also represents a stage of all aphasic syndromes when they improve (**Figure 2**) [1, 2, 5, 23–25].

### **6.7 Peculiar aphasic syndromes**

### *6.7.1 Crossed aphasias*

This is a very rare condition (1% of all acute ischemic stroke aphasias) [39], defined by an aphasic syndrome in a right-handed patient (free from developmental disorders and previous brain lesions, fully lateralized, which is demonstrated using a questionnaire like Edinburgh Inventory) [40], caused by a right hemisphere lesion (nondominant hemisphere).

The anatomical determinants are similar to those observed in left hemisphere lesion, although a higher proportion of deviant cases are observed, particularly with mild aphasia contrasting with the large lesion. This fact is usually reported as evidence for bilateral representation of the language [2].

In the past, crossed aphasia was considered to be nonfluent, although today is reported that all aphasic syndromes can be registered (some cases of crossed Wernicke's aphasia in right-handed patients with lesions in the homologous area of the right cerebral hemisphere are noted [2].

#### *6.7.2 Subcortical aphasias*

Pure left striatocapsular infarcts (left deep MCA infarcts) can produce different types of aphasias (mainly nonfluent, especially motor transcortical aphasia and Broca's aphasia). Frequently, hypophonia (poor speech volume) can be noted.

Fluent and nonfluent aphasias have been reported in thalamic lesions. Usually, a thalamic aphasia presents a significant impairment of spontaneous speech, with verbal paraphasias, but with oral comprehension and repetition relatively spared [1, 2, 5, 28]. Patients with subcortical aphasias are older, because the main mechanism of ischemic stroke is small vascular disease.

There are two distinct mechanisms concerning subcortical vascular aphasias: (a) a possible sustained cortical hypoperfusion and infarction not visible on structural imaging studies and (b) a possible thalamic disconnection, due to striatocapsular infarcts [28].

## **7. Etiology of aphasias**

Any type of lesion (localized/diffuse, acute/chronic, intermittent, progressive, or permanent) restricted to any of all mentioned language network from the dominant hemisphere in right-handed subjects (and rarely, in the nondominant hemisphere in right-handed subjects—"crossed aphasia") can cause aphasia [1, 2].

The most common causes of aphasia are the vascular pathology (ischemic and hemorrhagic stroke, aneurysm, cerebral veins, and dural sinus thrombosis), which produces vascular aphasias, traumatic brain injury, brain tumors, neuroinfections (especially Herpes simplex encephalitis), stroke mimics (aura migraine, epilepsy - ictal EEG sustaining the diagnosis of an epileptic seizure, and MRI-DWI), multiple sclerosis (rarely), and neurodegenerative diseases such as Alzheimer disease and primary progressive aphasia.

#### **7.1 Vascular aphasias**

Aphasia has a prevalence of 25–30% in acute ischemic stroke; it is a marker of stroke severity and of poststroke outcome, being associated with a higher risk of mortality, poor functional prognosis (can have a dramatic impact on person's ability to communicate), and increased risk of poststroke dementia [1, 2, 7–11, 41–43].

Vascular aphasias have not typically corresponded to linguistic domains network due to the fact that ischemic injuries specifically imply arterial territories, rather than being limited to the language network. Thus, the arterial syndromes include different concomitant neurological signs (hemiparesis, hemianopia, etc.,) that are reported together with aphasia because they all represent functions that depend on arterial supply of a peculiar brain region (vessel which can be occluded, producing an ischemic stroke) [1, 22, 44].

The main determinant of the type of vascular aphasia is the infarct location [1, 2]. Recent studies concerning the hyperacute stage of ischemic stroke have demonstrated that aphasic symptoms have a similar evolution to that of cortical hypoperfusion; thus, improvement in cortical perfusion (following spontaneous or therapeutic recanalization) generates recovery of aphasia [1, 2, 5, 28]. Recanalization of an occluded M1 branch of MCA through development of collateral blood flow or through treatment in a patient with aphasia and a striatocapsular infarct can reverse the aphasia (the patient may present the late vascular syndrome due to the infarct rather than the initial vascular syndrome due to the hypoperfused area [1, 2, 5, 28].

**53**

*Vascular Aphasias*

**8. Outcome**

modality [2].

F3 was affected [1, 2].

**8.4 Prognosis**

*DOI: http://dx.doi.org/10.5772/intechopen.92691*

**8.1 Perfusion computer tomography**

**PWI mismatch region in acute stroke**

region certified by the imaging mismatch.

never evolves into a nonfluent aphasia [45].

Using different functional imaging techniques (perfusion computer tomography, diffusion- and perfusion-weighted magnetic resonance imaging, and positron emission tomography), recent studies have indicated characteristics of aphasia (in hyperacute stage), suggested prognosis (in the era of thrombolysis), and observed even the potential new treatments [such as transcranial magnetic stimulation (TMS)] [2].

Measuring cerebral blood flow and volume enables the definition of maps of penumbra (diminution of cerebral blood flow and normal/increase of cerebral blood volume) and infarct (diminution of cerebral blood flow and volume) in the hyperacute stage of ischemic stroke. It has been demonstrated that penumbra dynamics is the major determinant for aphasia evolution. Saving a cerebral area implicated in a specific language function (naming, etc.) clinically improved this

**8.2 Diffusion- and perfusion-weighted magnetic resonance imaging: the DWI/**

Functional MRI studies demonstrated that cerebral tissue at risk of infarction (as indicated by the mismatch of PWI and DWI) can survive if recanalization occurs quickly. This represents the major site explaining postischemic recovery, as proved by language task-specific activation adjacent to the infarct lesion within the

Different studies using positron emission tomography reported that spontaneous recovery of vascular aphasias still occurs with the persistence of the lesion and it takes place by a few distinct mechanisms. The activation appears in some spared left hemisphere language areas, new left hemisphere areas not commonly involved in language processing (pars orbitalis of the inferior frontal gyrus, anterior insula, and middle frontal gyrus), and right hemisphere areas homotopic to control subjects language network. Interestingly, compensation by the right hemisphere respected the aphasia subtype network, the right F3 being recruited when the left

Usually, vascular aphasias become less severe in the first 3 months after stroke. The spontaneous recovery depends on the severity of the initial aphasia (which has been related to the lesion location and size), but also on general stroke severity, etiology (ischemic and hemorrhagic), time from onset, age, gender, handedness,

Nonfluent aphasia can rarely evolve into fluent aphasia, whereas a fluent aphasia

a.Global aphasia may regress to Broca's aphasia (or less frequently to Wernicke's aphasia). Prognosis for global aphasia persisting at 1 month is poor, because only one-third of aphasics communicate satisfactorily at 2 years [2, 13, 46].

treatment, motivation and personality, associated disorders, etc. [1, 2, 5].

**8.3 The networks for residual language function and recovery after stroke**

## **8. Outcome**

*Ischemic Stroke*

*6.7.2 Subcortical aphasias*

sular infarcts [28].

progressive aphasia.

**7.1 Vascular aphasias**

an ischemic stroke) [1, 22, 44].

**7. Etiology of aphasias**

nism of ischemic stroke is small vascular disease.

Pure left striatocapsular infarcts (left deep MCA infarcts) can produce different types of aphasias (mainly nonfluent, especially motor transcortical aphasia and Broca's aphasia). Frequently, hypophonia (poor speech volume) can be noted.

Fluent and nonfluent aphasias have been reported in thalamic lesions. Usually, a thalamic aphasia presents a significant impairment of spontaneous speech, with verbal paraphasias, but with oral comprehension and repetition relatively spared [1, 2, 5, 28]. Patients with subcortical aphasias are older, because the main mecha-

There are two distinct mechanisms concerning subcortical vascular aphasias: (a) a possible sustained cortical hypoperfusion and infarction not visible on structural imaging studies and (b) a possible thalamic disconnection, due to striatocap-

Any type of lesion (localized/diffuse, acute/chronic, intermittent, progressive, or permanent) restricted to any of all mentioned language network from the dominant hemisphere in right-handed subjects (and rarely, in the nondominant hemisphere in right-handed subjects—"crossed aphasia") can cause aphasia [1, 2]. The most common causes of aphasia are the vascular pathology (ischemic and hemorrhagic stroke, aneurysm, cerebral veins, and dural sinus thrombosis), which produces vascular aphasias, traumatic brain injury, brain tumors, neuroinfections (especially Herpes simplex encephalitis), stroke mimics (aura migraine, epilepsy - ictal EEG sustaining the diagnosis of an epileptic seizure, and MRI-DWI), multiple sclerosis (rarely), and neurodegenerative diseases such as Alzheimer disease and primary

Aphasia has a prevalence of 25–30% in acute ischemic stroke; it is a marker of stroke severity and of poststroke outcome, being associated with a higher risk of mortality, poor functional prognosis (can have a dramatic impact on person's ability to communicate), and increased risk of poststroke dementia [1, 2, 7–11, 41–43].

Vascular aphasias have not typically corresponded to linguistic domains network due to the fact that ischemic injuries specifically imply arterial territories, rather than being limited to the language network. Thus, the arterial syndromes include different concomitant neurological signs (hemiparesis, hemianopia, etc.,) that are reported together with aphasia because they all represent functions that depend on arterial supply of a peculiar brain region (vessel which can be occluded, producing

The main determinant of the type of vascular aphasia is the infarct location [1, 2]. Recent studies concerning the hyperacute stage of ischemic stroke have demonstrated that aphasic symptoms have a similar evolution to that of cortical hypoperfusion; thus, improvement in cortical perfusion (following spontaneous or therapeutic recanalization) generates recovery of aphasia [1, 2, 5, 28]. Recanalization of an occluded M1 branch of MCA through development of collateral blood flow or through treatment in a patient with aphasia and a striatocapsular infarct can reverse the aphasia (the patient may present the late vascular syndrome due to the infarct rather than the initial vascular syndrome due to the hypoperfused area [1, 2, 5, 28].

**52**

Using different functional imaging techniques (perfusion computer tomography, diffusion- and perfusion-weighted magnetic resonance imaging, and positron emission tomography), recent studies have indicated characteristics of aphasia (in hyperacute stage), suggested prognosis (in the era of thrombolysis), and observed even the potential new treatments [such as transcranial magnetic stimulation (TMS)] [2].

## **8.1 Perfusion computer tomography**

Measuring cerebral blood flow and volume enables the definition of maps of penumbra (diminution of cerebral blood flow and normal/increase of cerebral blood volume) and infarct (diminution of cerebral blood flow and volume) in the hyperacute stage of ischemic stroke. It has been demonstrated that penumbra dynamics is the major determinant for aphasia evolution. Saving a cerebral area implicated in a specific language function (naming, etc.) clinically improved this modality [2].

## **8.2 Diffusion- and perfusion-weighted magnetic resonance imaging: the DWI/ PWI mismatch region in acute stroke**

Functional MRI studies demonstrated that cerebral tissue at risk of infarction (as indicated by the mismatch of PWI and DWI) can survive if recanalization occurs quickly. This represents the major site explaining postischemic recovery, as proved by language task-specific activation adjacent to the infarct lesion within the region certified by the imaging mismatch.

## **8.3 The networks for residual language function and recovery after stroke**

Different studies using positron emission tomography reported that spontaneous recovery of vascular aphasias still occurs with the persistence of the lesion and it takes place by a few distinct mechanisms. The activation appears in some spared left hemisphere language areas, new left hemisphere areas not commonly involved in language processing (pars orbitalis of the inferior frontal gyrus, anterior insula, and middle frontal gyrus), and right hemisphere areas homotopic to control subjects language network. Interestingly, compensation by the right hemisphere respected the aphasia subtype network, the right F3 being recruited when the left F3 was affected [1, 2].

## **8.4 Prognosis**

Usually, vascular aphasias become less severe in the first 3 months after stroke. The spontaneous recovery depends on the severity of the initial aphasia (which has been related to the lesion location and size), but also on general stroke severity, etiology (ischemic and hemorrhagic), time from onset, age, gender, handedness, treatment, motivation and personality, associated disorders, etc. [1, 2, 5].

Nonfluent aphasia can rarely evolve into fluent aphasia, whereas a fluent aphasia never evolves into a nonfluent aphasia [45].

a.Global aphasia may regress to Broca's aphasia (or less frequently to Wernicke's aphasia). Prognosis for global aphasia persisting at 1 month is poor, because only one-third of aphasics communicate satisfactorily at 2 years [2, 13, 46].


The outcome of aphasia at 1 year after stroke can be predicted in the first week [45] by stroke subtype, the phonology score (the strongest predictor), age, educational level, and the Barthel Index score. Severe comprehension impairment is reported as a negative factor for stroke recovery, as the aphasic could not understand the rehabilitation tasks. In 2009, Parkinson et al. [47] observed improvement in object and action naming in chronic vascular aphasics. They noted that better recovery was associated with larger lesion in the anterior regions of the brain and absence of lesion in the subcortical regions.

## **9. Treatment**

### **9.1 Speech therapy**

Vascular aphasics may present some spontaneous language amelioration (spontaneous recovery), but speech therapy can significantly contribute to a better aphasia rehabilitation.

A very good language assessment is the key point for any program of speech therapy (the role of a dedicated and competent neurologist is very important) [48].

Speech therapy should not be used in the hyperacute stage of stroke. In this stage, we should focus on reperfusion (i.v. thrombolysis/thrombectomy) of the affected arterial territory. Speech and language therapy should be typically started as soon as the clinical condition becomes favorable, which is nowadays generally possible in acute stroke units (in the acute/subacute stage of stroke) [2].

The speech therapy has five objectives:

a.*To keep the aphasic verbally active*: the specialists, including the neurologists, speech therapists, psychologists, nurses, and the family have to communicate with the patient using verbal and written language, not only gesture.

**55**

*Vascular Aphasias*

*DOI: http://dx.doi.org/10.5772/intechopen.92691*

aphasias, not in Wernicke's aphasia.

porting him [49].

**9.2 Pharmacotherapy**

demonstrated.

first 3 months after stroke onset [2].

methods (nonverbal) of communicating, etc. [48].

**9.3 Transcranial magnetic stimulation (TMS)**

b.*To relearn language*: even if the patient is old or present a large infarct, it is generally accepted that he can still relearn some language, from the simpler to

c.*To provide strategies to improve language*: different language abilities can ameliorate if only selective strategies are used (depending on the peculiar type of aphasia; for example, the melodic intonation therapy is efficient only in Broca's

d.*To teach the family to improve communication*: to avoid especially verbal interference, to keep the conversational subject, to use plenty of redundant information, to speak slow, to use prosody, and to be aware that the aphasic's communication ability certainly fluctuates due to variations in attention, etc.

e.*To offer psychological support*: due to his/her communication difficulties, the aphasic needs somebody (the therapist) capable of understanding and sup-

Bhogal et al. [50] reviewed 10 studies and noted that intense speech therapy over a short period (approximately 9 hours of therapy per week during 12 weeks) ameliorate outcome. Conversely, lower intensity (2 hours a week) over a longer period (more than 20 weeks) did not improve evolution compared with informal support. In conclusion, speech therapy intensity should be of at least of 1 hour per day in the

Due to the specific level of the language which is affected, the speech therapy strategy to be used will be different (auditory analysis, word identification, etc.). For example, in global aphasia, the main goals of therapy are represented by helping the patient to use remaining abilities, to restore language abilities, to learn other

Nowadays, treatment of reperfusion (designed to restore cortical perfusion (i.v. thrombolysis/thrombectomy)) during the first 4–5 h (thrombolysis), and 6–12 h (thrombectomy) from the clinical onset, represents the main prevention approach. Preliminary positive results were found using piracetam in nonfluent aphasias

Functional imaging studies of language in nonfluent aphasics usually report a

Evidence exists that left hemisphere functional recovery is clinically more relevant than right hemisphere activation as a compensatory mechanism after stroke. Thus, right hemisphere activation might be a negative factor for aphasia recovery after stroke [55]. Use of TMS could provide right hemisphere inhibition and, therefore, ameliorate regression of language deficits. Preliminary reports suggested that

possible overactivation in right hemisphere language homologues [55].

[51], but it has not been proven to be effective in long-term use [52]. Despite positive preliminary reports, bromocriptine did not improve nonfluent aphasias in a randomized, double-blind, placebo-controlled clinical trial [53]. Preliminary positive results were also noted using cholinergic agents (donepezil) in fluent aphasias [2, 54]. Efficacy of pharmacological treatments in the chronic phase needs to be

the more complex (including the vocabulary or the grammar).

*Ischemic Stroke*

communicate satisfactorily [2].

regain ability to communicate [2].

absence of lesion in the subcortical regions.

The speech therapy has five objectives:

memory impairment.

[2, 13, 46].

**9. Treatment**

stroke) [2].

**9.1 Speech therapy**

aphasia rehabilitation.

b.Broca's aphasia may transform to anomic-plus aphasia. The prognostic for Broca's aphasia is relatively poor, because only 40% of patients regain ability to

c.Transcortical-motor aphasia may transform to anomic-plus aphasia. The prognosis of transcortical-motor aphasia is relatively good, depending on the severity of spontaneous speech diminution and associated executive and

d.Wernicke's aphasia may transform to conduction aphasia. The prognosis is relatively good, as nearly 60% of patients regain ability to communicate

e.Conduction aphasia has a relatively good prognosis, because 70% of patients

f. Transcortical sensory aphasia has a relatively good prognosis, because 60% of patients regain ability to communicate satisfactorily in everyday activities [2].

g.Anomic aphasia has a good prognosis (they have a good ability to communicate)

The outcome of aphasia at 1 year after stroke can be predicted in the first week [45] by stroke subtype, the phonology score (the strongest predictor), age, educational level, and the Barthel Index score. Severe comprehension impairment is reported as a negative factor for stroke recovery, as the aphasic could not understand the rehabilitation tasks. In 2009, Parkinson et al. [47] observed improvement in object and action naming in chronic vascular aphasics. They noted that better recovery was associated with larger lesion in the anterior regions of the brain and

Vascular aphasics may present some spontaneous language amelioration (spontaneous recovery), but speech therapy can significantly contribute to a better

A very good language assessment is the key point for any program of speech therapy (the role of a dedicated and competent neurologist is very important) [48]. Speech therapy should not be used in the hyperacute stage of stroke. In this stage, we should focus on reperfusion (i.v. thrombolysis/thrombectomy) of the affected arterial territory. Speech and language therapy should be typically started as soon as the clinical condition becomes favorable, which is nowadays generally possible in acute stroke units (in the acute/subacute stage of

a.*To keep the aphasic verbally active*: the specialists, including the neurologists, speech therapists, psychologists, nurses, and the family have to communicate

with the patient using verbal and written language, not only gesture.

satisfactorily (those involving in conduction aphasics) [2].

**54**


Bhogal et al. [50] reviewed 10 studies and noted that intense speech therapy over a short period (approximately 9 hours of therapy per week during 12 weeks) ameliorate outcome. Conversely, lower intensity (2 hours a week) over a longer period (more than 20 weeks) did not improve evolution compared with informal support. In conclusion, speech therapy intensity should be of at least of 1 hour per day in the first 3 months after stroke onset [2].

