***TASK*** the task is to summarize an input biomedical literature in six sentences 
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    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: BACKGROUND AND PURPOSE Telemedicine can disseminate vascular neurology expertise and optimize recombinant tissue plasminogen activator ( rt-PA ) use for acute ischemic stroke in rural underserved communities . The purpose of this study was to prospect ively assess whether telemedicine or telephone was superior for decision-making . METHODS The study design is a pooled analysis of two identically design ed r and omized controlled trials conducted in a multistate hub and spoke telestroke network setting with acute stroke syndrome patients , comparing telemedicine versus telephone-only consultations . From each trial , common data elements were pooled to assess , principally , for correctness of thrombolysis decision-making . Secondary outcomes included rt-PA use rate , 90-day functional outcome , post-thrombolysis intracranial hemorrhage , and data completeness . RESULTS Two hundred seventy-six pooled patients were evaluated .  Correct thrombolysis eligibility decisions were made more often with telemedicine ( 96 % telemedicine , 83 % telephone ; odds ratio [ OR ] 4.2 ; 95 % confidence interval [ CI ] 1.69 - 10.46 ; p=0.002 ) . Intravenous rt-PA usage was 26 % ( 29 % telemedicine , 24 % telephone ; OR 1.27 ; 95 % CI 0.71 - 2.25 ; p=0.41 ) . Ninety-day outcomes were not different for Barthel Index , modified Rankin Scale , or mortality . There was no difference in post-thrombolysis intracranial hemorrhage ( 8 % telemedicine , 6 % telephone ; p>0.999 ) . CONCLUSIONS This pooled analysis supports the hypothesis that stroke telemedicine consultations , compared with telephone-only , result in more accurate decision-making . Together with high rt-PA utilization rate , low post-rt-PA intracranial hemorrhage rate , and acceptable patient outcome , the results confirm that telemedicine is a viable consultative tool for acute stroke . The replication of the hub and spoke network infrastructure supports the generalizability of telemedicine when used in broader setting Background and Purpose — Telestroke networks offer an opportunity to increase tissue-type plasminogen activator use in community hospitals . Methods — We compared 83 patients treated with intravenous tissue-type plasminogen activator by telestroke to 59 patients treated after in-person evaluation by the same neurologists at a tertiary care stroke center . Onset and door-to-treatment times and functional outcome at 90 days were obtained prospect ively . Favorable outcome was defined as modified Rankin Scale score ⩽2 . Results — Favorable outcome rates were comparable between the groups ( 42.1 % versus 37.5 % , P=0.7 ) . There was no significant difference in the rate of symptomatic hemorrhage . Conclusions — Telestroke is a viable alternative to in-person evaluation when stroke expertise is not readily available BACKGROUND Intravenous thrombolysis with alteplase is the only approved treatment for acute ischemic stroke , but its efficacy and safety when administered more than 3 hours after the onset of symptoms have not been established . We tested the efficacy and safety of alteplase administered between 3 and 4.5 hours after the onset of a stroke . METHODS After exclusion of patients with a brain hemorrhage or major infa rct ion , as detected on a computed tomographic scan , we r and omly assigned patients with acute ischemic stroke in a 1:1 double-blind fashion to receive treatment with intravenous alteplase ( 0.9 mg per kilogram of body weight ) or placebo . The primary end point was disability at 90 days , dichotomized as a favorable outcome ( a score of 0 or 1 on the modified Rankin scale , which has a range of 0 to 6 , with 0 indicating no symptoms at all and 6 indicating death ) or an unfavorable outcome ( a score of 2 to 6 on the modified Rankin scale ) . The secondary end point was a global outcome analysis of four neurologic and disability scores combined . Safety end points included death , symptomatic intracranial hemorrhage , and other serious adverse events . RESULTS We enrolled a total of 821 patients in the study and r and omly assigned 418 to the alteplase group and 403 to the placebo group . The median time for the administration of alteplase was 3 hours 59 minutes . More patients had a favorable outcome with alteplase than with placebo ( 52.4 % vs. 45.2 % ; odds ratio , 1.34 ; 95 % confidence interval [ CI ] , 1.02 to 1.76 ; P=0.04 ) . In the global