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How Smart Is Your Smartphone? Smart Enough to Assess Stroke in Rural Areas, Study Finds


> are being studied increasingly for use in telemedicine networks.

NEW ORLEANS—Stroke patients in rural settings may benefit from specialty care with guidance from a vascular neurologist using the iPhone 4, according to a preliminary study presented at the 2012 AAN annual meeting here in April. [Other types of mobile devices are being tested for similar functions, but this study only focused on the iPhone 4.]

Studies have shown that stroke patients treated in rural hospitals are at increased risk of stroke-related morbidity and mortality because they are not likely to receive specialized care or intravenous (IV) tissue plasminogen activator (tPA) for acute treatment in those hospitals, explained poster author Eric Anderson, MD, PhD, a third-year resident at Emory University in Atlanta, GA. “Other studies have recently shown that IV tPA use is increased with use of teleneurology,” he added.

Current technology for telemedicine — which is recommended by the American Heart Association and American Stroke Association guidelines — traditionally involves a dedicated computer setup with separate video and audio equipment, often with proprietary web software set up for interfaces.

“Unfortunately, these telemedicine strategies are very expensive and often unaffordable in areas where they are needed most,” Dr. Anderson continued. Estimates for these strategies can run from tens to hundreds of thousands of dollars.

By contrast, the iPhone and other mobile “smartphones” are much less expensive, making it possible for a doctor in a remote or rural area to hook up with a vascular neurologist at a hub stroke center, he said.


To test the feasibility of using the mobile phone for stroke diagnosis and management, Dr. Anderson and colleagues studied 20 consecutive patients treated at Grady Memorial Hospital in Atlanta. All 20 patients presented to the Emergency Department with stroke symptoms and were diagnosed with stroke by conventional means by an on-site neurologist using the National Institute of Health Stroke Scale (NIHSS).


said the study demonstrates “proof of concept” that mobile smartphones could offer an “economical mobile solution for assessing stroke patients remotely with high fidelity and can be incorporated into a telestroke network.”

After gaining informed consent for the pilot study, all 20 patients were evaluated again by an on-site neurologist at the bedside (blinded to the original NIHSS), who gave each patient an NIHSS score for stroke severity. The on-site neurologist using the mobile phone then contacted a remote neurologist from the same healthcare system to initiate a session, where they could see other on screen. The remote neurologist (who was blinded to the NIHSS score identified by the on-site neurologist) directed the on-site neurologist to conduct the same exam and determined his or her own NIHSS score for stroke severity.

The two NIHSS scores for each patient were then compared for reliability. “Inter-rater reliability was in excellent agreement for 10 items on the NIHSS, moderate agreement for three items, and in poor agreement for only one item [ataxia], which is consistent with prior studies,” Dr. Anderson said.

The study demonstrates “proof of concept” that mobile smartphones could offer an “economical mobile solution for assessing stroke patients remotely with high fidelity and can be incorporated into a telestroke network,” Dr. Anderson said.

“Traditionally, the vascular neurologist uses the NIHSS at the bedside to diagnose stroke and stroke severity and implement management. Our study showed that doing this using the mobile phone is as effective as doing it at the bedside.”

Dr. Anderson and his colleagues are also doing preliminary studies using the smar phone to evaluate remotely other neurological conditions, including epilepsy and movement disorders. Thus far, preliminary experience is encouraging.


In general, telestroke has been successful in providing stroke expertise to areas where it is not available on site, explained Lawrence Wechsler, MD, chair of the department of neurology and vice-president of telemedicine at University of Pittsburgh Medical Center. But videoconferencing is expensive for small rural hospitals, where this solution is needed the most, he said.

“The study by Anderson and colleagues is a good example of how we can leverage existing technology to deliver acute stroke care to small rural hospitals where cost is a significant issue. The authors have shown that the smartphone can be used to determine the NIHSS in a patient with acute stroke reliably with a simple inexpensive technology, and this study is a step forward,” Dr. Wechsler said.

The NIHSS is only one component of stroke evaluation, he noted, pointing out that the mobile smartphone may not be the ideal technology for other components of stroke evaluation that may require a more robust two-way interactive process, including obtaining history from the patient or family and reviewing the informed consent process.