Due to the specific level of the language which is affected, the speech therapy strategy to be used will be different (auditory analysis, word identification, etc.). For example, in global aphasia, the main goals of therapy are represented by helping the patient to use remaining abilities, to restore language abilities, to learn other methods (nonverbal) of communicating, etc. [48].

## **9.2 Pharmacotherapy**

Nowadays, treatment of reperfusion (designed to restore cortical perfusion (i.v. thrombolysis/thrombectomy)) during the first 4–5 h (thrombolysis), and 6–12 h (thrombectomy) from the clinical onset, represents the main prevention approach.

Preliminary positive results were found using piracetam in nonfluent aphasias [51], but it has not been proven to be effective in long-term use [52]. Despite positive preliminary reports, bromocriptine did not improve nonfluent aphasias in a randomized, double-blind, placebo-controlled clinical trial [53]. Preliminary positive results were also noted using cholinergic agents (donepezil) in fluent aphasias [2, 54]. Efficacy of pharmacological treatments in the chronic phase needs to be demonstrated.

## **9.3 Transcranial magnetic stimulation (TMS)**

Functional imaging studies of language in nonfluent aphasics usually report a possible overactivation in right hemisphere language homologues [55].

Evidence exists that left hemisphere functional recovery is clinically more relevant than right hemisphere activation as a compensatory mechanism after stroke. Thus, right hemisphere activation might be a negative factor for aphasia recovery after stroke [55]. Use of TMS could provide right hemisphere inhibition and, therefore, ameliorate regression of language deficits. Preliminary reports suggested that TMS can improve naming in nonfluent vascular aphasics [55]. This assertion needs to be confirmed by randomized controlled trials.

As a general rule, pharmacological treatment or TMS would be better delivered just before speech and language therapy [2].

## **10. Conclusions**

Vascular aphasia is a term that covers complex syndromes, and it is considered not only a stroke severity marker outcome (it is associated with a higher risk of mortality) but also a poststroke poor functional outcome (can have a dramatic impact on person's ability to communicate and increased risk of developing poststroke dementia). Taking into consideration the unpredictable evolution of all mentioned aphasic syndromes and the lack of treatment strategies, next researches should focus on combined methods of improving patients' language after acute and even chronic stage of stroke (such as transcranial magnetic stimulation and speech therapy applied in consecutive, consequent, and sustained sessions).

## **Author details**

Dragoș Cătălin Jianu1,2\*, Silviana Nina Jianu3 , Ligia Petrica4 , Traian Flavius Dan1,2 and Georgiana Munteanu2

1 Department of Neurology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania

2 Head of the First Department of Neurology, "Pius Brânzeu" County Emergency Clinical Hospita, Timisoara, Romania

3 Department of Ophthalmology, Military Emergency Hospital, Timisoara, Romania

4 Department of Nephrology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania

\*Address all correspondence to: dcjianu@yahoo.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**57**

1982

*Vascular Aphasias*

**References**

pp. 65-75

éditeurs; 1968. p. 19

Neurology. 1989

Mirton; 2001

1978;**7**:41-49

and Febiger; 1983

*DOI: http://dx.doi.org/10.5772/intechopen.92691*

[11] Kertesz A, Sheppard A. The epidemiology of aphasic and cognitive impairment in stroke: Age, sex, aphasia type an laterality differences. Brain.

[12] Nadeau SE, Crosson B. Subcortical

[13] Verstichel P. Thalamic aphasia. Revue Neurologique (Paris).

[14] Lhermitte F, Derouesné J. L'aphasie amnéstique. Revue Neurologique.

[16] Alexander MP, Naeser MA. Broca's area aphasics. Brain and Language.

[17] Haartmann HJ, Kolk HHJ. The production of grammatical morphology in Broca's and Wernicke's aphasics.

Zolog A. Diagnosticul diferenţial între tulburările fonetice şi fonologice la afazici (Romanian). Neurologie, Psihiatrie, Psihologie, Psihoterapie. (Revista Societăţii de Neurologie şi Psihiatrie pentru Copii şi adolescenţi din România), Bucuresti, Romania.

[19] Jianu DC. Managementul afazicilor romani consecutiv infarctelor cerebrale (Romanian). Timisoara, Romania:

[20] Damasio AR. Aphasia. New England Journal of Medicine. 1992;**326**:531-539

[15] Kearns KP. Chapter 8. Broca's aphasia. In: La Pointe LL, editor. Aphasia and Related Neurogenic Language Disorders. 3rd ed. New York, Stuttgart: Thieme; 2005. pp. 117-141

aphasia. Brain and Language.

1981;**104**:117-128

1997;**58**:355-402

2003;**122**:947-957

1976;**132**:669-685

1992;**43**(3):215-227

Cortex. 1992;**28**:97-112

[18] Jianu DC, Bednar M,

1999;**2**:55-58

Mirton; 2011

[1] Abou Zeki D, Hillis A. Chapter 12. Acquired disorders of language and speech. In: Masud H, Schott JM, editors. Oxford Textbook of Cognitive Neurology and Dementia. UK: Oxford University Press; 2016. pp. 123-133

[2] Croquelois A, Godefroy O. Chapter 7. Vascular aphasias. In: Godefroy O, editor. The Behavioral and Cognitive Neurology of Stroke. 2nd ed. UK: Cambridge University Press; 2013.

[3] Alajouanine T. L'aphasie et le langage pathologique. Paris : J.B. Baillière et fils

[4] Benson FD, Geschwind N. Chapter 5. Aphasia and related disorders, a clinical approach. In: Principles of Behavioral

[5] Jianu DC. Elemente de afaziologie (Romanian). Timisoara, Romania:

[6] Ardila A. Chapter 10. Assessment of aphasia. In: Aphasia Handbook 2. Miami, Florida, USA: Florida International University; 2014. pp. 171-188

[7] De Renzi E, Faglioni P. Normative data and screening power of a shortened

[8] Goodglass H, Kaplan E, editors. The Assessment of Aphasia and Related Disorders. 2nd ed. Philadelphia, PA: Lea

[9] Kertesz A. The Western Aphasia Battery. New York: Grune & Stratton;

[10] Nespoulous JL, Lecours AR,

Montreal: L'Ortho Edition; 1986

Lafond D, editors. Protocole Montreal— Toulouse de l'examen de l'aphasie: Module Standard Initial (Version Beta).

version of the token test. Cortex.

## **References**

*Ischemic Stroke*

**10. Conclusions**

**Author details**

and Georgiana Munteanu2

Timisoara, Romania

Timisoara, Romania

Romania

Dragoș Cătălin Jianu1,2\*, Silviana Nina Jianu3

Clinical Hospita, Timisoara, Romania

\*Address all correspondence to: dcjianu@yahoo.com

provided the original work is properly cited.

, Ligia Petrica4

1 Department of Neurology, "Victor Babes" University of Medicine and Pharmacy,

TMS can improve naming in nonfluent vascular aphasics [55]. This assertion needs

As a general rule, pharmacological treatment or TMS would be better delivered

Vascular aphasia is a term that covers complex syndromes, and it is considered not only a stroke severity marker outcome (it is associated with a higher risk of mortality) but also a poststroke poor functional outcome (can have a dramatic impact on person's ability to communicate and increased risk of developing poststroke dementia). Taking into consideration the unpredictable evolution of all mentioned aphasic syndromes and the lack of treatment strategies, next researches should focus on combined methods of improving patients' language after acute and even chronic stage of stroke (such as transcranial magnetic stimulation and speech

therapy applied in consecutive, consequent, and sustained sessions).

to be confirmed by randomized controlled trials.

just before speech and language therapy [2].

2 Head of the First Department of Neurology, "Pius Brânzeu" County Emergency

4 Department of Nephrology, "Victor Babes" University of Medicine and Pharmacy,

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

3 Department of Ophthalmology, Military Emergency Hospital, Timisoara,

, Traian Flavius Dan1,2

**56**

[1] Abou Zeki D, Hillis A. Chapter 12. Acquired disorders of language and speech. In: Masud H, Schott JM, editors. Oxford Textbook of Cognitive Neurology and Dementia. UK: Oxford University Press; 2016. pp. 123-133

[2] Croquelois A, Godefroy O. Chapter 7. Vascular aphasias. In: Godefroy O, editor. The Behavioral and Cognitive Neurology of Stroke. 2nd ed. UK: Cambridge University Press; 2013. pp. 65-75

[3] Alajouanine T. L'aphasie et le langage pathologique. Paris : J.B. Baillière et fils éditeurs; 1968. p. 19

[4] Benson FD, Geschwind N. Chapter 5. Aphasia and related disorders, a clinical approach. In: Principles of Behavioral Neurology. 1989

[5] Jianu DC. Elemente de afaziologie (Romanian). Timisoara, Romania: Mirton; 2001

[6] Ardila A. Chapter 10. Assessment of aphasia. In: Aphasia Handbook 2. Miami, Florida, USA: Florida International University; 2014. pp. 171-188

[7] De Renzi E, Faglioni P. Normative data and screening power of a shortened version of the token test. Cortex. 1978;**7**:41-49

[8] Goodglass H, Kaplan E, editors. The Assessment of Aphasia and Related Disorders. 2nd ed. Philadelphia, PA: Lea and Febiger; 1983

[9] Kertesz A. The Western Aphasia Battery. New York: Grune & Stratton; 1982

[10] Nespoulous JL, Lecours AR, Lafond D, editors. Protocole Montreal— Toulouse de l'examen de l'aphasie: Module Standard Initial (Version Beta). Montreal: L'Ortho Edition; 1986

[11] Kertesz A, Sheppard A. The epidemiology of aphasic and cognitive impairment in stroke: Age, sex, aphasia type an laterality differences. Brain. 1981;**104**:117-128

[12] Nadeau SE, Crosson B. Subcortical aphasia. Brain and Language. 1997;**58**:355-402

[13] Verstichel P. Thalamic aphasia. Revue Neurologique (Paris). 2003;**122**:947-957

[14] Lhermitte F, Derouesné J. L'aphasie amnéstique. Revue Neurologique. 1976;**132**:669-685

[15] Kearns KP. Chapter 8. Broca's aphasia. In: La Pointe LL, editor. Aphasia and Related Neurogenic Language Disorders. 3rd ed. New York, Stuttgart: Thieme; 2005. pp. 117-141

[16] Alexander MP, Naeser MA. Broca's area aphasics. Brain and Language. 1992;**43**(3):215-227

[17] Haartmann HJ, Kolk HHJ. The production of grammatical morphology in Broca's and Wernicke's aphasics. Cortex. 1992;**28**:97-112

[18] Jianu DC, Bednar M, Zolog A. Diagnosticul diferenţial între tulburările fonetice şi fonologice la afazici (Romanian). Neurologie, Psihiatrie, Psihologie, Psihoterapie. (Revista Societăţii de Neurologie şi Psihiatrie pentru Copii şi adolescenţi din România), Bucuresti, Romania. 1999;**2**:55-58

[19] Jianu DC. Managementul afazicilor romani consecutiv infarctelor cerebrale (Romanian). Timisoara, Romania: Mirton; 2011

[20] Damasio AR. Aphasia. New England Journal of Medicine. 1992;**326**:531-539

[21] Kertesz A. Clinical forms of aphasia. Acta Neurochirurgica. Supplementum (Wien). 1993;**56**:52-58

[22] Kory Calomfirescu S, Kory Mercea M. Afazia în accidentele vasculare cerebrale (Romanian). Cluj-Napoca, Romania: Casa Cărţii de Ştiinţă; 1996

[23] Thompson CK. Chapter 2. Functional neuroimaging. In: La Pointe LL, editor. Aphasia and Related Neurogenic Language Disorders. 3rd ed. New York-Stuttgart: Thieme; 2005. pp. 19-38

[24] Hanna D. Chapter I. Neuroimaging contributions to the understanding of aphasia. In: Boller F, editor. Handbook of Neuropsychology. Vol. 2. Amsterdam, Netherlands: Elsevier Science Publishers, B.V.; 1989

[25] Poeck K, de Bleser R, von Keyserlink DG. Computed tomography localization of standard aphasic syndromes. In: Rose FC, editor. Advances in Neurology. Vol. 42: Progress in Aphasiology. New York: Raven Press; 1984. pp. 71-89

[26] Caspari I. Chapter 9. Wernicke's aphasia. In: La Pointe LL, editor. Aphasia and Related Neurogenic Language Disorders. 3rd ed. New York-Stuttgart: Thieme; 2005. pp. 142-154

[27] Gainotti G, Ibba A, Caltagirone C. Perturbations acoustiques et semantiques de la compréhension dans l'aphasie. Revue Neurologique (Paris). 1975;**131**(9):645-659

[28] Jianu DC, Petrica M, Matcău L, Zolog A. Observaţii anatomo-clinice asupra unor cazuri de afazie fluentă Wernicke (Romanian). Neurologia Medico-Chirurgica. 2001;**6**(1):69-79

[29] Simmons-Mackie N. Chapter 10. Conduction aphasia. In: La Pointe LL, editor. Aphasia and Related Neurogenic Language Disorders. 3rd ed. New York-Stuttgart: Thieme; 2005. pp. 155-168

[30] Benson FD, Sheremata WA, Bouchard R, et al. Conduction aphasia, a clinico-pathological study. Archives of Neurology. 1973;**38**:339-346

[31] Geschwind N. Disconnection syndromes in animals and man: Part 1. Brain. 1965;**88**:237-294

[32] Jianu DC. Observaţii asupra unui caz de afazie de conducţie (Romanian). Neurologia Medico-Chirurgica. 1996;**1**(1):35-38

[33] Cimino-Knight A, Hollingsworth AL, Gonzalez Rothi LJ. Chapter 11. The transcortical aphasias. In: La Pointe LL, editor. Aphasia and Related Neurogenic Language Disorders. 3rd ed. New York-Stuttgart: Thieme; 2005. pp. 169-185

[34] Jianu DC. Observaţii asupra unui caz de afazie paroxistică prin interesarea ariei motorii suplimentare Penfield, în cursul evoluţiei unui meningiom de sinus longitudinal superior (Romanian). Neurologia Medico-Chirurgica. 1998;**5**(2):51-53

[35] Jianu DC, Petrica M, Deme S, Scutelnicu D, Matcău L, Zolog A, et al. Consideraţii anatomo-clinice asupra unor cazuri de afazie transcorticală motorie, senzorială şi mixtă (Romanian). Neurologia Medico-Chirurgica. 2000;**5**(1):45-54

[36] Grossi D et al. Mixed transcortical aphasia: Clinical features and neuroanatomical corelates. European Neurology. 1991;**31**:204-211

[37] Collins M. Chapter 12. Global aphasia. In: La Pointe LL, editor. Aphasia and Related Neurogenic Language Disorders. 3rd ed. New York-Stuttgart: Thieme; 2005. pp. 186-198

[38] Hanlon RE, Lux WE, Dromerick AW. Global aphasia without hemiparesis: Language profiles and lesion distribution. Journal

**59**

*Vascular Aphasias*

*DOI: http://dx.doi.org/10.5772/intechopen.92691*

treatment improvement in object and action naming for patients with chronic aphasia. Brain and Language.

[48] Ardila A. Chapter 12. Aphasia rehabilitation. In: Aphasia Handbook 2.

[49] Ardila A. Chapter 11. Recovery and prognosis in aphasia. In: Aphasia Handbook 2. Miami, Florida, USA: Florida International University; 2014.

[50] Bhogal SK, Teasell R, Speechley M. Intensity of aphasia therapy, impact on recovery. Stroke. 2003;**34**:987-993

[51] Greener J, Enderby P, Whurr R. Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews. 2001;**2**:CD000125

[52] Güngör L, Terzi M, Onar MK. Does long term use of piracetam improve speech disturbances due to ischemic cerebrovascular diseases? Brain and Language, Elsevier. 2011;**117**:23-27

[53] Ashtary F, Janghorhani M, Chitsaz A, Reisi M, Bahrami A. A randomized, double-blind trial of bromocriptine efficacy in nonfluent aphasia after stroke. Neurology.

[54] Berthier ML. Poststroke aphasia: Epidemiology, pathophysiology and treatment. Drugs & Aging.

[55] Naeser MA, Martin PI, Ho M, et al. Transcranial magnetic stimulation and aphasia rehabilitation. Archives of Physical Medicine and Rehabilitation.

2006;**27**:97-98

2005;**22**:163-182

2012;**93**:S26-S34

Miami, Florida, USA: Florida International University; 2014.

2009;**40**:23-23

pp. 198-208

pp. 189-197

[39] Godefroy O, Dubois C, Debachy B, Leclerc M, Kreisler A. Vascular aphasias:

[40] Oldfield RC. The assessment and analysis of handedness: The Edinburgh

[41] LaPointe LL. Aphasia and Related Neurogenic Language Disorders. 3rd ed. Tallahassee, Florida: Department of Communication Disorders, Florida State

[42] Kreisler A, Godefroy O, Delmaire C, et al. The anatomy of aphasia revisited. Neurology. 2000;**54**(5):1117-1123

[43] Coppens P. Why are Wernicke's aphasia patients older than Broca's? A critical view of the hypotheses. Aphasiology. 1991;**5**:279-290

[44] Lecours AR, Lhermitte F, Bryans B. Aphasiology. London: Baillière-Tindall;

[45] El Hachioui H, Lingsma HF, van de Sandt-Koenderman MWME,

[46] Jianu DC, Jianu SN, Dan TF, Munteanu G. Extra and transcranial color-coded sonography findings in aphasics with internal carotid artery, and/or left middle cerebral artery stenosis or occlusion. European Journal of Neurology. 2018;**25**(Suppl 1):35-36

[47] Parkinson BR, Raymer A, Chang YL, Fitzgerald DB, Crosson B. Lesion characteristics related to

Visch-Brink EG. Long term prognosis of aphasia after stroke. Journal of Neurology, Neurosurgery, and Psychiatry. 2013;**84**:310-315

Dippel DWJ, Koudstall PJ,

of Neurology, Neurosurgery, and Psychiatry (England). 1999;**66**(3):365-369

Main characteristics of patients hospitalized in acute stroke units.

inventory. Neuropsychologia.

Stroke. 2002;**33**:702-705

1971;**9**:97-113

University; 2005

1983

*Vascular Aphasias DOI: http://dx.doi.org/10.5772/intechopen.92691*

of Neurology, Neurosurgery, and Psychiatry (England). 1999;**66**(3):365-369

*Ischemic Stroke*

B.V.; 1989

1984. pp. 71-89

(Wien). 1993;**56**:52-58

[22] Kory Calomfirescu S, Kory

[21] Kertesz A. Clinical forms of aphasia. Acta Neurochirurgica. Supplementum

[30] Benson FD, Sheremata WA, Bouchard R, et al. Conduction aphasia, a clinico-pathological study. Archives of

[31] Geschwind N. Disconnection syndromes in animals and man: Part 1.