analysis , the outcome was also improved with alteplase as compared with placebo ( odds ratio , 1.28 ; 95 % CI , 1.00 to 1.65 ; P<0.05 ) . The incidence of intracranial hemorrhage was higher with alteplase than with placebo ( for any intracranial hemorrhage , 27.0 % vs. 17.6 % ; P=0.001 ; for symptomatic intracranial hemorrhage , 2.4 % vs. 0.2 % ; P=0.008 ) . Mortality did not differ significantly between the alteplase and placebo groups ( 7.7 % and 8.4 % , respectively ; P=0.68 ) . There was no significant difference in the rate of other serious adverse events . CONCLUSIONS As compared with placebo , intravenous alteplase administered between 3 and 4.5 hours after the onset of symptoms significantly improved clinical outcomes in patients with acute ischemic stroke ; alteplase was more frequently associated with symptomatic intracranial hemorrhage . ( Clinical Trials.gov number , NCT00153036 . Background : IV thrombolysis represents the most effective acute stroke therapy . However , it is almost exclusively performed in stroke centers and is not available in most community areas . The Telemedical Pilot Project for Integrative Stroke Care ( TEMPiS ) was started in February 2003 . Twelve community hospitals with no or very limited stroke thrombolysis experience and two stroke centers were connected via a network providing online neurologic examination and transfer of neuroradiologic scans . Following recently published preliminary results on acute phase safety of telethrombolysis , the present study reports on its long-term functional outcome . Methods : Modified Rankin Scale ( mRS ) , Barthel Index ( BI ) , and mortality rate were prospect ively collected 3 and 6 months after IV thrombolysis in patients of community network hospitals ( telemedical group ) and the stroke centers . Values of 95/100 for the BI and 0/1 for the mRS were defined as a favorable outcome . Results : Over the first 22 months , 170 patients were treated with tPA in the telemedical hospitals and 132 in the stroke center hospitals .  Mortality rates were 11.2 % vs 11.5 % at 3 months ( p = 0.55 ) and 14.2 % vs 13 % at 6 months ( p = 0.45 ) . A good functional outcome after 6 months was found in 39.5 % of the telemedical hospitals vs 30.9 % of the stroke centers ( p = 0.10 ) for the mRS and 47.1 % vs 44.8 % ( p = 0.44 ) regarding the BI . Conclusions : Mortality rates and functional outcomes for telemedicine-linked community hospitals and stroke centers were similar and comparable to the results from r and omized trials Background and Purpose — Telemedicine techniques can be used to address the rural – metropolitan disparity in acute stroke care . The Stroke Team Remote Evaluation Using a Digital Observation Camera ( STRokE DOC ) trial reported more accurate decision making for telemedicine consultations compared with telephone-only and that the California-based research network facilitated a high rate of thrombolysis use , improved data collection , low risk of complications , low technical complications , and favorable assessment times . The main objective of the STRokE DOC Arizona TIME ( The Initial Mayo Clinic Experience ) trial was to determine the feasibility of establishing , de novo , a single-hub , multirural spoke hospital telestroke research network across a large geographical area in Arizona by replicating the STRokE DOC protocol . Methods — Methods included prospect i ve , single-hub , 2-spoke , r and omized , blinded , controlled trial of a 2-way , site-independent , audiovisual telemedicine system design ed for remote examination of adult patients with acute stroke versus telephone consultation to assess eligibility for treatment with intravenous thrombolysis .  The primary outcome measure was whether the decision to give thrombolysis was correct . Secondary outcomes were rate of thrombolytic use , 90-day functional outcomes , incidence of intracerebral hemorrhages , and technical observations . Results — From December 2007 to October 2008 , 54 patients were assessed , 27 of whom were r and omized to each arm . Mean National Institutes of Health Stroke Scale score at presentation was 7.3 ( SD 6.2 ) points . No consultations were aborted ; however , technical problems ( 74 % ) were prevalent in the telemedicine arm . Overall , the correct treatment decision was established in 87 % of the consultations . Both modalities , telephone ( 89 % correct ) and telemedicine ( 85 % correct ) , performed well . Intravenous thrombolytic treatment was used in 30 % of the telemedicine and telephone consultations . Good functional outcomes at 90 days were