[32] Jianu DC. Observaţii asupra unui caz de afazie de conducţie (Romanian).

Hollingsworth AL, Gonzalez Rothi LJ. Chapter 11. The transcortical aphasias. In: La Pointe LL, editor. Aphasia and Related Neurogenic Language Disorders. 3rd ed. New York-Stuttgart:

[34] Jianu DC. Observaţii asupra unui caz de afazie paroxistică prin interesarea ariei motorii suplimentare Penfield, în cursul evoluţiei unui meningiom de sinus longitudinal superior (Romanian).

Neurologia Medico-Chirurgica.

[35] Jianu DC, Petrica M, Deme S, Scutelnicu D, Matcău L, Zolog A, et al. Consideraţii anatomo-clinice asupra unor cazuri de afazie transcorticală motorie, senzorială şi mixtă (Romanian). Neurologia Medico-Chirurgica. 2000;**5**(1):45-54

[36] Grossi D et al. Mixed transcortical

neuroanatomical corelates. European

Dromerick AW. Global aphasia without

[37] Collins M. Chapter 12. Global aphasia. In: La Pointe LL, editor. Aphasia and Related Neurogenic Language Disorders. 3rd ed. New York-Stuttgart: Thieme; 2005. pp. 186-198

aphasia: Clinical features and

Neurology. 1991;**31**:204-211

[38] Hanlon RE, Lux WE,

hemiparesis: Language profiles and lesion distribution. Journal

1998;**5**(2):51-53

Neurologia Medico-Chirurgica.

Neurology. 1973;**38**:339-346

Brain. 1965;**88**:237-294

[33] Cimino-Knight A,

Thieme; 2005. pp. 169-185

1996;**1**(1):35-38

Mercea M. Afazia în accidentele vasculare cerebrale (Romanian). Cluj-Napoca, Romania: Casa Cărţii de Ştiinţă; 1996

[23] Thompson CK. Chapter 2. Functional neuroimaging. In: La Pointe LL, editor. Aphasia and Related Neurogenic Language Disorders. 3rd ed. New York-Stuttgart: Thieme; 2005. pp. 19-38

[24] Hanna D. Chapter I. Neuroimaging contributions to the understanding of aphasia. In: Boller F, editor. Handbook of Neuropsychology. Vol. 2. Amsterdam, Netherlands: Elsevier Science Publishers,

Keyserlink DG. Computed tomography

Advances in Neurology. Vol. 42: Progress in Aphasiology. New York: Raven Press;

[26] Caspari I. Chapter 9. Wernicke's aphasia. In: La Pointe LL, editor. Aphasia and Related Neurogenic Language Disorders. 3rd ed. New York-Stuttgart: Thieme; 2005. pp. 142-154

[27] Gainotti G, Ibba A, Caltagirone C.

semantiques de la compréhension dans l'aphasie. Revue Neurologique (Paris).

[28] Jianu DC, Petrica M, Matcău L, Zolog A. Observaţii anatomo-clinice asupra unor cazuri de afazie fluentă Wernicke (Romanian). Neurologia Medico-Chirurgica. 2001;**6**(1):69-79

[29] Simmons-Mackie N. Chapter 10. Conduction aphasia. In: La Pointe LL, editor. Aphasia and Related Neurogenic Language Disorders. 3rd ed. New York-Stuttgart: Thieme; 2005. pp. 155-168

Perturbations acoustiques et

1975;**131**(9):645-659

[25] Poeck K, de Bleser R, von

localization of standard aphasic syndromes. In: Rose FC, editor.

**58**

[39] Godefroy O, Dubois C, Debachy B, Leclerc M, Kreisler A. Vascular aphasias: Main characteristics of patients hospitalized in acute stroke units. Stroke. 2002;**33**:702-705

[40] Oldfield RC. The assessment and analysis of handedness: The Edinburgh inventory. Neuropsychologia. 1971;**9**:97-113

[41] LaPointe LL. Aphasia and Related Neurogenic Language Disorders. 3rd ed. Tallahassee, Florida: Department of Communication Disorders, Florida State University; 2005

[42] Kreisler A, Godefroy O, Delmaire C, et al. The anatomy of aphasia revisited. Neurology. 2000;**54**(5):1117-1123

[43] Coppens P. Why are Wernicke's aphasia patients older than Broca's? A critical view of the hypotheses. Aphasiology. 1991;**5**:279-290

[44] Lecours AR, Lhermitte F, Bryans B. Aphasiology. London: Baillière-Tindall; 1983

[45] El Hachioui H, Lingsma HF, van de Sandt-Koenderman MWME, Dippel DWJ, Koudstall PJ, Visch-Brink EG. Long term prognosis of aphasia after stroke. Journal of Neurology, Neurosurgery, and Psychiatry. 2013;**84**:310-315

[46] Jianu DC, Jianu SN, Dan TF, Munteanu G. Extra and transcranial color-coded sonography findings in aphasics with internal carotid artery, and/or left middle cerebral artery stenosis or occlusion. European Journal of Neurology. 2018;**25**(Suppl 1):35-36

[47] Parkinson BR, Raymer A, Chang YL, Fitzgerald DB, Crosson B. Lesion characteristics related to

treatment improvement in object and action naming for patients with chronic aphasia. Brain and Language. 2009;**40**:23-23

[48] Ardila A. Chapter 12. Aphasia rehabilitation. In: Aphasia Handbook 2. Miami, Florida, USA: Florida International University; 2014. pp. 198-208

[49] Ardila A. Chapter 11. Recovery and prognosis in aphasia. In: Aphasia Handbook 2. Miami, Florida, USA: Florida International University; 2014. pp. 189-197

[50] Bhogal SK, Teasell R, Speechley M. Intensity of aphasia therapy, impact on recovery. Stroke. 2003;**34**:987-993

[51] Greener J, Enderby P, Whurr R. Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews. 2001;**2**:CD000125

[52] Güngör L, Terzi M, Onar MK. Does long term use of piracetam improve speech disturbances due to ischemic cerebrovascular diseases? Brain and Language, Elsevier. 2011;**117**:23-27

[53] Ashtary F, Janghorhani M, Chitsaz A, Reisi M, Bahrami A. A randomized, double-blind trial of bromocriptine efficacy in nonfluent aphasia after stroke. Neurology. 2006;**27**:97-98

[54] Berthier ML. Poststroke aphasia: Epidemiology, pathophysiology and treatment. Drugs & Aging. 2005;**22**:163-182

[55] Naeser MA, Martin PI, Ho M, et al. Transcranial magnetic stimulation and aphasia rehabilitation. Archives of Physical Medicine and Rehabilitation. 2012;**93**:S26-S34

**61**

**Chapter 4**

**Abstract**

*and Aliza Brown*

and around the world.

**1. Introduction**

Telestroke: A New Paradigm

*Rohan Sharma, Krishna Nalleballe, Nidhi Kapoor,* 

*Vasuki Dandu, Karthika Veerapaneni, Sisira Yadala,* 

*Madhu Jasti, Suman Siddamreddy, Sanjeeva Onteddu* 

Stroke is one of the leading causes of death and disability across the world. With the development of new modalities of treatment, including the use of intravenous tissue plasminogen activator and mechanical thrombectomy, clinical outcomes have improved in patients with acute ischemic strokes. However, these interventions are time dependent, and there exists a great disparity between the rural and urban parts of the world in terms of the availability of neurologists and these lifesaving treatment options. Telestroke networks utilize digital technology for two-way, highresolution video teleconferencing to help abate these disparities by bringing safe, efficient, and cost-effective care to underserved communities in the United States

**Keywords:** telestroke, acute ischemic stroke, tPA, teleconference, quality measures

In the United States (US), stroke is the fifth leading cause of mortality with a stroke occurring approximately every 40 seconds and stroke-related death approximately every 4 minutes [1, 2]. In 2011, stroke was found to be the leading cause of disability in the US, with around 7 million stroke survivors [3]. In 2016, the World Health Organization designated stroke as the second leading cause of mortality worldwide. Acute ischemic strokes account for about 80% of all stroke-related deaths [4]. Intravenous tissue plasminogen activator (tPA) has been shown to improve outcomes in acute ischemic stroke [5, 6]. In patients who receive tPA, early administration has been shown to reduce morbidity, mortality, and adverse events such as intracranial hemorrhages, promoting early discharges and higher rates of independent ambulation at discharge [5, 7]. Mechanical thrombectomies performed by neuro-interventionists have shown to improve outcomes for patients with proximal intracranial arterial occlusion [8–11] and have become the standard of care for patients who qualify for intervention. However, this procedure is performed only at tertiary care centers and is not available at smaller hospitals around the country. Despite the obvious benefits of tPA administration, only a small percentage of patients presenting with acute ischemic strokes are eligible to receive it [12–15]. The most common reason attributed to this is a delay between the development of stroke symptoms and the patient seeking treatment at a hospital [16, 17]. There are also marked rural–urban disparities in stroke care [18–20]. These disparities are,

## **Chapter 4** Telestroke: A New Paradigm

*Rohan Sharma, Krishna Nalleballe, Nidhi Kapoor, Vasuki Dandu, Karthika Veerapaneni, Sisira Yadala, Madhu Jasti, Suman Siddamreddy, Sanjeeva Onteddu and Aliza Brown*

## **Abstract**

Stroke is one of the leading causes of death and disability across the world. With the development of new modalities of treatment, including the use of intravenous tissue plasminogen activator and mechanical thrombectomy, clinical outcomes have improved in patients with acute ischemic strokes. However, these interventions are time dependent, and there exists a great disparity between the rural and urban parts of the world in terms of the availability of neurologists and these lifesaving treatment options. Telestroke networks utilize digital technology for two-way, highresolution video teleconferencing to help abate these disparities by bringing safe, efficient, and cost-effective care to underserved communities in the United States and around the world.

**Keywords:** telestroke, acute ischemic stroke, tPA, teleconference, quality measures

## **1. Introduction**

In the United States (US), stroke is the fifth leading cause of mortality with a stroke occurring approximately every 40 seconds and stroke-related death approximately every 4 minutes [1, 2]. In 2011, stroke was found to be the leading cause of disability in the US, with around 7 million stroke survivors [3]. In 2016, the World Health Organization designated stroke as the second leading cause of mortality worldwide. Acute ischemic strokes account for about 80% of all stroke-related deaths [4]. Intravenous tissue plasminogen activator (tPA) has been shown to improve outcomes in acute ischemic stroke [5, 6]. In patients who receive tPA, early administration has been shown to reduce morbidity, mortality, and adverse events such as intracranial hemorrhages, promoting early discharges and higher rates of independent ambulation at discharge [5, 7]. Mechanical thrombectomies performed by neuro-interventionists have shown to improve outcomes for patients with proximal intracranial arterial occlusion [8–11] and have become the standard of care for patients who qualify for intervention. However, this procedure is performed only at tertiary care centers and is not available at smaller hospitals around the country.

Despite the obvious benefits of tPA administration, only a small percentage of patients presenting with acute ischemic strokes are eligible to receive it [12–15]. The most common reason attributed to this is a delay between the development of stroke symptoms and the patient seeking treatment at a hospital [16, 17]. There are also marked rural–urban disparities in stroke care [18–20]. These disparities are,

in part, a result of the scarcity of neurologists [21–24]. Studies have shown better outcomes in stroke patients under the care of neurologists as compared to physicians of other specialties, such as Internal Medicine or Family Medicine [22, 25, 26]. Telestroke aims to bridge this gap by providing neurology expertise in remote areas around the world through high-quality audio-video conferencing and digital image sharing.

## **2. Historical perspective**

Communication of medical information across long distances has occurred throughout history. It is well documented that bonfires and heliographs were used to send communications about the bubonic plague in Europe [27]. Telegraph communication was used in the civil war and radio communication was used in World War I, and wars thereafter, to send information about casualties and to request medical dispatches and transport for wounded soldiers [28]. Telemedicine in its current form was developed by NASA to monitor the physiologic states of astronauts during manned space missions [29]. The first interactive video telemedicine systems were established for psychiatry [30] and radiology [31] but later expanded to critical care [32] and oncology [33] to bridge the shortage of specialists in these fields. In 1999, the term *telestroke* was first coined by Levine and Gorman, who described the use of video telecommunications as a means to facilitate cerebrovascular consults to remote areas adding great expertise to the care of stroke patients [34]. Since then the number of telestroke networks around the world has expanded significantly [35–38].

## **3. Telestroke models**

Before discussing telestroke models, it is important to understand the terminology used to describe telestroke systems, as described by the American Telemedicine Association [39].


Several different telestroke models have been described and are listed below [38, 39].

**63**

*Telestroke: A New Paradigm*

*DOI: http://dx.doi.org/10.5772/intechopen.92831*

2.Hub and spoke with external sites.

affiliated network of telestroke providers.

for on-call clinical coverage.

ees within the hospital system.

further management [40].

**ischemic stroke**

3.Horizontal hubless network: interconnected sites within a large hospital system

4.Third-party distribution model: telestroke services are provided to multiple originating sites through arrangements with an independent corporation or an

5.Supervisory training model: academic teleneurology programs to assist train-

Hub and Spoke with external sites and third-party distribution models are the most commonly used models within telestroke [35]. In telestroke networks, the majority of spoke sites are small hospitals (i.e., 0–99 beds) [37], but the spoke hospital size may vary from 25 to 500 beds in different telestroke networks [17]. A telestroke consult typically starts with a patient presenting to a spoke site with a suspected stroke. After an initial assessment by the physician at the spoke site, a triage process is conducted through telephone operators, followed by a video teleconferencing call with the neurologist at the distant site [see flow diagram of a telestroke system]. After reviewing the National Institute of Health Stroke Scale (NIHSS) and brain imaging (typically a non-contrasted CT scan of the head) and reviewing the patient's history for indications/contraindications for tPA, a decision is made for administration of tPA. After this initial process, the decision of transferring the patient to the hub site is made, depending upon the need for further investigation, possible thrombectomy/neurosurgical intervention, or requirement of a higher level of care as compared to the spoke site. The term "Drip and Ship" is often used to describe transfer from spoke to hub sites, where after receiving the bolus dose of tPA, the patient is started on tPA drip and transferred emergently for

The majority of the hospitals in telestroke systems have formal written contracts between the hub and the spoke site with a closed-loop communication system in place [37]. A vast array of Food and Drug Administration (FDA) approved two-way video-conferencing modalities with picture archiving and communication system are available for use by these networks that provide Health Insurance Portability and Accountability Act (HIPPA) compliant, secure, encrypted multipoint data sharing with evolving functionality through the use of desktops, robotic carts, laptops, tablets, and even mobile phones with provider-to-provider interfaces [37, 38]. More recent advancements in telestroke systems include an ambulance-based telemedicine system that provides a feasible tool for prehospital stroke assessment [41–44]. Early attempts at prehospital telestroke consults were limited due to technical difficulties [44]. Newer studies have shown a high level of agreement in evaluation and treatment by mobile stroke units with a vascular neurologist on board compared to telestroke consults by a vascular neurologist [45] at a distant site who guides immediate treatment [46]. The data, however, is still limited and requires further investigation before the utility and efficacy of telestroke programs can be ascertained.

**4. Effectiveness and utility of telestroke in management of acute** 

The primary goal of telestroke models is to establish a network of neurology consults across underserved areas that do not have in-house neurology consultants

1.Hub and spoke within a single healthcare system.

*Ischemic Stroke*

sharing.

**2. Historical perspective**

significantly [35–38].

**3. Telestroke models**

Association [39].

in part, a result of the scarcity of neurologists [21–24]. Studies have shown better outcomes in stroke patients under the care of neurologists as compared to physicians of other specialties, such as Internal Medicine or Family Medicine [22, 25, 26]. Telestroke aims to bridge this gap by providing neurology expertise in remote areas around the world through high-quality audio-video conferencing and digital image

Communication of medical information across long distances has occurred throughout history. It is well documented that bonfires and heliographs were used to send communications about the bubonic plague in Europe [27]. Telegraph communication was used in the civil war and radio communication was used in World War I, and wars thereafter, to send information about casualties and to request medical dispatches and transport for wounded soldiers [28]. Telemedicine in its current form was developed by NASA to monitor the physiologic states of astronauts during manned space missions [29]. The first interactive video telemedicine systems were established for psychiatry [30] and radiology [31] but later expanded to critical care [32] and oncology [33] to bridge the shortage of specialists in these fields. In 1999, the term *telestroke* was first coined by Levine and Gorman, who described the use of video telecommunications as a means to facilitate cerebrovascular consults to remote areas adding great expertise to the care of stroke patients [34]. Since then the number of telestroke networks around the world has expanded

Before discussing telestroke models, it is important to understand the terminology used to describe telestroke systems, as described by the American Telemedicine

3.Telestroke network: a group of primary, secondary, and tertiary care settings that provide acute stroke care to patient populations. Telestroke networks consist of originating sites where the patients are located and distant sites where

4.Spoke: the affiliate or partner site in a telestroke network that is underserviced or under-supported by neurologists where patient services are delivered.

Several different telestroke models have been described and are listed below [38, 39].

5.Hub: a comprehensive tertiary care center where vascular neurologists and other acute stroke specialists compose a call panel delivering telestroke services to network partner sites (i.e., spoke sites). This is also the center where the

patient may be transferred if a higher level of care is needed.

1.Hub and spoke within a single healthcare system.

1.Distant site: the distant telestroke provider location.

the telestroke provider is located.

2.Originating site: the site where the patient is initially located.

**62**


Hub and Spoke with external sites and third-party distribution models are the most commonly used models within telestroke [35]. In telestroke networks, the majority of spoke sites are small hospitals (i.e., 0–99 beds) [37], but the spoke hospital size may vary from 25 to 500 beds in different telestroke networks [17]. A telestroke consult typically starts with a patient presenting to a spoke site with a suspected stroke. After an initial assessment by the physician at the spoke site, a triage process is conducted through telephone operators, followed by a video teleconferencing call with the neurologist at the distant site [see flow diagram of a telestroke system]. After reviewing the National Institute of Health Stroke Scale (NIHSS) and brain imaging (typically a non-contrasted CT scan of the head) and reviewing the patient's history for indications/contraindications for tPA, a decision is made for administration of tPA. After this initial process, the decision of transferring the patient to the hub site is made, depending upon the need for further investigation, possible thrombectomy/neurosurgical intervention, or requirement of a higher level of care as compared to the spoke site. The term "Drip and Ship" is often used to describe transfer from spoke to hub sites, where after receiving the bolus dose of tPA, the patient is started on tPA drip and transferred emergently for further management [40].

The majority of the hospitals in telestroke systems have formal written contracts between the hub and the spoke site with a closed-loop communication system in place [37]. A vast array of Food and Drug Administration (FDA) approved two-way video-conferencing modalities with picture archiving and communication system are available for use by these networks that provide Health Insurance Portability and Accountability Act (HIPPA) compliant, secure, encrypted multipoint data sharing with evolving functionality through the use of desktops, robotic carts, laptops, tablets, and even mobile phones with provider-to-provider interfaces [37, 38].

More recent advancements in telestroke systems include an ambulance-based telemedicine system that provides a feasible tool for prehospital stroke assessment [41–44]. Early attempts at prehospital telestroke consults were limited due to technical difficulties [44]. Newer studies have shown a high level of agreement in evaluation and treatment by mobile stroke units with a vascular neurologist on board compared to telestroke consults by a vascular neurologist [45] at a distant site who guides immediate treatment [46]. The data, however, is still limited and requires further investigation before the utility and efficacy of telestroke programs can be ascertained.

## **4. Effectiveness and utility of telestroke in management of acute ischemic stroke**

The primary goal of telestroke models is to establish a network of neurology consults across underserved areas that do not have in-house neurology consultants available, thereby expediting the initial stroke exam and care. As the effective tPA window is time-sensitive, and early administration of tPA is known to improve outcomes [5, 6, 13, 47], delay in transport of patients to tertiary care centers can lead to loss of the crucial intervention time window in acute ischemic stroke patients. After adequate training, the use of telestroke systems to measure NIHSS scores is viable and scoring is reliable, with inter-rater reliability comparable to that of in-person measurements [48, 49] even in telemedicine-naïve stroke practitioners [50]. Such assessment has also been found to be reliable when performed by neurology trained nurse practitioners [51], on laptop-based workstations [52], or even mobile-based video telestroke consults [53, 54]. Also, the FDA has approved teleradiology systems that enable effective and rapid evaluation of images by stroke specialists [55]. Stroke specialist evaluation via teleradiology systems has been found to be comparable to assessment by a neuroradiologist in aiding the decision making for tPA administration [56, 57].

Studies have shown that telestroke facilitated administration of tPA to patients in community hospitals and rural hospitals (as small as 100 beds or less) has outcomes comparable to those of in-person treatment at comprehensive stroke care centers [58–61]. Even with in a stroke network, the performance of spoke sites is similar regardless of the bedsize [62]. Also, the use of telestroke at rural hospitals can provide patients with comparable or reduced time between symptom onset and tPA administration [door-to-needle time (DTN)] compared to those directly presenting to tertiary care centers [63]. A non-blinded randomized control trial in the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) network in Germany showed that patients treated in telestroke network hospitals had significantly fewer poor outcomes compared to patients treated in community hospitals without telestroke capabilities [64]. Telestroke consults are becoming exceedingly cost-effective in dealing with acute strokes in the community [65–69].

## **5. Telestroke for post-tPA care and work up**

Telestroke consults also have utility beyond acute stroke. Patients receiving tPA or those with subacute strokes with milder symptoms not requiring emergent intravascular intervention can remain at the spoke site for further investigation. Telestroke follow-up consults can aid in guiding the physicians at the spoke sites to continue further stroke workup and discharge patients from the spoke site. This may also reduce the cost of transport and limit patients being transferred to hub sites to only those requiring urgent neurosurgical/intravascular intervention. A randomized control trial by Evans et al. showed that the management of stroke patients in dedicated stroke units showed better outcomes for large vessel infarcts but not for small lacunar infarcts when compared to those in general medical wards with stroke team support [70]. Based on this hypothesis, small lacunar strokes could potentially be managed by the medical team at spokes sites with telestroke consults and followups. The Telemedicine in Stroke in Swabia Project and The Order of St. Francis Stroke Network study experience demonstrated the safety and reliability of such telestroke models [71, 72]. Even for patients requiring treatment in an intensive care unit, teleneurointensive care units are providing valuable support for prevention, diagnosis, and the timely management of cerebrovascular conditions induced secondary to neurologic injuries [73] and have shown improved outcomes [74].

Telestroke has also been studied in in-home and ambulatory post-stroke rehabilitation settings for serial neurologic assessments and timely adjustments of therapies. These studies have shown that telerehabilitation approaches are comparable to conventional rehabilitation in improving activities of daily living and

**65**

*Telestroke: A New Paradigm*

stroke patients [77].

further investigation.

*DOI: http://dx.doi.org/10.5772/intechopen.92831*

**6. Telestroke outcomes and cost-effectiveness**

spurred the growth of telestroke networks around the world.

Continuous quality improvement is a key element for any successful telestroke program. Several elements play a role in this improvement, including adaptation to

**7. Telestroke quality measures**

motor function for stroke survivors [75, 76]. Virtual neurovascular clinics aimed at secondary stroke prevention are another evolving avenue for follow-up visits for

In the field of clinical research, telestroke consults may aid in identifying patients who are eligible for trials of therapies for ischemic or hemorrhagic

strokes, neuroprotective agents, or innovative diagnostic tests, thereby facilitating expedited enrollment at the originating sites after transfer to stroke centers [78]. Telestroke models are being incorporated into the education and training of neurologists, emergency teams, and nursing staff [77, 79–82]. With the ever-expanding horizons of telestroke, training in telemedicine will likely become mainstream for all future physician and medical personnel training programs. However, the data regarding the use of telestroke beyond acute stroke care is still limited and needs

Zaidi et al. showed that outcomes at 90 days were no different between patients treated with tPA by telemedicine and patients treated by the same neurologists over the same time interval at the stroke center hub hospital [83]. They also found no difference in time from stroke onset to treatment. Switzer et al. found that the average time between symptom onset and treatment at the spoke sites in their telestroke system was lower than the emergency department at their hub site [63]. As previously mentioned, several studies have found post-tPA outcomes at spoke sites were comparable to those of in-person treatment at comprehensive stroke care centers [58–61]. Implementation of a standardized regional telestroke program in a community setting increased utilization of alteplase, improved DTN time, decreased length of stay, and significantly increased the chances of patients going home [84]. Establishing a telestroke network requires infrastructure and technology-related expenses along with the expenses of round-the-clock neurology coverage and the cost of transport. Initial projects around the country were supported by government funds and research grants, but to develop a self-sustaining model, telestroke networks need to be cost-effective. For a Danish telestroke system consisting of five hubs and five spokes, a 2008 study by Ehlers et al. calculated an incremental costeffectiveness ratio (the cost of thrombolysis per quality-adjusted life year [QALY]) to be approximately US\$50,000 after 1 year [69]. In 2011, Nelson et al. conducted cost data analyses of telestroke networks in rural Arizona and Utah and found the incremental cost-effectiveness ratio using a 90-day horizon of \$108,363 per QALY and a lifetime horizon of \$2449 per QALY [66], which reflected a high initial cost but overall long-term cost reduction, likely due to rehabilitation cost reduction from early tPA administration. Also, the highest cost-effectiveness was seen in the most severe stroke cases. In a 2013 study by Switzer et al., cost savings of \$358,435 per year over 5 years were observed in a telestroke system consisting of one hub and seven spokes, as well as an improvement in patients' quality of life associated with increased numbers of individuals being discharged to home [67]. Growing evidence for the cost-effectiveness of telestroke networks and improved patient outcomes has

#### *Telestroke: A New Paradigm DOI: http://dx.doi.org/10.5772/intechopen.92831*

*Ischemic Stroke*

administration [56, 57].

available, thereby expediting the initial stroke exam and care. As the effective tPA window is time-sensitive, and early administration of tPA is known to improve outcomes [5, 6, 13, 47], delay in transport of patients to tertiary care centers can lead to loss of the crucial intervention time window in acute ischemic stroke patients. After adequate training, the use of telestroke systems to measure NIHSS scores is viable and scoring is reliable, with inter-rater reliability comparable to that of in-person measurements [48, 49] even in telemedicine-naïve stroke practitioners [50]. Such assessment has also been found to be reliable when performed by neurology trained nurse practitioners [51], on laptop-based workstations [52], or even mobile-based video telestroke consults [53, 54]. Also, the FDA has approved teleradiology systems that enable effective and rapid evaluation of images by stroke specialists [55]. Stroke specialist evaluation via teleradiology systems has been found to be comparable to assessment by a neuroradiologist in aiding the decision making for tPA

Studies have shown that telestroke facilitated administration of tPA to patients

in community hospitals and rural hospitals (as small as 100 beds or less) has outcomes comparable to those of in-person treatment at comprehensive stroke care centers [58–61]. Even with in a stroke network, the performance of spoke sites is similar regardless of the bedsize [62]. Also, the use of telestroke at rural hospitals can provide patients with comparable or reduced time between symptom onset and tPA administration [door-to-needle time (DTN)] compared to those directly presenting to tertiary care centers [63]. A non-blinded randomized control trial in the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) network in Germany showed that patients treated in telestroke network hospitals had significantly fewer poor outcomes compared to patients treated in community hospitals without telestroke capabilities [64]. Telestroke consults are becoming exceedingly

cost-effective in dealing with acute strokes in the community [65–69].

Telestroke consults also have utility beyond acute stroke. Patients receiving tPA or those with subacute strokes with milder symptoms not requiring emergent intravascular intervention can remain at the spoke site for further investigation. Telestroke follow-up consults can aid in guiding the physicians at the spoke sites to continue further stroke workup and discharge patients from the spoke site. This may also reduce the cost of transport and limit patients being transferred to hub sites to only those requiring urgent neurosurgical/intravascular intervention. A randomized control trial by Evans et al. showed that the management of stroke patients in dedicated stroke units showed better outcomes for large vessel infarcts but not for small lacunar infarcts when compared to those in general medical wards with stroke team support [70]. Based on this hypothesis, small lacunar strokes could potentially be managed by the medical team at spokes sites with telestroke consults and followups. The Telemedicine in Stroke in Swabia Project and The Order of St. Francis Stroke Network study experience demonstrated the safety and reliability of such telestroke models [71, 72]. Even for patients requiring treatment in an intensive care unit, teleneurointensive care units are providing valuable support for prevention, diagnosis, and the timely management of cerebrovascular conditions induced secondary to neurologic injuries [73] and have shown improved outcomes [74]. Telestroke has also been studied in in-home and ambulatory post-stroke rehabilitation settings for serial neurologic assessments and timely adjustments of therapies. These studies have shown that telerehabilitation approaches are comparable to conventional rehabilitation in improving activities of daily living and

**5. Telestroke for post-tPA care and work up**

**64**

motor function for stroke survivors [75, 76]. Virtual neurovascular clinics aimed at secondary stroke prevention are another evolving avenue for follow-up visits for stroke patients [77].

In the field of clinical research, telestroke consults may aid in identifying patients who are eligible for trials of therapies for ischemic or hemorrhagic strokes, neuroprotective agents, or innovative diagnostic tests, thereby facilitating expedited enrollment at the originating sites after transfer to stroke centers [78]. Telestroke models are being incorporated into the education and training of neurologists, emergency teams, and nursing staff [77, 79–82]. With the ever-expanding horizons of telestroke, training in telemedicine will likely become mainstream for all future physician and medical personnel training programs. However, the data regarding the use of telestroke beyond acute stroke care is still limited and needs further investigation.

## **6. Telestroke outcomes and cost-effectiveness**

Zaidi et al. showed that outcomes at 90 days were no different between patients treated with tPA by telemedicine and patients treated by the same neurologists over the same time interval at the stroke center hub hospital [83]. They also found no difference in time from stroke onset to treatment. Switzer et al. found that the average time between symptom onset and treatment at the spoke sites in their telestroke system was lower than the emergency department at their hub site [63]. As previously mentioned, several studies have found post-tPA outcomes at spoke sites were comparable to those of in-person treatment at comprehensive stroke care centers [58–61]. Implementation of a standardized regional telestroke program in a community setting increased utilization of alteplase, improved DTN time, decreased length of stay, and significantly increased the chances of patients going home [84].

Establishing a telestroke network requires infrastructure and technology-related expenses along with the expenses of round-the-clock neurology coverage and the cost of transport. Initial projects around the country were supported by government funds and research grants, but to develop a self-sustaining model, telestroke networks need to be cost-effective. For a Danish telestroke system consisting of five hubs and five spokes, a 2008 study by Ehlers et al. calculated an incremental costeffectiveness ratio (the cost of thrombolysis per quality-adjusted life year [QALY]) to be approximately US\$50,000 after 1 year [69]. In 2011, Nelson et al. conducted cost data analyses of telestroke networks in rural Arizona and Utah and found the incremental cost-effectiveness ratio using a 90-day horizon of \$108,363 per QALY and a lifetime horizon of \$2449 per QALY [66], which reflected a high initial cost but overall long-term cost reduction, likely due to rehabilitation cost reduction from early tPA administration. Also, the highest cost-effectiveness was seen in the most severe stroke cases. In a 2013 study by Switzer et al., cost savings of \$358,435 per year over 5 years were observed in a telestroke system consisting of one hub and seven spokes, as well as an improvement in patients' quality of life associated with increased numbers of individuals being discharged to home [67]. Growing evidence for the cost-effectiveness of telestroke networks and improved patient outcomes has spurred the growth of telestroke networks around the world.

### **7. Telestroke quality measures**

Continuous quality improvement is a key element for any successful telestroke program. Several elements play a role in this improvement, including adaptation to local laws and statues, effective training programs, identification of competency issues, and overcoming challenges with technical and manpower issues at both provider and recipient sites. In 1988, Donebedian was the first to describe the model of structure, process, and outcomes measurements for assessing the quality of healthcare [85]. Systematic collection and analysis of quality data has been shown to improve the quality of stroke care that is delivered [86], and telestroke is no exception to this. Several quality measures help assess and quantify the overall function of telestroke systems. Most hub hospitals have stroke certification and emergency and ICU staff training through standards set by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) process.

#### **7.1 Structural measures**

The capacity of the healthcare system, staffing ratios of specialists, availability of specialized units and equipment, and the organization structure with hospital networking should all be carefully studied and analyzed for any telehealth network systems. Defined protocols should be in place both at the originating and distant sites.

#### **7.2 Process measures**

Analogous to the traditional stroke pathway, the key global component of telestroke quality is still DTN time. Median DTN with telestroke varies from 106 to 121 minutes, even though the recommendation is less than 1 hour [58]. Several aspects of stroke chain-of-care that play an important role in DTN include Emergency Department (ED) door to CT scan (D-CT) time, ED door to teleneurologist consult time, teleneurologist to camera/phone time, and teleconsult duration (Con).

Clear definitions of these times are important as no uniform definitions currently exist. In some centers, a consult with teleneurologist occurs after CT scan results are obtained, while in other centers, a consult is initiated even before the CT scan is ordered. The time from ED to consult differs in these situations, which can affect these measures. Similarly, the definition of consult time varies between centers. At some centers, consult time is defined as the time spent on camera evaluating patients, and at other centers, it is defined as time spent on camera along with the time spent reviewing the images and other diagnostic results. Because of these variations, consult duration varied from 14 to 32 minutes in different studies [87, 88]. Studies showed that telestroke by itself might not decrease the DTN as there are variations in the subsects of stroke chain-of-care [89].

It has been shown that D-NC and Con play a major role in DTN [90]. Various factors including, when the consultant is notified, the time a consultant takes to interview the patient, and the experience level of the staff aiding with the examination will have to be considered while analyzing such data. The percentage of patients transferred after a telestroke consult to a destination hospital is also an important factor as it involves significant costs [67]. Data should be collected quantifying the rate of transfers after the consult and steps should be taken to minimize unnecessary transfers.

#### **7.3 Outcome measures**

The success of any program is ultimately decided by measuring outcomes, which could be patient related or system related. A modified Rankin scale, which is measured 90 days after a stroke, is the most commonly used measurement of

**67**

*Telestroke: A New Paradigm*

*DOI: http://dx.doi.org/10.5772/intechopen.92831*

administration rate of 5–8% [91].

behind this discrepancy [92].

**7.5 Technological quality measures**

should be collected and evaluated regularly [95].

**7.6 Quality measures: final thoughts**

**7.4 Patient/provider-related outcomes**

stroke outcome [83]. Steps should be taken to ensure a 90-day follow-up on all the telestroke treated patients. No significant differences in mortality or morbidity were noted in patients in the hub and spoke hospitals of the TEMPiS network [91]. Even though 90-day outcomes after stroke are reported in most clinical trials, this data is not routinely collected by hospitals because of the cost and complexity involved. Data on stroke mimics that were treated by telestroke networks is an important factor as it plays a big role in minimizing costs, even though tPA administration might not increase the risk to these patients. Similarly, data on the percentage of patients receiving tPA through telestroke networks is very useful to compare with in-person stroke treatment numbers. In a study that examined several telestroke networks, the rate of tPA via telestroke was 18–36% compared to the national average tPA

Data collection regarding patient characteristics, NIHSS score pre/post-treatment and before discharge, length of hospital stay, discharge disposition (home vs. rehab vs. sub-acute rehab), readmission rate, complications including intracranial hemorrhage, other significant hemorrhages, mortality, and 90-day follow-up outcomes are recommended by the American Heart Association and the American Stroke Association [92]. One of the highest priorities for several healthcare systems is patient satisfaction. Attempts should be made to follow-up with the treated patients and family members about their satisfaction with the telestroke process. LaMonte et al. found that the telestroke process enhanced patient satisfaction in their study [93]. Measuring provider satisfaction is equally important for improving telestroke service quality. Studies showed that patients are more enthusiastic about telemedicine compared to providers even though both of the groups were satisfied [94]. Providers having less of a personal benefit was one of the possible reasons

In a good telestroke program, the technology involved is as important as the physicians' clinical expertise. Video and audio conferencing equipment quality, transmission clarity, internet speed, user-friendliness of the software, accessibility of personnel training modules, and encryption of patient information in transit to protect patient privacy all play a role for effective delivery of telestroke care. All technical difficulties, failures, and limitations should be continuously monitored,

Lastly, apart from the issues unique to telestroke, data on regular measures as recommended by National Quality Forum for stroke patients, including use of tPA, anti-thrombolysis therapy by day 2, thromboembolism prophylaxis, lipid-lowering medications on discharge, anti-thrombotic therapy on discharge, anticoagulation in the setting of atrial fibrillation, rehabilitation evaluation, and stroke education

There are still challenges with current models. In the last 15 years, there has been

a substantial improvement in stroke quality measures. Most of the measures are already being performed with a high compliance rate and innovation. They should be expanded to pre-hospitalization and post-hospitalization settings as well as to telestroke for further improvement of stroke care [62, 96–99]. Universal guidelines

documented, and analyzed promptly to prevent repeated occurrences.

#### *Telestroke: A New Paradigm DOI: http://dx.doi.org/10.5772/intechopen.92831*

*Ischemic Stroke*

**7.1 Structural measures**

**7.2 Process measures**

duration (Con).

unnecessary transfers.