not significantly different . There were no statistically significant differences in mortality ( 4 % in telemedicine and 11 % in telephone ) or rates of intracerebral hemorrhage ( 4 % in telemedicine and 0 % in telephone ) . Conclusions — It is feasible to extend the original STRokE DOC trial protocol to a new state and establish an operational single-hub , multispoke rural hospital telestroke research network in Arizona . The trial was not design ed to have sufficient power to detect a difference between the 2 consultative modes : telemedicine and telephone-only . Whether by telemedicine or telephone consultative modalities , there were appropriate treatment decisions , high rates of thrombolysis use , improved data collection , low rates of intracerebral hemorrhage , and equally favorable time requirements . The learning curve was steep for the hub and spoke personnel of the new telestroke network , as reflected by frequent technical problems . Overall , the results support the effectiveness of highly organized and structured stroke telemedicine networks for extending expert stroke care into rural remote communities lacking sufficient neurological expertise Background and Purpose — Systemic thrombolysis is the only therapy proven to be effective for ischemic stroke .  Telemedicine may help to extend its use . However , concerns remain whether management and safety of  tissue plasminogen activator ( tPA ) administration after telemedical consultation are equivalent in less experienced hospitals compared with tPA administration in academic stroke centers . Methods — During the second year of the ongoing Telemedical Pilot Project for Integrative Stroke Care , all systemic thrombolyses in stroke patients of the 12 regional clinics and the 2 stroke centers were recorded prospect ively .  Patients ’ demographics , stroke severity ( National Institutes of Health Stroke Scale ) , frequency of administration , time management , protocol violations , and safety were included in the analysis . Results — In 2004 , 115 of 4727 stroke or transient ischemic attack patients ( 2.4 % ) in the community hospitals and 110 of 1889 patients in the stroke centers ( 5.8 % ) received systemic thrombolysis .  Prehospital latencies were shorter in the regional hospitals despite longer distances . Door to needle times were shorter in the stroke centers . Although blood pressure was controlled more strictly in community hospitals , symptomatic intracerebral hemorrhage rate ( 7.8 % ) was higher ( P=0.14 ) than in stroke centers ( 2.7 % ) but still within the range of the National Institute of Neurological Disorders and Stroke trial . In-hospital mortality rate was low in community hospitals ( 3.5 % ) and in stroke centers ( 4.5 % ) . Conclusions — Although with a lower rate of systemic thrombolysis , there was no evidence of lower treatment quality in the remote hospitals . With increasing numbers of tPA administration and growing training effects , the telestroke concept promises better coverage of systemic thrombolysis in nonurban areas Background and Purpose — In acute stroke care , rapid but careful evaluation of patients is m and atory but requires an experienced stroke neurologist . Telemedicine offers the possibility of bringing such expertise quickly to more patients . This study tested for the first time whether remote video examination is feasible and reliable when applied in emergency stroke care using the National Institutes of Health Stroke Scale ( NIHSS ) . Methods — We used a novel multimedia telesupport system for transfer of real-time video sequences and audio data . The remote examiner could direct the set-top camera and zoom from distant overviews to close-ups from the personal computer in his office . Acute stroke patients admitted to our stroke unit were examined on admission in the emergency room . St and ardized examination was performed by use of the NIHSS ( German version ) via telemedicine and compared with bedside application . Results — In this pilot study , 41 patients were examined .  Total examination time was 11.4 minutes on average ( range , 8 to 18 minutes ) . None of the examinations had to be stopped or interrupted for technical reasons , although minor problems ( brightness , audio quality ) with influence on the examination process occurred in 2 sessions . Unweighted & kgr ; coefficients ranged from 0.44 to 0.89 ; weight 
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Conclusions : Our findings indicate that IV tPA delivery through telestroke networks is safe and effective in the 3-hour time window .