**7.3 Outcome measures**

sites.

local laws and statues, effective training programs, identification of competency issues, and overcoming challenges with technical and manpower issues at both provider and recipient sites. In 1988, Donebedian was the first to describe the model of structure, process, and outcomes measurements for assessing the quality of healthcare [85]. Systematic collection and analysis of quality data has been shown to improve the quality of stroke care that is delivered [86], and telestroke is no exception to this. Several quality measures help assess and quantify the overall function of telestroke systems. Most hub hospitals have stroke certification and emergency and ICU staff training through standards set by the Joint Commission on the

The capacity of the healthcare system, staffing ratios of specialists, availability of specialized units and equipment, and the organization structure with hospital networking should all be carefully studied and analyzed for any telehealth network systems. Defined protocols should be in place both at the originating and distant

Analogous to the traditional stroke pathway, the key global component of telestroke quality is still DTN time. Median DTN with telestroke varies from 106 to 121 minutes, even though the recommendation is less than 1 hour [58]. Several aspects of stroke chain-of-care that play an important role in DTN include Emergency Department (ED) door to CT scan (D-CT) time, ED door to teleneurologist consult time, teleneurologist to camera/phone time, and teleconsult

Clear definitions of these times are important as no uniform definitions currently exist. In some centers, a consult with teleneurologist occurs after CT scan results are obtained, while in other centers, a consult is initiated even before the CT scan is ordered. The time from ED to consult differs in these situations, which can affect these measures. Similarly, the definition of consult time varies between centers. At some centers, consult time is defined as the time spent on camera evaluating patients, and at other centers, it is defined as time spent on camera along with the time spent reviewing the images and other diagnostic results. Because of these variations, consult duration varied from 14 to 32 minutes in different studies [87, 88]. Studies showed that telestroke by itself might not decrease the DTN as there are

It has been shown that D-NC and Con play a major role in DTN [90]. Various factors including, when the consultant is notified, the time a consultant takes to interview the patient, and the experience level of the staff aiding with the examination will have to be considered while analyzing such data. The percentage of patients transferred after a telestroke consult to a destination hospital is also an important factor as it involves significant costs [67]. Data should be collected quantifying the rate of transfers after the consult and steps should be taken to minimize

The success of any program is ultimately decided by measuring outcomes, which could be patient related or system related. A modified Rankin scale, which is measured 90 days after a stroke, is the most commonly used measurement of

Accreditation of Healthcare Organizations (JCAHO) process.

variations in the subsects of stroke chain-of-care [89].

**66**

stroke outcome [83]. Steps should be taken to ensure a 90-day follow-up on all the telestroke treated patients. No significant differences in mortality or morbidity were noted in patients in the hub and spoke hospitals of the TEMPiS network [91]. Even though 90-day outcomes after stroke are reported in most clinical trials, this data is not routinely collected by hospitals because of the cost and complexity involved. Data on stroke mimics that were treated by telestroke networks is an important factor as it plays a big role in minimizing costs, even though tPA administration might not increase the risk to these patients. Similarly, data on the percentage of patients receiving tPA through telestroke networks is very useful to compare with in-person stroke treatment numbers. In a study that examined several telestroke networks, the rate of tPA via telestroke was 18–36% compared to the national average tPA administration rate of 5–8% [91].

## **7.4 Patient/provider-related outcomes**

Data collection regarding patient characteristics, NIHSS score pre/post-treatment and before discharge, length of hospital stay, discharge disposition (home vs. rehab vs. sub-acute rehab), readmission rate, complications including intracranial hemorrhage, other significant hemorrhages, mortality, and 90-day follow-up outcomes are recommended by the American Heart Association and the American Stroke Association [92]. One of the highest priorities for several healthcare systems is patient satisfaction. Attempts should be made to follow-up with the treated patients and family members about their satisfaction with the telestroke process. LaMonte et al. found that the telestroke process enhanced patient satisfaction in their study [93]. Measuring provider satisfaction is equally important for improving telestroke service quality. Studies showed that patients are more enthusiastic about telemedicine compared to providers even though both of the groups were satisfied [94]. Providers having less of a personal benefit was one of the possible reasons behind this discrepancy [92].

## **7.5 Technological quality measures**

In a good telestroke program, the technology involved is as important as the physicians' clinical expertise. Video and audio conferencing equipment quality, transmission clarity, internet speed, user-friendliness of the software, accessibility of personnel training modules, and encryption of patient information in transit to protect patient privacy all play a role for effective delivery of telestroke care. All technical difficulties, failures, and limitations should be continuously monitored, documented, and analyzed promptly to prevent repeated occurrences.

Lastly, apart from the issues unique to telestroke, data on regular measures as recommended by National Quality Forum for stroke patients, including use of tPA, anti-thrombolysis therapy by day 2, thromboembolism prophylaxis, lipid-lowering medications on discharge, anti-thrombotic therapy on discharge, anticoagulation in the setting of atrial fibrillation, rehabilitation evaluation, and stroke education should be collected and evaluated regularly [95].

## **7.6 Quality measures: final thoughts**

There are still challenges with current models. In the last 15 years, there has been a substantial improvement in stroke quality measures. Most of the measures are already being performed with a high compliance rate and innovation. They should be expanded to pre-hospitalization and post-hospitalization settings as well as to telestroke for further improvement of stroke care [62, 96–99]. Universal guidelines

about definitions of times in stroke chain-of-care, protocols for consultant notification, and specific standard stepwise processes that can be applied universally for telestroke networks will be useful in standardizing telestroke models. As telestroke is becoming more popular in delivering care for acute stroke patients, there is a need for strict quality metrics to ensure safe and effective care for the patients. Even though in several aspects telestroke is as effective as in-person stroke care, there are several issues pertinent to telestroke like technology, policies, and challenges with data collection due to distant participating sites that need to be refined for effective and timely management of stroke patients.

## **8. Telestroke across the world**

Lack of neurology coverage is not unique to the US; it is a problem worldwide [100]. Several countries in Europe have developed efficient telestroke networks [59, 64, 69, 101–103], with the TEMPiS network in Germany showing remarkable results [64, 104, 105]. The Telestroke Committee of the European Stroke Organization has recently published recommendations regarding telestroke networks in Europe concerning infrastructure, teleconsultation service, transfer options, standard operating procedures, professional training, and quality monitoring and improvement. They have also made recommendations about the technical and ethical aspects of telemedicine [106], which are similar to ones in the US.

Asia is quite heterogeneous in terms of variability in language, governments, culture, historical links, socioeconomic development, and organization of health services. In China, the National Telestroke Center, established in 2014, was designed to provide neurological coverage to 300 rural hospitals throughout the country through the telestroke network [107]. This was also the first platform where Google Glasses were used for real-time telestroke consults. The system is still evolving and data from China is still limited. In India, telestroke systems are still uncommon, but they show prospects for expansion, aiming to provide care to rural communities that are limited in their resources [108, 109]. Japan, Singapore, and South Korea have rather advanced nationwide medical systems, but telemedicine experience in these countries is still limited [110–112]. Teleneurology and telestroke have great potential to extend neurology expertise to underserved populations in the world; however, further investment in creating infrastructure and technology is needed before their impact on healthcare is realized.

## **9. Telestroke in the new era of novel coronavirus (COVID-19)**

In December 2019, the first case of the novel coronavirus COVID-19 was identified in China [113]. Since then, the rapid spread of the virus has led to a worldwide pandemic [114]. The US has become the epicenter of this pandemic with the largest number of reported cases worldwide. Of all COVID-19 cases, an estimated 19% are healthcare personnel [115]. The COVID-19 pandemic has put a significant strain on healthcare personnel in providing in-person care, especially in an acute setting. Several States in the US and countries around the world have implemented stay-athome orders. Hospitals have canceled elective procedures and outpatient in-person clinic visits to minimize the exposure risk to patients and healthcare workers. Additionally, COVID-19 is associated with an increased risk of thromboembolic complications [116]. This puts neurologists at risk of exposure while assessing patients with acute neurological deficits. Screening for symptoms of COVID-19 has

**69**

administration [128].

*Telestroke: A New Paradigm*

*DOI: http://dx.doi.org/10.5772/intechopen.92831*

growing need at a much faster pace.

**10.1 Issues regarding reimbursement**

underserved areas of the country.

**10.2 Licensure and credentialing constraints**

**10. Hurdles and barriers**

also become difficult in the setting of neurological deficits, especially aphasia and encephalopathy. Most countries around the world, including the US, already suffer from a lack of adequate neurology coverage [100] and COVID-19 exposure not only puts neurologists' wellbeing and life at risk but also exacerbates this deficiency. This pandemic has brought the need and utility of telemedicine, teleneurology, and telestroke into the limelight [117–120]. Teleconsults are an effective way of providing outpatient care as well was acute care inside the hospitals, limiting the exposure risk to physicians and patients, as well as limiting the use of personal protective equipment which is in short supply. The pandemic may change the paradigm of teleneurology and telestroke permanently and force the system to adapt to its

Despite the utility and efficacy of telestroke networks, there exist significant hurdles in establishing and efficiently sustaining a viable telestroke program.

The most important hurdle is third party reimbursement. It took decades for the concept of telemedicine to come to fruition, and pay parity kept telemedicine programs across the country from flourishing, sustaining, and expanding [121–126]. Without appropriate reimbursement, the burden of financial overhead in maintaining the high-quality video interface, teleneurology and teleradiology coverage, and costs of emergent care including imaging, tPA, and transportation to hub hospitals would make telestroke network unsustainable. The Centers for Medicare and Medicaid Services (CMS) has addressed the need for reimbursement for telemedicine services and third-party payers have followed suit [37, 121]. Appropriate reimbursement for teleservices remains a concern among providers [127] and continues to be a barrier for the expansion of telestroke networks to

Licensure and hospital credentialing, often across state lines, further burdens physicians and hospitals to spend resources, thus putting additional constraints on the expansion of these services. Physicians are required to maintain a license in the state where the spoke site is located in addition to the hub site where they usually work. This requires unrestricted licensure to be maintained in every state where the teleconsult is requested. A national or multistate license for telemedicine would reduce the necessity for a consultant to be licensed in multiple individual states, but this kind of license does not currently exist [128]. In 2011, CMS began allowing credentialing and privileging by proxy at small and criticalaccess hospitals, which has allowed these hospitals to rely on the credentialing and privileging process performed at the hub site [92, 129]. However, this policy needs to be adopted by all 50 states to mitigate the onus of licensing and credentialing on physicians and small hospitals. Also, reimbursement in cases where the patient receives tPA at the spoke site and is transferred to the hub hospital remains an issue, as neither the spoke nor hub facility is eligible to bill the higher Medicare diagnosis-related group codes that are associated with thrombolytic

#### *Telestroke: A New Paradigm DOI: http://dx.doi.org/10.5772/intechopen.92831*

*Ischemic Stroke*

and timely management of stroke patients.

before their impact on healthcare is realized.

**9. Telestroke in the new era of novel coronavirus (COVID-19)**

In December 2019, the first case of the novel coronavirus COVID-19 was identified in China [113]. Since then, the rapid spread of the virus has led to a worldwide pandemic [114]. The US has become the epicenter of this pandemic with the largest number of reported cases worldwide. Of all COVID-19 cases, an estimated 19% are healthcare personnel [115]. The COVID-19 pandemic has put a significant strain on healthcare personnel in providing in-person care, especially in an acute setting. Several States in the US and countries around the world have implemented stay-athome orders. Hospitals have canceled elective procedures and outpatient in-person clinic visits to minimize the exposure risk to patients and healthcare workers. Additionally, COVID-19 is associated with an increased risk of thromboembolic complications [116]. This puts neurologists at risk of exposure while assessing patients with acute neurological deficits. Screening for symptoms of COVID-19 has

**8. Telestroke across the world**

about definitions of times in stroke chain-of-care, protocols for consultant notification, and specific standard stepwise processes that can be applied universally for telestroke networks will be useful in standardizing telestroke models. As telestroke is becoming more popular in delivering care for acute stroke patients, there is a need for strict quality metrics to ensure safe and effective care for the patients. Even though in several aspects telestroke is as effective as in-person stroke care, there are several issues pertinent to telestroke like technology, policies, and challenges with data collection due to distant participating sites that need to be refined for effective

Lack of neurology coverage is not unique to the US; it is a problem worldwide [100]. Several countries in Europe have developed efficient telestroke networks [59, 64, 69, 101–103], with the TEMPiS network in Germany showing remarkable results [64, 104, 105]. The Telestroke Committee of the European Stroke Organization has recently published recommendations regarding telestroke networks in Europe concerning infrastructure, teleconsultation service, transfer options, standard operating procedures, professional training, and quality monitoring and improvement. They have also made recommendations about the technical and ethical aspects of telemedicine [106], which are similar to ones in the US. Asia is quite heterogeneous in terms of variability in language, governments, culture, historical links, socioeconomic development, and organization of health services. In China, the National Telestroke Center, established in 2014, was designed to provide neurological coverage to 300 rural hospitals throughout the country through the telestroke network [107]. This was also the first platform where Google Glasses were used for real-time telestroke consults. The system is still evolving and data from China is still limited. In India, telestroke systems are still uncommon, but they show prospects for expansion, aiming to provide care to rural communities that are limited in their resources [108, 109]. Japan, Singapore, and South Korea have rather advanced nationwide medical systems, but telemedicine experience in these countries is still limited [110–112]. Teleneurology and telestroke have great potential to extend neurology expertise to underserved populations in the world; however, further investment in creating infrastructure and technology is needed

**68**

also become difficult in the setting of neurological deficits, especially aphasia and encephalopathy. Most countries around the world, including the US, already suffer from a lack of adequate neurology coverage [100] and COVID-19 exposure not only puts neurologists' wellbeing and life at risk but also exacerbates this deficiency. This pandemic has brought the need and utility of telemedicine, teleneurology, and telestroke into the limelight [117–120]. Teleconsults are an effective way of providing outpatient care as well was acute care inside the hospitals, limiting the exposure risk to physicians and patients, as well as limiting the use of personal protective equipment which is in short supply. The pandemic may change the paradigm of teleneurology and telestroke permanently and force the system to adapt to its growing need at a much faster pace.

## **10. Hurdles and barriers**

Despite the utility and efficacy of telestroke networks, there exist significant hurdles in establishing and efficiently sustaining a viable telestroke program.

## **10.1 Issues regarding reimbursement**

The most important hurdle is third party reimbursement. It took decades for the concept of telemedicine to come to fruition, and pay parity kept telemedicine programs across the country from flourishing, sustaining, and expanding [121–126]. Without appropriate reimbursement, the burden of financial overhead in maintaining the high-quality video interface, teleneurology and teleradiology coverage, and costs of emergent care including imaging, tPA, and transportation to hub hospitals would make telestroke network unsustainable. The Centers for Medicare and Medicaid Services (CMS) has addressed the need for reimbursement for telemedicine services and third-party payers have followed suit [37, 121]. Appropriate reimbursement for teleservices remains a concern among providers [127] and continues to be a barrier for the expansion of telestroke networks to underserved areas of the country.

## **10.2 Licensure and credentialing constraints**

Licensure and hospital credentialing, often across state lines, further burdens physicians and hospitals to spend resources, thus putting additional constraints on the expansion of these services. Physicians are required to maintain a license in the state where the spoke site is located in addition to the hub site where they usually work. This requires unrestricted licensure to be maintained in every state where the teleconsult is requested. A national or multistate license for telemedicine would reduce the necessity for a consultant to be licensed in multiple individual states, but this kind of license does not currently exist [128]. In 2011, CMS began allowing credentialing and privileging by proxy at small and criticalaccess hospitals, which has allowed these hospitals to rely on the credentialing and privileging process performed at the hub site [92, 129]. However, this policy needs to be adopted by all 50 states to mitigate the onus of licensing and credentialing on physicians and small hospitals. Also, reimbursement in cases where the patient receives tPA at the spoke site and is transferred to the hub hospital remains an issue, as neither the spoke nor hub facility is eligible to bill the higher Medicare diagnosis-related group codes that are associated with thrombolytic administration [128].

#### **10.3 Infrastructure and technological challenges**

Establishing and maintaining the infrastructure for high-quality video conferencing in small rural hospitals also adds to the financial burden on these hospitals. There is also marked heterogeneity in the platforms available, which spoke sites need to take into account before joining a telestroke model [37, 128]. Platform differences also limit the flexibility of these rural hospitals in terms of associating with more than one network or transitioning to a different network as the platforms utilized by these networks may be incompatible. Additionally, to comply with CMS billing requirements, a high-quality, two-way video connection is recommended and a minimum frame rate of at least 20 frames per second has been suggested [130]. Thus, high-speed internet is an essential component of telestroke networks. The availability of high-speed internet connections in rural parts of the country is limited and is a separate problem limiting the implementation of telestroke networks. These issues become exceedingly challenging in resource-limited countries around the world.

#### **10.4 Physician buy-in and telestroke staff training**

Convincing the leadership of potential spoke sites of the cost-effectiveness of joining a telestroke system requires time and effort on the part of the hub telestroke providers. Joining a telestroke system not only requires investment in infrastructure but also requires extensive training and development of protocols for teleconsults and transfers. These requirements may appear daunting to the leadership and hospital staff, especially at small rural hospitals with limited resources. However, the literature supporting the safety, cost-effectiveness, and improved patient outcomes related to telestroke networks may help encourage their buy-in to such programs. Joining such a system implies a long-term partnership between the hub and the spoke sites. Trust also needs to be established between the spoke site ED staff and consulting neurologists. Endorsements and testimony from the leadership of existing spoke sites in similar settings, hearing patient experiences from those who benefitted from these networks, and meeting with the team of consulting neurologists may prove useful in building this trust.

Along with the establishment of infrastructure for telestroke, medical staff at spokes sites need to be trained for ever-evolving telestroke protocols and joint commission requirements. They need to be able to recognize the early signs and symptoms of acute stroke, perform NIHSS exams, screen for eligibility for tPA, and to be proficient at using the teleconsult interface to facilitate the process efficiently. Telestroke systems can include stroke patient management training to spoke medical staff on education NIHSS exam demonstrations, reviews of alteplase reconstitution, administration and considerations, alteplase dosage calculations and telemedicine cart demonstration and review. Other patient management training can be provided to paramedics local to the spoke sites, these sessions typically include; impact of and time sensitivity of strokes, what is a stroke, types of stroke, stroke mimics, EMS neurological assessments, stroke management/prehospital guidelines and telemedicine and alteplase through an organizational system of care.

Given the wide variability of telestroke systems based on AHA/ASA guidelines and local governing factors, each network should develop an standard operating protocol (SOP) that suits their needs (**Tables 1**–**3**) [131]. The volume of teleconsults can vary greatly between the spoke hospitals, thus training needs to be reinforced at specified intervals to ensure efficient and seamless consults and to maintain high-quality patient care. This may lead to telemedicine fatigue in the staff at lowvolume hospitals that needs to be mitigated during the training by emphasizing the importance of their work in the teleconsult system in their community at improving

**71**

*\**

*†*

**Table 1.**

**10.5 Data security and sharing**

outcomes in patients who may have otherwise not had an opportunity for timely

*The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic* 

*For comparative-effectiveness recommendations (COR I and IIa; LOE A and B only), studies that support the use of* 

Telestroke networks, like traditional practices, are required to be compliant with HIPAA, which governs protected health information in the US. Given that telestroke

stroke intervention due to time lost in transportation to larger centers.

*American Heart Association summary of recommendations for telestrokes [131].*

*comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.*

*Telestroke: A New Paradigm*

• Is recommended

• Is reasonable

*DOI: http://dx.doi.org/10.5772/intechopen.92831*

Suggested phrases for writing recommendations:

○ Treatment A should be chosen over treatment B

: ○ Treatment/strategy A is recommended/indicated in preference to treatment B

:

• Usefulness/effectiveness is unknown/unclear/uncertain or not well established **Class III: no benefit (moderate) (generally, LOE A or B use only)—benefit = risk**

○ It is reasonable to choose treatment A over treatment B

○ Treatment/strategy A is probably recommended/indicated in preference to treatment B

**Class (strength) of recommendation Class I (strong)—benefit >>> risk**

• Is indicated/useful/effective/beneficial • Should be performed/administered/others • Comparative-effectiveness phrases†

**Class IIa (moderate)—benefit >> risk** Suggested phrases for writing recommendations:

• Can be useful/effective/beneficial • Comparative-effectiveness phrases†

**Class IIb (weak)—benefit ≥ risk**

• May/might be reasonable • May/might be considered

• Is not recommended

• Potentially harmful • Causes harm

Suggested phrases for writing recommendations:

Suggested phrases for writing recommendations:

• Is not indicated/useful/effective/beneficial • Should not be performed/administered/others

• Associated with excess morbidity/mortality • Should not be performed/administered/others

*accuracy or incremental prognostic information).*

**Class III: harm (strong)—risk > benefit** Suggested phrases for writing recommendations:

**American College of Cardiology/American Heart Association class of recommendation and level of evidence to clinical strategies, interventions, treatments, or diagnostic testing in patient care\***

#### **American College of Cardiology/American Heart Association class of recommendation and level of evidence to clinical strategies, interventions, treatments, or diagnostic testing in patient care\***

#### **Class (strength) of recommendation**

## **Class I (strong)—benefit >>> risk**

Suggested phrases for writing recommendations:

• Is recommended

*Ischemic Stroke*

**10.3 Infrastructure and technological challenges**

**10.4 Physician buy-in and telestroke staff training**

neurologists may prove useful in building this trust.

Establishing and maintaining the infrastructure for high-quality video conferencing in small rural hospitals also adds to the financial burden on these hospitals. There is also marked heterogeneity in the platforms available, which spoke sites need to take into account before joining a telestroke model [37, 128]. Platform differences also limit the flexibility of these rural hospitals in terms of associating with more than one network or transitioning to a different network as the platforms utilized by these networks may be incompatible. Additionally, to comply with CMS billing requirements, a high-quality, two-way video connection is recommended and a minimum frame rate of at least 20 frames per second has been suggested [130]. Thus, high-speed internet is an essential component of telestroke networks. The availability of high-speed internet connections in rural parts of the country is limited and is a separate problem limiting the implementation of telestroke networks. These issues become exceedingly challenging in resource-limited countries around the world.

Convincing the leadership of potential spoke sites of the cost-effectiveness of joining a telestroke system requires time and effort on the part of the hub telestroke providers. Joining a telestroke system not only requires investment in infrastructure but also requires extensive training and development of protocols for teleconsults and transfers. These requirements may appear daunting to the leadership and hospital staff, especially at small rural hospitals with limited resources. However, the literature supporting the safety, cost-effectiveness, and improved patient outcomes related to telestroke networks may help encourage their buy-in to such programs. Joining such a system implies a long-term partnership between the hub and the spoke sites. Trust also needs to be established between the spoke site ED staff and consulting neurologists. Endorsements and testimony from the leadership of existing spoke sites in similar settings, hearing patient experiences from those who benefitted from these networks, and meeting with the team of consulting

Along with the establishment of infrastructure for telestroke, medical staff at spokes sites need to be trained for ever-evolving telestroke protocols and joint commission requirements. They need to be able to recognize the early signs and symptoms of acute stroke, perform NIHSS exams, screen for eligibility for tPA, and to be proficient at using the teleconsult interface to facilitate the process efficiently. Telestroke systems can include stroke patient management training to spoke medical staff on education NIHSS exam demonstrations, reviews of alteplase reconstitution, administration and considerations, alteplase dosage calculations and telemedicine cart demonstration and review. Other patient management training can be provided to paramedics local to the spoke sites, these sessions typically include; impact of and time sensitivity of strokes, what is a stroke, types of stroke, stroke mimics, EMS neurological assessments, stroke management/prehospital guidelines and telemedicine and alteplase through an organizational system of care. Given the wide variability of telestroke systems based on AHA/ASA guidelines and local governing factors, each network should develop an standard operating protocol (SOP) that suits their needs (**Tables 1**–**3**) [131]. The volume of teleconsults can vary greatly between the spoke hospitals, thus training needs to be reinforced at specified intervals to ensure efficient and seamless consults and to maintain high-quality patient care. This may lead to telemedicine fatigue in the staff at lowvolume hospitals that needs to be mitigated during the training by emphasizing the importance of their work in the teleconsult system in their community at improving

**70**


## **Class IIa (moderate)—benefit >> risk**

Suggested phrases for writing recommendations:

	- Treatment/strategy A is probably recommended/indicated in preference to treatment B
	- It is reasonable to choose treatment A over treatment B

### **Class IIb (weak)—benefit ≥ risk**

Suggested phrases for writing recommendations:


#### **Class III: no benefit (moderate) (generally, LOE A or B use only)—benefit = risk**

Suggested phrases for writing recommendations:


#### **Class III: harm (strong)—risk > benefit**


*\* The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).*

*† For comparative-effectiveness recommendations (COR I and IIa; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.*

#### **Table 1.**

*American Heart Association summary of recommendations for telestrokes [131].*

outcomes in patients who may have otherwise not had an opportunity for timely stroke intervention due to time lost in transportation to larger centers.

#### **10.5 Data security and sharing**

Telestroke networks, like traditional practices, are required to be compliant with HIPAA, which governs protected health information in the US. Given that telestroke

#### **Level A**


#### **Level B-R (randomized)**


#### **Level B-NR (nonrandomized)**


#### **Level C-LD (limited data)**


*Class of recommendation (COR) and level of evidence (LOE) are determined independently (any COR may be paired with any LOE). A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a specific test or therapy is useful or effective. ‡The method of assessing quality is evolving, including the application of standardized, widely used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee. COR, class of recommendation; EO, expert opinion; LD, limited data; LOE, level of evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled trial.*

#### **Table 2.**

*Level (quality) of evidence‡ [131].*


#### **Table 3.**

*American Heart Association/American Stroke Association guidelines for telemedicine [131].*

networks rely on real-time data sharing between the spoke and the hub, data security becomes a concern. Data security requires end-to-end encryption on the sharing platform, reliable documentation and storage, strict control of access to users within

**73**

**Author details**

**11. Conclusion**

Rohan Sharma1

United States

Karthika Veerapaneni1

**Conflict of interest**

Little Rock, AR, United States

Center, Glen Burnie, MD, United States

provided the original work is properly cited.

Sanjeeva Onteddu1

, Krishna Nalleballe1

areas of the country as well as around the world.

, Sisira Yadala1

The authors have no conflicts of interest to disclose.

and Aliza Brown1

\*Address all correspondence to: brownalizat@uams.edu

, Nidhi Kapoor1

the network, and cooperation between the information technology staff at both sites. To ensure 24-hour coverage, consulting physicians often use a mobile device for such calls and must be cognizant of their surroundings while consulting remotely. For example, most telestroke systems provide home accessibility for physician consults. Currently due to HIPPA rules the use of hand held mobile phones remains limited for detection of stroke. Given the renewed interest in telehealth with the COVID-19 pandemic, there is a potential for use of mobile phone application technology.

Healthcare data breaches have been on the rise with larger and teaching hospitals being at a greater risk [132, 133]. Given multiple points of entry and the potential for data breaches in telestroke networks, extra care is needed at the hub and spokes sites to ensure data safety. Despite these challenges, telestroke networks have shown to provide safe, efficient, and cost-effective stroke care to underserved communities. There is still enormous potential for telestroke networks to expand into rural

Since its conception, telestroke has expanded greatly in its scope and utility in bridging the gap in stroke care between the rural and urban communities, in both acute and continued care. Despite the challenges faced in establishing and sustaining telestroke networks, these networks are flourishing and expanding, creating an everevolving paradigm for stroke care throughout the country and around the world.

, Madhu Jasti3

\*

1 Department of Neurology, University of Arkansas for Medical Sciences,

2 Department of Neurology, Baptist Health Program, North Little Rock, AR,

3 Department of Neurology, University of Maryland Baltimore Washington Medical

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

, Vasuki Dandu2

, Suman Siddamreddy2

,

,

*Telestroke: A New Paradigm*

*DOI: http://dx.doi.org/10.5772/intechopen.92831*

*Telestroke: A New Paradigm DOI: http://dx.doi.org/10.5772/intechopen.92831*

the network, and cooperation between the information technology staff at both sites. To ensure 24-hour coverage, consulting physicians often use a mobile device for such calls and must be cognizant of their surroundings while consulting remotely. For example, most telestroke systems provide home accessibility for physician consults. Currently due to HIPPA rules the use of hand held mobile phones remains limited for detection of stroke. Given the renewed interest in telehealth with the COVID-19 pandemic, there is a potential for use of mobile phone application technology.

Healthcare data breaches have been on the rise with larger and teaching hospitals being at a greater risk [132, 133]. Given multiple points of entry and the potential for data breaches in telestroke networks, extra care is needed at the hub and spokes sites to ensure data safety. Despite these challenges, telestroke networks have shown to provide safe, efficient, and cost-effective stroke care to underserved communities. There is still enormous potential for telestroke networks to expand into rural areas of the country as well as around the world.

## **11. Conclusion**

*Ischemic Stroke*

**Level A**

• High-quality evidence‡

**Level B-R (randomized)** • Moderate-quality evidence‡

**Level B-NR (nonrandomized)** • Moderate-quality evidence‡

• Meta-analyses of such studies **Level C-LD (limited data)**

• Meta-analyses of such studies

**Level C-EO (expert opinion)**

**Table 2.**

*Level (quality) of evidence‡*

thrombectomy.

• Meta-analyses of high-quality RCTs

• Meta-analyses of moderate-quality RCTs

observational studies, or registry studies

*R, randomized; and RCT, randomized controlled trial.*

 *[131].*

• Physiological or mechanistic studies in human subjects

• The consensus of expert opinion based on clinical experience

• One or more RCTs corroborated by high-quality registry studies

from one or more RCTs

**72**

**Table 3.**

networks rely on real-time data sharing between the spoke and the hub, data security becomes a concern. Data security requires end-to-end encryption on the sharing platform, reliable documentation and storage, strict control of access to users within

from more than one randomized controlled trial (RCT)

• Randomized or nonrandomized observational or registry studies with limitations of design or execution

*Class of recommendation (COR) and level of evidence (LOE) are determined independently (any COR may be paired with any LOE). A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a specific test or therapy is useful or effective. ‡The method of assessing quality is evolving, including the application of standardized, widely used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee. COR, class of recommendation; EO, expert opinion; LD, limited data; LOE, level of evidence; NR, nonrandomized;* 

**Telemedicine COR LOE**

I A

I A

IIa B-R

IIb B-NR

IIb C-LD

IIb B-NR

1. For sites without in-house imaging interpretation expertise, teleradiology systems approved by the US Food and Drug Administration are recommended for timely

2. When implemented within a telestroke network, teleradiology systems approved by the US Food and Drug Administration are useful in supporting rapid imaging interpretation in time for IV alteplase administration decision making.

3. Telestroke/teleradiology evaluations of acute ischemic stroke (AIS) patients can

4. Administration of IV alteplase guided by telestroke consultation for patients with

*American Heart Association/American Stroke Association guidelines for telemedicine [131].*

5. Providing alteplase decision-making support via telephone consultation to community physicians is feasible and safe and may be considered when a hospital

has access to neither an in-person stroke team nor a telestroke system.

6. Telestroke networks may be reasonable for triaging patients with AIS who may be eligible for interfacility transfer to be considered for acute mechanical

review of brain imaging in patients with suspected acute stroke.

be effective for correct IV alteplase eligibility decision making.

AIS may be as safe and as beneficial as that of stroke centers.

from one or more well-designed, well-executed nonrandomized studies,

Since its conception, telestroke has expanded greatly in its scope and utility in bridging the gap in stroke care between the rural and urban communities, in both acute and continued care. Despite the challenges faced in establishing and sustaining telestroke networks, these networks are flourishing and expanding, creating an everevolving paradigm for stroke care throughout the country and around the world.

### **Conflict of interest**

The authors have no conflicts of interest to disclose.

## **Author details**

Rohan Sharma1 , Krishna Nalleballe1 , Nidhi Kapoor1 , Vasuki Dandu2 , Karthika Veerapaneni1 , Sisira Yadala1 , Madhu Jasti3 , Suman Siddamreddy2 , Sanjeeva Onteddu1 and Aliza Brown1 \*

1 Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, United States

2 Department of Neurology, Baptist Health Program, North Little Rock, AR, United States

3 Department of Neurology, University of Maryland Baltimore Washington Medical Center, Glen Burnie, MD, United States

\*Address all correspondence to: brownalizat@uams.edu

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **References**

[1] Grysiewicz RA, Thomas K, Pandey DK. Epidemiology of ischemic and hemorrhagic stroke: Incidence, prevalence, mortality, and risk factors. Neurologic Clinics. 2008;**26**(4): 871-895, vii

[2] Benjamin EJ et al. Heart disease and stroke statistics—2018 update: A report from the American Heart Association. Circulation. 2018

[3] Roger VL et al. Heart disease and stroke statistics—2011 update: A report from the American Heart Association. Circulation. 2011;**123**(4):e18-e209

[4] Rosamond W et al. Heart disease and stroke statistics—2007 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;**115**(5):e69-e171

[5] Saver JL et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013;**309**(23):2480-2488

[6] Mitka M. Early treatment of ischemic stroke with intravenous tPA reduces disability risk. JAMA. 2013;**310**(11):1111

[7] Meretoja A et al. Stroke thrombolysis: Save a minute, save a day. Stroke. 2014;**45**(4):1053-1058

[8] Nogueira RG et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. The New England Journal of Medicine. 2018;**378**(1):11-21

[9] Albers GW et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. The New England Journal of Medicine. 2018;**378**(8):708-718

[10] Berkhemer OA et al. A randomized trial of intraarterial treatment for acute ischemic stroke. The New England Journal of Medicine. 2015;**372**:11-20

[11] Jovin TG et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. The New England Journal of Medicine. 2015;**372**(24):2296-2306

[12] Fang MC, Cutler DM, Rosen AB. Trends in thrombolytic use for ischemic stroke in the United States. Journal of Hospital Medicine. 2010;**5**(7):406-409

[13] Katzan IL et al. Utilization of intravenous tissue plasminogen activator for acute ischemic stroke. Archives of Neurology. 2004;**61**(3):346-350

[14] Adeoye O et al. Recombinant tissue-type plasminogen activator use for ischemic stroke in the United States: A doubling of treatment rates over the course of 5 years. Stroke. 2011;**42**(7):1952-1955

[15] Prabhakaran S et al. Intravenous thrombolysis for stroke increases over time at primary stroke centers. Stroke. 2012;**43**(3):875-877

[16] Kleindorfer D et al. US geographic distribution of rt-PA utilization by hospital for acute ischemic stroke. Stroke. 2009;**40**(11):3580-3584

[17] Nalleballe K et al. Why are acute ischemic stroke patients not receiving thrombolysis in a telestroke network? Journal of Telemedicine and Telecare. 2019:1357633X18824518

[18] Leira EC et al. Rural-urban differences in acute stroke management practices: A modifiable disparity. Archives of Neurology. 2008;**65**(7):887-891

[19] Joubert J et al. Stroke in rural areas and small communities. Stroke. 2008;**39**(6):1920-1928

**75**

*Telestroke: A New Paradigm*

733.e1-733.e18

2003;**34**(11):2765

*DOI: http://dx.doi.org/10.5772/intechopen.92831*

[20] Burgin WS et al. Acute stroke care in non-urban emergency departments. Neurology. 2001;**57**(11):2006-2012

[30] Wittson CL, Benschoter R. Twoway television: Helping the medical center reach out. American Journal of Psychiatry. 1972;**129**(5):624-627

[31] Jutras A. Teleroentgen diagnosis by means of video-tape recording. The American Journal of Roentgenology, Radium Therapy, and Nuclear Medicine.

[32] Grundy BL et al. Telemedicine in critical care: An experiment in health care delivery. JACEP.

[33] Braly D. Telecom use grows for regional data access. Health Management Technology.

[34] Levine SR, Gorman M. "Telestroke": The application of telemedicine for stroke. Stroke. 1999;**30**(2):464-469

[35] Hess DC, Audebert HJ. The history and future of telestroke. Nature Reviews

[36] Zachrison KS et al. Characterizing New England emergency departments by telemedicine use. The Western Journal of Emergency Medicine.

telestroke in the United States: A survey of currently active stroke telemedicine programs. Stroke. 2012;**43**(8):2078-2085

[39] Demaerschalk BM et al. American Telemedicine Association: Telestroke guidelines. Telemedicine Journal and

[37] Silva GS et al. The status of

[38] Solenski NJ. Telestroke. Neuroimaging Clinics. 2018;**28**(4):551-563

E-Health. 2017;**23**(5):376-389

[40] Holodinsky JK et al. Drip and ship versus direct to comprehensive stroke center: Conditional probability modeling. Stroke. 2017;**48**(1):233-238

Neurology. 2013;**9**(6):340

2017;**18**(6):1055

1959;**82**:1099-1102

1977;**6**(10):439-444

1995;**16**(7):22-24

[21] McConnell KJ et al. The on-call crisis: A statewide assessment of the costs of providing on-call specialist coverage. Annals of Emergency Medicine. 2007;**49**(6):727-733,

[22] Donnan GA, Davis SM. Neurologist, internist, or strokologist? Stroke.

[23] McConnell KJ, Newgard CD, Lee R. Changes in the cost and management of emergency department on-call coverage: Evidence from a longitudinal statewide survey. Annals of Emergency

Medicine. 2008;**52**(6):635-642

[25] Goldstein LB et al. VA Stroke Study: Neurologist care is associated with increased testing but improved outcomes. Neurology.

2003;**61**(6):792-796

2006;**22**(1):21-26

[24] Rudkin SE et al. The state of ED on-call coverage in California. The American Journal of Emergency Medicine. 2004;**22**(7):575-581

[26] Smith MA et al. 30-day survival and rehospitalization for stroke patients according to physician specialty. Cerebrovascular Diseases.

[27] Zundel KM. Telemedicine: History, applications, and impact on librarianship. Bulletin of the Medical Library Association. 1996;**84**(1):71

Mary Ann Liebert; 2009

1977;**48**(1):65-70

[28] Bashshur R, Shannon GW. History of Telemedicine: Evolution, Context, and Transformation. New Rochelle, NY:

[29] Bashshur R, Lovett J. Assessment of telemedicine: Results of the initial experience. Aviation, Space, and Environmental Medicine.

*Telestroke: A New Paradigm DOI: http://dx.doi.org/10.5772/intechopen.92831*

[20] Burgin WS et al. Acute stroke care in non-urban emergency departments. Neurology. 2001;**57**(11):2006-2012

[21] McConnell KJ et al. The on-call crisis: A statewide assessment of the costs of providing on-call specialist coverage. Annals of Emergency Medicine. 2007;**49**(6):727-733, 733.e1-733.e18

[22] Donnan GA, Davis SM. Neurologist, internist, or strokologist? Stroke. 2003;**34**(11):2765

[23] McConnell KJ, Newgard CD, Lee R. Changes in the cost and management of emergency department on-call coverage: Evidence from a longitudinal statewide survey. Annals of Emergency Medicine. 2008;**52**(6):635-642

[24] Rudkin SE et al. The state of ED on-call coverage in California. The American Journal of Emergency Medicine. 2004;**22**(7):575-581

[25] Goldstein LB et al. VA Stroke Study: Neurologist care is associated with increased testing but improved outcomes. Neurology. 2003;**61**(6):792-796

[26] Smith MA et al. 30-day survival and rehospitalization for stroke patients according to physician specialty. Cerebrovascular Diseases. 2006;**22**(1):21-26

[27] Zundel KM. Telemedicine: History, applications, and impact on librarianship. Bulletin of the Medical Library Association. 1996;**84**(1):71

[28] Bashshur R, Shannon GW. History of Telemedicine: Evolution, Context, and Transformation. New Rochelle, NY: Mary Ann Liebert; 2009

[29] Bashshur R, Lovett J. Assessment of telemedicine: Results of the initial experience. Aviation, Space, and Environmental Medicine. 1977;**48**(1):65-70

[30] Wittson CL, Benschoter R. Twoway television: Helping the medical center reach out. American Journal of Psychiatry. 1972;**129**(5):624-627

[31] Jutras A. Teleroentgen diagnosis by means of video-tape recording. The American Journal of Roentgenology, Radium Therapy, and Nuclear Medicine. 1959;**82**:1099-1102

[32] Grundy BL et al. Telemedicine in critical care: An experiment in health care delivery. JACEP. 1977;**6**(10):439-444

[33] Braly D. Telecom use grows for regional data access. Health Management Technology. 1995;**16**(7):22-24

[34] Levine SR, Gorman M. "Telestroke": The application of telemedicine for stroke. Stroke. 1999;**30**(2):464-469

[35] Hess DC, Audebert HJ. The history and future of telestroke. Nature Reviews Neurology. 2013;**9**(6):340

[36] Zachrison KS et al. Characterizing New England emergency departments by telemedicine use. The Western Journal of Emergency Medicine. 2017;**18**(6):1055

[37] Silva GS et al. The status of telestroke in the United States: A survey of currently active stroke telemedicine programs. Stroke. 2012;**43**(8):2078-2085

[38] Solenski NJ. Telestroke. Neuroimaging Clinics. 2018;**28**(4):551-563

[39] Demaerschalk BM et al. American Telemedicine Association: Telestroke guidelines. Telemedicine Journal and E-Health. 2017;**23**(5):376-389

[40] Holodinsky JK et al. Drip and ship versus direct to comprehensive stroke center: Conditional probability modeling. Stroke. 2017;**48**(1):233-238

**74**

*Ischemic Stroke*

**References**

871-895, vii

Circulation. 2018

2007;**115**(5):e69-e171

[1] Grysiewicz RA, Thomas K,

Neurologic Clinics. 2008;**26**(4):

Pandey DK. Epidemiology of ischemic and hemorrhagic stroke: Incidence, prevalence, mortality, and risk factors. ischemic stroke. The New England Journal of Medicine. 2015;**372**:11-20

[11] Jovin TG et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. The New England Journal of Medicine. 2015;**372**(24):2296-2306

[12] Fang MC, Cutler DM, Rosen AB. Trends in thrombolytic use for ischemic stroke in the United States. Journal of Hospital Medicine. 2010;**5**(7):406-409

[13] Katzan IL et al. Utilization of intravenous tissue plasminogen activator for acute ischemic stroke. Archives of Neurology.

[14] Adeoye O et al. Recombinant tissue-type plasminogen activator use for ischemic stroke in the United States: A doubling of treatment rates over the course of 5 years. Stroke.

[15] Prabhakaran S et al. Intravenous thrombolysis for stroke increases over time at primary stroke centers. Stroke.

[16] Kleindorfer D et al. US geographic distribution of rt-PA utilization by hospital for acute ischemic stroke. Stroke. 2009;**40**(11):3580-3584

[17] Nalleballe K et al. Why are acute ischemic stroke patients not receiving thrombolysis in a telestroke network? Journal of Telemedicine and Telecare.

2004;**61**(3):346-350

2011;**42**(7):1952-1955

2012;**43**(3):875-877

2019:1357633X18824518

2008;**65**(7):887-891

2008;**39**(6):1920-1928

[18] Leira EC et al. Rural-urban differences in acute stroke

management practices: A modifiable disparity. Archives of Neurology.

[19] Joubert J et al. Stroke in rural areas and small communities. Stroke.

[2] Benjamin EJ et al. Heart disease and stroke statistics—2018 update: A report from the American Heart Association.

[3] Roger VL et al. Heart disease and stroke statistics—2011 update: A report from the American Heart Association. Circulation. 2011;**123**(4):e18-e209

[4] Rosamond W et al. Heart disease and stroke statistics—2007 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation.

[5] Saver JL et al. Time to treatment with intravenous tissue plasminogen

[6] Mitka M. Early treatment of ischemic stroke with intravenous tPA reduces disability risk. JAMA. 2013;**310**(11):1111

[7] Meretoja A et al. Stroke thrombolysis:

[8] Nogueira RG et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. The New England Journal of Medicine.

[9] Albers GW et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. The New England Journal of Medicine.

[10] Berkhemer OA et al. A randomized trial of intraarterial treatment for acute

Save a minute, save a day. Stroke.

2014;**45**(4):1053-1058

2018;**378**(1):11-21

2018;**378**(8):708-718

activator and outcome from acute ischemic stroke. JAMA. 2013;**309**(23):2480-2488

[41] LaMonte MP et al. TeleBAT: Mobile telemedicine for the Brain Attack Team. Journal of Stroke and Cerebrovascular Diseases. 2000;**9**(3):128-135

[42] LaMonte MP et al. Shortening time to stroke treatment using ambulance telemedicine: TeleBAT. Journal of Stroke and Cerebrovascular Diseases. 2004;**13**(4):148-154

[43] Lippman JM et al. Mobile telestroke during ambulance transport is feasible in a rural EMS setting: The iTREAT Study. Telemedicine and e-Health. 2016;**22**(6):507-513

[44] Liman TG et al. Telestroke ambulances in prehospital stroke management: Concept and pilot feasibility study. Stroke. 2012;**43**(8):2086-2090

[45] Wu T-C et al. Telemedicine can replace the neurologist on a mobile stroke unit. Stroke. 2017;**48**(2):493-496

[46] Bowry R et al. Time to decision and treatment with tPA (tissuetype plasminogen activator) using telemedicine versus an onboard neurologist on a mobile stroke unit. Stroke. 2018;**49**(6):1528-1530

[47] Hacke W et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. The New England Journal of Medicine. 2008;**359**(13):1317-1329

[48] Wang S et al. Remote evaluation of acute ischemic stroke: Reliability of National Institutes of Health Stroke Scale via telestroke. Stroke. 2003;**34**(10):e188-e191

[49] Handschu R et al. Telemedicine in emergency evaluation of acute stroke: Interrater agreement in remote video examination with a novel multimedia system. Stroke. 2003;**34**(12):2842-2846 [50] Meyer BC et al. Reliability of site-independent telemedicine when assessed by telemedicine-naive stroke practitioners. Journal of Stroke and Cerebrovascular Diseases. 2008;**17**(4):181-186

[51] Demaerschalk BM, Kiernan T-EJ. Vascular neurology nurse practitioner provision of telemedicine consultations. International Journal of Telemedicine and Applications. 2010;**2010**

[52] Meyer B et al. Prospective reliability of the STRokE DOC wireless/site independent telemedicine system. Neurology. 2005;**64**(6):1058-1060

[53] Gonzalez MA et al. Reliability of prehospital real-time cellular video phone in assessing the simplified National Institutes of Health Stroke Scale in patients with acute stroke: A novel telemedicine technology. Stroke. 2011;**42**(6):1522-1527

[54] Demaerschalk BM et al. Reliability of real-time video smartphone for assessing National Institutes of Health Stroke Scale scores in acute stroke patients. Stroke. 2012;**43**(12):3271-3277

[55] Schwamm LH et al. A review of the evidence for the use of telemedicine within stroke systems of care: A scientific statement from the American Heart Association/ American Stroke Association. Stroke. 2009;**40**(7):2616-2634

[56] Puetz V et al. Reliability of brain CT evaluation by stroke neurologists in telemedicine. Neurology. 2013;**80**(4):332-338

[57] Demaerschalk BM et al. CT interpretation in a telestroke network: Agreement among a spoke radiologist, hub vascular neurologist, and hub neuroradiologist. Stroke. 2012;**43**(11):3095-3097

**77**

*Telestroke: A New Paradigm*

2004;**11**(11):1193-1197

2003;**34**(12):2951-2956

2004;**35**(7):1763-1768

2019;**50**(Suppl\_1):ATP270

Medicine. 2009;**36**(1):12-18

[58] Schwamm LH et al. Virtual TeleStroke support for the emergency department evaluation of acute stroke. Academic Emergency Medicine.

to improve stroke care in rural areas: The Telemedicine in Stroke in Swabia (TESS) Project. Stroke.

[60] Hess DC et al. REACH: Clinical feasibility of a rural telestroke network.

[61] Wang S et al. Remote evaluation of acute ischemic stroke in rural

[62] Joiner R et al. Abstract TP270: When telestroke programs work, bed size really doesn't matter. Stroke.

[63] Switzer JA et al. A web-based telestroke system facilitates rapid treatment of acute ischemic stroke patients in rural emergency departments. The Journal of Emergency

[64] Audebert HJ et al. Effects of the implementation of a telemedical stroke network: The Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany. The Lancet Neurology. 2006;**5**(9):742-748

[65] Demaerschalk BM et al. Cost utility of hub-and-spoke telestroke networks from societal perspective. The American Journal of Managed Care.

[66] Nelson RE et al. The costeffectiveness of telestroke in the treatment of acute ischemic stroke. Neurology. 2011;**77**(17):1590-1598

[67] Switzer JA et al. Cost-effectiveness of hub-and-spoke telestroke networks

2013;**19**(12):976-985

community hospitals in Georgia. Stroke.

Stroke. 2005;**36**(9):2018-2020

*DOI: http://dx.doi.org/10.5772/intechopen.92831*

for the management of acute ischemic stroke from the hospitals' perspectives. Circulation. Cardiovascular Quality and

effectiveness of telestroke in the Pacific Northwest region of the USA. Journal

Outcomes. 2013;**6**(1):18-26

[68] Nelson RE et al. The cost-

of Telemedicine and Telecare.

[69] Ehlers L et al. National use of thrombolysis with alteplase for acute ischaemic stroke via telemedicine in Denmark. CNS Drugs. 2008;**22**(1):73-81

[70] Evans A et al. Randomized controlled study of stroke unit care versus stroke team Care in Different Stroke Subtypes. Stroke.

[71] Wang DZ et al. Treating acute stroke patients with intravenous tPA: The OSF stroke network experience. Stroke.

[72] Wiborg A, Widder B. Teleneurology to improve stroke care in rural areas. Stroke. 2003;**34**(12):2951-2956

neurointensive care. Surgical Neurology.

[74] Klein KE et al. Teleneurocritical care and telestroke. Critical Care Clinics.

[75] Laver KE et al. Telerehabilitation services for stroke. Cochrane Database of Systematic Reviews. 2013;**12**:1-41

[76] Chen J et al. Telerehabilitation approaches for stroke patients:

Systematic review and meta-analysis of randomized controlled trials. Journal of Stroke and Cerebrovascular Diseases.

[73] Vespa PM et al. Intensive care unit robotic telepresence facilitates rapid physician response to unstable patients and decreased cost in

2016;**22**(7):413-421

2002;**33**(2):449-455

2000;**31**(1):77-81

2007;**67**(4):331-337

2015;**31**(2):197-224

2015;**24**(12):2660-2668

[59] Wiborg A, Widder B. Teleneurology

*Telestroke: A New Paradigm DOI: http://dx.doi.org/10.5772/intechopen.92831*

*Ischemic Stroke*

[41] LaMonte MP et al. TeleBAT: Mobile telemedicine for the Brain Attack Team. Journal of Stroke and Cerebrovascular

[50] Meyer BC et al. Reliability of site-independent telemedicine when assessed by telemedicine-naive stroke practitioners. Journal of Stroke and Cerebrovascular Diseases.

[51] Demaerschalk BM, Kiernan T-EJ. Vascular neurology nurse practitioner provision of telemedicine consultations. International Journal of Telemedicine and Applications.

[52] Meyer B et al. Prospective reliability of the STRokE DOC wireless/site independent telemedicine system. Neurology. 2005;**64**(6):1058-1060

[53] Gonzalez MA et al. Reliability of prehospital real-time cellular video phone in assessing the simplified National Institutes of Health Stroke Scale in patients with acute stroke: A novel telemedicine technology. Stroke.

[54] Demaerschalk BM et al. Reliability of real-time video smartphone for assessing National Institutes of Health Stroke Scale scores in acute stroke patients. Stroke. 2012;**43**(12):3271-3277

[55] Schwamm LH et al. A review of the evidence for the use of telemedicine within stroke systems of care: A scientific statement from the American Heart Association/ American Stroke Association. Stroke.

[56] Puetz V et al. Reliability of brain CT evaluation by stroke neurologists

2011;**42**(6):1522-1527

2009;**40**(7):2616-2634

2013;**80**(4):332-338

2012;**43**(11):3095-3097

in telemedicine. Neurology.

[57] Demaerschalk BM et al. CT interpretation in a telestroke

network: Agreement among a spoke radiologist, hub vascular neurologist, and hub neuroradiologist. Stroke.

2008;**17**(4):181-186

2010;**2010**

[42] LaMonte MP et al. Shortening time to stroke treatment using ambulance telemedicine: TeleBAT. Journal of Stroke and Cerebrovascular Diseases.

[43] Lippman JM et al. Mobile telestroke during ambulance transport is feasible in a rural EMS setting: The iTREAT Study. Telemedicine and e-Health.

Diseases. 2000;**9**(3):128-135

2004;**13**(4):148-154

2016;**22**(6):507-513

2017;**48**(2):493-496

[44] Liman TG et al. Telestroke ambulances in prehospital stroke management: Concept and pilot feasibility study. Stroke. 2012;**43**(8):2086-2090

[45] Wu T-C et al. Telemedicine can replace the neurologist on a mobile stroke unit. Stroke.

[46] Bowry R et al. Time to decision and treatment with tPA (tissuetype plasminogen activator) using telemedicine versus an onboard neurologist on a mobile stroke unit. Stroke. 2018;**49**(6):1528-1530

[47] Hacke W et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. The New England Journal of Medicine. 2008;**359**(13):1317-1329

[48] Wang S et al. Remote evaluation of acute ischemic stroke: Reliability of National Institutes of Health Stroke Scale via telestroke. Stroke.

[49] Handschu R et al. Telemedicine in emergency evaluation of acute stroke: Interrater agreement in remote video examination with a novel multimedia system. Stroke. 2003;**34**(12):2842-2846

2003;**34**(10):e188-e191

**76**

[58] Schwamm LH et al. Virtual TeleStroke support for the emergency department evaluation of acute stroke. Academic Emergency Medicine. 2004;**11**(11):1193-1197

[59] Wiborg A, Widder B. Teleneurology to improve stroke care in rural areas: The Telemedicine in Stroke in Swabia (TESS) Project. Stroke. 2003;**34**(12):2951-2956

[60] Hess DC et al. REACH: Clinical feasibility of a rural telestroke network. Stroke. 2005;**36**(9):2018-2020

[61] Wang S et al. Remote evaluation of acute ischemic stroke in rural community hospitals in Georgia. Stroke. 2004;**35**(7):1763-1768

[62] Joiner R et al. Abstract TP270: When telestroke programs work, bed size really doesn't matter. Stroke. 2019;**50**(Suppl\_1):ATP270

[63] Switzer JA et al. A web-based telestroke system facilitates rapid treatment of acute ischemic stroke patients in rural emergency departments. The Journal of Emergency Medicine. 2009;**36**(1):12-18

[64] Audebert HJ et al. Effects of the implementation of a telemedical stroke network: The Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany. The Lancet Neurology. 2006;**5**(9):742-748

[65] Demaerschalk BM et al. Cost utility of hub-and-spoke telestroke networks from societal perspective. The American Journal of Managed Care. 2013;**19**(12):976-985

[66] Nelson RE et al. The costeffectiveness of telestroke in the treatment of acute ischemic stroke. Neurology. 2011;**77**(17):1590-1598

[67] Switzer JA et al. Cost-effectiveness of hub-and-spoke telestroke networks

for the management of acute ischemic stroke from the hospitals' perspectives. Circulation. Cardiovascular Quality and Outcomes. 2013;**6**(1):18-26

[68] Nelson RE et al. The costeffectiveness of telestroke in the Pacific Northwest region of the USA. Journal of Telemedicine and Telecare. 2016;**22**(7):413-421

[69] Ehlers L et al. National use of thrombolysis with alteplase for acute ischaemic stroke via telemedicine in Denmark. CNS Drugs. 2008;**22**(1):73-81

[70] Evans A et al. Randomized controlled study of stroke unit care versus stroke team Care in Different Stroke Subtypes. Stroke. 2002;**33**(2):449-455

[71] Wang DZ et al. Treating acute stroke patients with intravenous tPA: The OSF stroke network experience. Stroke. 2000;**31**(1):77-81

[72] Wiborg A, Widder B. Teleneurology to improve stroke care in rural areas. Stroke. 2003;**34**(12):2951-2956

[73] Vespa PM et al. Intensive care unit robotic telepresence facilitates rapid physician response to unstable patients and decreased cost in neurointensive care. Surgical Neurology. 2007;**67**(4):331-337

[74] Klein KE et al. Teleneurocritical care and telestroke. Critical Care Clinics. 2015;**31**(2):197-224

[75] Laver KE et al. Telerehabilitation services for stroke. Cochrane Database of Systematic Reviews. 2013;**12**:1-41

[76] Chen J et al. Telerehabilitation approaches for stroke patients: Systematic review and meta-analysis of randomized controlled trials. Journal of Stroke and Cerebrovascular Diseases. 2015;**24**(12):2660-2668

[77] Blacquiere D et al. Canadian stroke best practice recommendations: Telestroke best practice guidelines update 2017. International Journal of Stroke. 2017;**12**(8):886-895

[78] Switzer JA et al. A telestroke network enhances recruitment into acute stroke clinical trials. Stroke. 2010;**41**(3):566-569

[79] Kramer NM, Demaerschalk BM. A novel application of teleneurology: Robotic telepresence in supervision of neurology trainees. Telemedicine and e-Health. 2014;**20**(12):1087-1092

[80] Jagolino AL et al. A call for formal telemedicine training during stroke fellowship. Neurology. 2016;**86**(19):1827-1833

[81] Richard S et al. Simulation training for emergency teams to manage acute ischemic stroke by telemedicine. Medicine. 2016;**95**(24):e3924

[82] Rafter RH, Kelly TM. Nursing implementation of a telestroke programme in a community hospital in the US. Journal of Nursing Management. 2011;**19**(2):193-200

[83] Zaidi SF et al. Telestroke-guided intravenous tissue-type plasminogen activator treatment achieves a similar clinical outcome as thrombolysis at a comprehensive stroke center. Stroke. 2011;**42**(11):3291-3293

[84] Huynh MNN et al. Abstract 173: Effect of a regional telestroke program on door-to-needle time and clinical outcomes. Stroke. 2019;**50**(Suppl\_1):A173

[85] Donabedian A. The quality of care: How can it be assessed? JAMA. 1988;**260**(12):1743-1748

[86] Schwamm LH et al. Get With the Guidelines—Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack. Circulation. 2009;**119**(1):107-115

[87] Yang JP et al. Targeting telestroke: Benchmarking time performance in telestroke consultations. Journal of Stroke and Cerebrovascular Diseases. 2013;**22**(4):470-475

[88] Meyer BC et al. Efficacy of siteindependent telemedicine in the STRokE DOC trial: A randomised, blinded, prospective study. The Lancet Neurology. 2008;**7**(9):787-795

[89] Amorim E et al. Impact of telemedicine implementation in thrombolytic use for acute ischemic stroke: The University of Pittsburgh Medical Center telestroke network experience. Journal of Stroke and Cerebrovascular Diseases. 2013;**22**(4):527-531

[90] Nalleballe K et al. Ideal telestroke time targets: Telestroke-based treatment times in the United States stroke belt. Journal of Telemedicine and Telecare. 2020;**26**(3):174-179

[91] Schwab S et al. Long-term outcome after thrombolysis in telemedical stroke care. Neurology. 2007;**69**(9):898-903

[92] Wechsler LR et al. Telemedicine quality and outcomes in stroke: A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017;**48**(1):e3-e25

[93] LaMonte MP et al. Telemedicine for acute stroke: Triumphs and pitfalls. Stroke. 2003;**34**(3):725-728

[94] Whitten P, Love B. Patient and provider satisfaction with the use of telemedicine: Overview and rationale for cautious enthusiasm. Journal of Postgraduate Medicine. 2005;**51**(4):294

**79**

*Telestroke: A New Paradigm*

DC: NQF; 2009:1-13

2013;**12**(6):585-596

2012;**34**(3):182-190

2005;**19**(2):96-101

2014;**3**(1):e000408

2020;**176**(5):316-324

*DOI: http://dx.doi.org/10.5772/intechopen.92831*

in rural areas: 10-year experience of the TeleMedical project for integrative stroke care. Stroke.

[105] Audebert HJ et al. Long-term effects of specialized stroke care with telemedicine support in community hospitals on behalf of the Telemedical Project for Integrative Stroke Care (TEMPiS). Stroke. 2009;**40**(3):902-908

[106] Hubert GJ et al. Recommendations on telestroke in Europe. European Stroke Journal. 2019;**4**(2):101-109

[107] Zhao G, Huang H, Yang F. The progress of telestroke in China. Stroke and Vascular Neurology.

[108] Sharma S et al. Telestroke in resource-poor developing country model. Neurology India. 2016;**64**(5):934

[109] Srivastava PV et al. Telestroke a viable option to improve stroke care in India. International Journal of Stroke.

[110] Imai T et al. Specific needs for telestroke networks for thrombolytic therapy in Japan. Journal of Stroke and Cerebrovascular Diseases.

[111] Ang SH, Tan C, Singh R. Telestroke: Rapid treatment of acute ischemic stroke patients using telemedicine in a Singapore emergency department. European Journal of Emergency Medicine. 2013;**20**(5):322-326

[112] Rho MJ, Choi IY, Lee J. Predictive

factors of telemedicine service acceptance and behavioral intention of physicians. International Journal of Medical Informatics. 2014;**83**(8):559-571

[113] Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease

2017;**2**(3):168-171

2014;**9**(SA100):133-134

2014;**23**(5):811-816

2014;**45**(9):2739-2744

[95] National Quality Forum (NQF) Stroke Prevention and Management. National Voluntary Consensus Standards for Stroke Prevention and Management across the Continuum of Care. A Consensus Report. Washington,

[96] Brown A et al. A pilot study validating video-based training on pre-hospital stroke recognition. Journal of Neurology, Neurosurgery, and Psychiatry Research. 2019;**1**(1):1-12

[97] Fassbender K et al. Streamlining of prehospital stroke management: The golden hour. The Lancet Neurology.

[98] Baldereschi M et al. Relevance of prehospital stroke code activation for acute treatment measures in stroke care: A review. Cerebrovascular Diseases.

[99] Belvís R et al. Benefits of a prehospital stroke code system. Cerebrovascular Diseases.

[100] Burton A. How do we fix the shortage of neurologists? The Lancet Neurology. 2018;**17**(6):502-503

[101] Agarwal S et al. Thrombolysis delivery by a regional telestroke network—Experience from the UK National Health Service. Journal of the American Heart Association.

[102] Sairanen T et al. Two years of Finnish telestroke: Thrombolysis at spokes equal to that at the hub. Neurology. 2011;**76**(13):1145-1152

[103] Ohannessian R et al. Acute telestroke in France: A systematic review. Revue Neurologique.

[104] Muller-Barna P et al. TeleStroke units serving as a model of care

### *Telestroke: A New Paradigm DOI: http://dx.doi.org/10.5772/intechopen.92831*

*Ischemic Stroke*

[77] Blacquiere D et al. Canadian stroke best practice recommendations: Telestroke best practice guidelines update 2017. International Journal of

with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack. Circulation. 2009;**119**(1):107-115

[87] Yang JP et al. Targeting telestroke: Benchmarking time performance in telestroke consultations. Journal of Stroke and Cerebrovascular Diseases.

[88] Meyer BC et al. Efficacy of siteindependent telemedicine in the STRokE DOC trial: A randomised, blinded, prospective study. The Lancet

Neurology. 2008;**7**(9):787-795

[89] Amorim E et al. Impact of telemedicine implementation in thrombolytic use for acute ischemic stroke: The University of Pittsburgh Medical Center telestroke network experience. Journal of Stroke and Cerebrovascular Diseases.

[90] Nalleballe K et al. Ideal telestroke time targets: Telestroke-based treatment times in the United States stroke belt. Journal of Telemedicine and Telecare.

[91] Schwab S et al. Long-term outcome after thrombolysis in telemedical stroke care. Neurology. 2007;**69**(9):898-903

[92] Wechsler LR et al. Telemedicine quality and outcomes in stroke: A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017;**48**(1):e3-e25

[93] LaMonte MP et al. Telemedicine for acute stroke: Triumphs and pitfalls.

[94] Whitten P, Love B. Patient and provider satisfaction with the use of telemedicine: Overview and rationale for cautious enthusiasm. Journal of Postgraduate Medicine. 2005;**51**(4):294

Stroke. 2003;**34**(3):725-728

2013;**22**(4):470-475

2013;**22**(4):527-531

2020;**26**(3):174-179

[78] Switzer JA et al. A telestroke network enhances recruitment into acute stroke clinical trials. Stroke.

[80] Jagolino AL et al. A call for formal telemedicine training during stroke fellowship. Neurology. 2016;**86**(19):1827-1833

[79] Kramer NM, Demaerschalk BM. A novel application of teleneurology: Robotic telepresence in supervision of neurology trainees. Telemedicine and e-Health. 2014;**20**(12):1087-1092

[81] Richard S et al. Simulation training for emergency teams to manage acute ischemic stroke by telemedicine. Medicine. 2016;**95**(24):e3924

[82] Rafter RH, Kelly TM. Nursing implementation of a telestroke programme in a community hospital

[83] Zaidi SF et al. Telestroke-guided intravenous tissue-type plasminogen activator treatment achieves a similar clinical outcome as thrombolysis at a comprehensive stroke center. Stroke.

in the US. Journal of Nursing Management. 2011;**19**(2):193-200

2011;**42**(11):3291-3293

[84] Huynh MNN et al. Abstract 173: Effect of a regional telestroke program on door-to-needle time and clinical outcomes. Stroke. 2019;**50**(Suppl\_1):A173

[85] Donabedian A. The quality of care: How can it be assessed? JAMA.

[86] Schwamm LH et al. Get With the Guidelines—Stroke is associated

1988;**260**(12):1743-1748

Stroke. 2017;**12**(8):886-895

2010;**41**(3):566-569

**78**

[95] National Quality Forum (NQF) Stroke Prevention and Management. National Voluntary Consensus Standards for Stroke Prevention and Management across the Continuum of Care. A Consensus Report. Washington, DC: NQF; 2009:1-13

[96] Brown A et al. A pilot study validating video-based training on pre-hospital stroke recognition. Journal of Neurology, Neurosurgery, and Psychiatry Research. 2019;**1**(1):1-12

[97] Fassbender K et al. Streamlining of prehospital stroke management: The golden hour. The Lancet Neurology. 2013;**12**(6):585-596

[98] Baldereschi M et al. Relevance of prehospital stroke code activation for acute treatment measures in stroke care: A review. Cerebrovascular Diseases. 2012;**34**(3):182-190

[99] Belvís R et al. Benefits of a prehospital stroke code system. Cerebrovascular Diseases. 2005;**19**(2):96-101

[100] Burton A. How do we fix the shortage of neurologists? The Lancet Neurology. 2018;**17**(6):502-503

[101] Agarwal S et al. Thrombolysis delivery by a regional telestroke network—Experience from the UK National Health Service. Journal of the American Heart Association. 2014;**3**(1):e000408

[102] Sairanen T et al. Two years of Finnish telestroke: Thrombolysis at spokes equal to that at the hub. Neurology. 2011;**76**(13):1145-1152

[103] Ohannessian R et al. Acute telestroke in France: A systematic review. Revue Neurologique. 2020;**176**(5):316-324

[104] Muller-Barna P et al. TeleStroke units serving as a model of care

in rural areas: 10-year experience of the TeleMedical project for integrative stroke care. Stroke. 2014;**45**(9):2739-2744

[105] Audebert HJ et al. Long-term effects of specialized stroke care with telemedicine support in community hospitals on behalf of the Telemedical Project for Integrative Stroke Care (TEMPiS). Stroke. 2009;**40**(3):902-908

[106] Hubert GJ et al. Recommendations on telestroke in Europe. European Stroke Journal. 2019;**4**(2):101-109

[107] Zhao G, Huang H, Yang F. The progress of telestroke in China. Stroke and Vascular Neurology. 2017;**2**(3):168-171

[108] Sharma S et al. Telestroke in resource-poor developing country model. Neurology India. 2016;**64**(5):934

[109] Srivastava PV et al. Telestroke a viable option to improve stroke care in India. International Journal of Stroke. 2014;**9**(SA100):133-134

[110] Imai T et al. Specific needs for telestroke networks for thrombolytic therapy in Japan. Journal of Stroke and Cerebrovascular Diseases. 2014;**23**(5):811-816

[111] Ang SH, Tan C, Singh R. Telestroke: Rapid treatment of acute ischemic stroke patients using telemedicine in a Singapore emergency department. European Journal of Emergency Medicine. 2013;**20**(5):322-326

[112] Rho MJ, Choi IY, Lee J. Predictive factors of telemedicine service acceptance and behavioral intention of physicians. International Journal of Medical Informatics. 2014;**83**(8):559-571

[113] Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020;**323**(13):1329-1242

[114] Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed. 2020;**91**(1):157-160

[115] Characteristics of Health Care Personnel with COVID-19—United States, February 12–April 9, 2020. Available from: https://www.cdc.gov/ mmwr/volumes/69/wr/mm6915e6. htm?s\_cid=mm6915e6\_x [Accessed: 16 April 2020]

[116] Klok F et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thrombosis Research. 2020;**191**:145-147

[117] Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. The New England Journal of Medicine. 2020;**382**(18):1679-1681

[118] Klein BC, Busis NA. COVID-19 is catalyzing the adoption of teleneurology. Neurology. 2020;**94**(21):903-904

[119] Reider-Demer M et al. Tele neurology-cost effective and convenient (1205). AAN Enterprises. Science Highlight Virtual Presentations. Cerebrovascular Disease and Interventional Neurology; 2020

[120] Trevino A et al. Inpatient teleneurology follow-up has similar outcomes to in-person neurology and provides an alternative to transfer (1861). AAN Enterprises. Science Highlight Virtual Presentations. Cerebrovascular Disease and Interventional Neurology; 2020

[121] Aita MC et al. Obstacles and solutions in the implementation of telestroke: Billing, licensing, and legislation. Stroke. 2013;**44**(12):3602-3606

[122] Weinstein RS et al. Telemedicine, telehealth, and mobile health applications that work: Opportunities and barriers. The American Journal of Medicine. 2014;**127**(3):183-187

[123] Akbik F et al. Telestroke—The promise and the challenge. Part two—Expansion and horizons. Journal of Neurointerventional Surgery. 2017;**9**(4):361-365

[124] Audebert HJ, Schwamm L. Telestroke: Scientific results. Cerebrovascular Diseases. 2009;**27**(Suppl 4):15-20

[125] Cho S et al. An analysis of business issues in a telestroke project. Journal of Telemedicine and Telecare. 2007;**13**(5):257-262

[126] De Bustos EM, Moulin T, Audebert HJ. Barriers, legal issues, limitations and ongoing questions in telemedicine applied to stroke. Cerebrovascular Diseases. 2009;**27**(Suppl. 4):36-39

[127] Rogove HJ et al. Barriers to telemedicine: Survey of current users in acute care units. Telemedicine and e-Health. 2012;**18**(1):48-53

[128] Switzer JA, Demaerschalk BM. Overcoming challenges to sustain a telestroke network. Journal of Stroke and Cerebrovascular Diseases. 2012;**21**(7):535-540

[129] Joint Commission on Accreditation of Healthcare Organizations. Joint Commission realigns telemedicine requirements with CMS changes. Joint Commission Perspectives. 2011;**31**(10):6

[130] Schwamm LH et al. Recommendations for the implementation of telemedicine within stroke systems of care: A policy statement from the American Heart Association. Stroke. 2009;**40**(7):2635-2660

**81**

*Telestroke: A New Paradigm*

2018;**49**(3):e46-e99

(IJHISI). 2014;**9**(1):42-60

*DOI: http://dx.doi.org/10.5772/intechopen.92831*

[131] Powers WJ et al. 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke.

[132] Kamoun F, Nicho M. Human and organizational factors of healthcare data breaches: The swiss cheese model of data breach causation and prevention. International Journal of Healthcare Information Systems and Informatics

[133] Bai G, Jiang JX, Flasher R. Hospital risk of data breaches. JAMA Internal Medicine. 2017;**177**(6):878-880

*Telestroke: A New Paradigm DOI: http://dx.doi.org/10.5772/intechopen.92831*

*Ischemic Stroke*

April 2020]

2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA.

[122] Weinstein RS et al. Telemedicine,

applications that work: Opportunities and barriers. The American Journal of

[123] Akbik F et al. Telestroke—The promise and the challenge. Part two—Expansion and horizons. Journal of Neurointerventional Surgery.

[124] Audebert HJ, Schwamm L. Telestroke: Scientific results. Cerebrovascular Diseases. 2009;**27**(Suppl 4):15-20

[125] Cho S et al. An analysis of business issues in a telestroke project. Journal of Telemedicine and Telecare.

[126] De Bustos EM, Moulin T, Audebert HJ. Barriers, legal issues, limitations and ongoing questions in telemedicine applied to stroke. Cerebrovascular Diseases. 2009;**27**(Suppl. 4):36-39

[127] Rogove HJ et al. Barriers to telemedicine: Survey of current users in acute care units. Telemedicine and

[128] Switzer JA, Demaerschalk BM. Overcoming challenges to sustain a telestroke network. Journal of Stroke and Cerebrovascular Diseases.

[129] Joint Commission on Accreditation of Healthcare Organizations. Joint Commission realigns telemedicine requirements with CMS changes. Joint Commission Perspectives. 2011;**31**(10):6

American Heart Association. Stroke.

e-Health. 2012;**18**(1):48-53

2012;**21**(7):535-540

[130] Schwamm LH et al. Recommendations for the implementation of telemedicine within stroke systems of care: A policy statement from the

2009;**40**(7):2635-2660

telehealth, and mobile health

Medicine. 2014;**127**(3):183-187

2017;**9**(4):361-365

2007;**13**(5):257-262

[114] Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta

[115] Characteristics of Health Care Personnel with COVID-19—United States, February 12–April 9, 2020. Available from: https://www.cdc.gov/ mmwr/volumes/69/wr/mm6915e6. htm?s\_cid=mm6915e6\_x [Accessed: 16

2020;**323**(13):1329-1242

Biomed. 2020;**91**(1):157-160

[116] Klok F et al. Incidence of

2020;**382**(18):1679-1681

2020;**94**(21):903-904

thrombotic complications in critically ill ICU patients with COVID-19. Thrombosis Research. 2020;**191**:145-147

[117] Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. The New England Journal of Medicine.

[118] Klein BC, Busis NA. COVID-19 is catalyzing the adoption of teleneurology. Neurology.

[119] Reider-Demer M et al. Tele

[120] Trevino A et al. Inpatient teleneurology follow-up has similar outcomes to in-person neurology and provides an alternative to transfer (1861). AAN Enterprises. Science Highlight Virtual Presentations. Cerebrovascular Disease and Interventional Neurology; 2020

[121] Aita MC et al. Obstacles and solutions in the implementation of telestroke: Billing, licensing,

and legislation. Stroke. 2013;**44**(12):3602-3606

neurology-cost effective and convenient (1205). AAN Enterprises. Science Highlight Virtual Presentations. Cerebrovascular Disease and Interventional Neurology; 2020

**80**

[131] Powers WJ et al. 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2018;**49**(3):e46-e99

[132] Kamoun F, Nicho M. Human and organizational factors of healthcare data breaches: The swiss cheese model of data breach causation and prevention. International Journal of Healthcare Information Systems and Informatics (IJHISI). 2014;**9**(1):42-60

[133] Bai G, Jiang JX, Flasher R. Hospital risk of data breaches. JAMA Internal Medicine. 2017;**177**(6):878-880

Section 2

Treatment of Ischemic Stroke

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Section 2
