This document analyzes 352 cases of non-stroke neurological conditions evaluated using a telestroke network in Germany. The key findings were: 1) The diagnosis was changed in 48.9% of non-stroke cases after an in-person exam, compared to 12.5% of stroke cases, indicating lower diagnostic accuracy for non-stroke conditions via telemedicine. 2) Teleconsultations for non-stroke conditions took longer on average (26.5 minutes vs 14.3 minutes for stroke). 3) The neurological exam had to be expanded beyond standard stroke scales for most non-stroke cases. 4) Experience from telestroke services may not directly transfer to other neurological conditions which require different evaluation protocols.

1. ORIGINAL COMMUNICATION
Use of a telestroke service for evaluation of non-stroke
neurological cases
Rene´ Handschu1,2 • Angela Wacker2 • Mateusz Scibor2 • Camelia Sancu3 •
Stefan Schwab2 • Frank Erbguth4 • Patrick Oschmann5 • David Stark2 •
Lars Marquardt2
Received: 13 February 2015 / Revised: 4 March 2015 / Accepted: 5 March 2015 / Published online: 21 March 2015
Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Telemedicine is a growing field in many med-
ical specialties. Within clinical neurosciences one of its
largest applications is in acute stroke care. However, little
is known about its value and effect in general neurology,
despite stroke. In a retrospective survey of 1500 telecon-
sultations over a time period of 12 months from October
2008 to September 2009, from a large telestroke network in
Germany, we evaluated 352 cases with a non-stroke diag-
nosis. Duration and methods of teleconsultation as well as
neurological consultations at bedside and discharge diag-
nosis were analyzed and compared to stroke cases. Dis-
charge diagnosis was not identical to teleconsultation
diagnosis in 48.9 % of all non-stroke cases compared to
12.5 % of all stroke cases. Duration of teleconsultation was
26.5 min in non-stroke cases compared to 14.3 min for
stroke cases. In non-stroke cases other parts of the neuro-
logical examination were added to the pure administration
of a stroke scale. There were no significant differences
between non-stroke cases with correct and incorrect con-
sultation diagnoses concerning in-hospital mortality (4.6
vs. 5.0 %) and length of hospital stay (8.3 vs. 7.6 days).
We conclude that diagnostic accuracy and protocol routine
is not as exact in non-stroke cases compared to acute stroke
cases. Other neurologic conditions may need different al-
gorithms for a telemedicine service. Thus experience from
a telestroke service cannot be transferred to other neuro-
logic conditions on a routine basis.
Keywords Telemedicine Á Teleneurology Á Clinical
neurology Á Clinical examination Á Teleconsultation Á
Stroke network
Introduction
Telemedicine is a growing field in many medical spe-
cialties such as radiology or cardiology. First reports of
using telemedicine in neurology date back in the early
1990s about initial attempts of applying it in the care of
patients with Parkinson’s disease [1]. Videoconferencing
was used for advising general practitioners by neurologists
of a university hospital [2]. Today comments and reviews
of ‘‘teleneurology’’ already exist reporting even routine use
[3, 4], but only few original scientific studies are published
exploring telemedical care in general neurology [5–7].
Thus little is known about the validity and reliability of
telemedicine for general neurological care.
The most expanding field of telemedicine within
clinical neurosciences is acute stroke care. From the first
study of Shafqat et al. [8] as early as 1999 feasibility
and reliability of guiding therapy after remote examina-
tion of stroke patients by audiovisual connection is now
well established [8–10], especially for facilitating ad-
ministration of thrombolysis [11, 12]. Accordingly large
hospital networks were created in Europe and North
America with specialists on duty for telemedical
& Rene´ Handschu
rene.handschu@klnikum.neumarkt.de
1
Department of Neurology, Klinikum Neumarkt, Nu¨rnberger
Str. 12, 92318 Neumarkt, Germany
2
STENO Coordinating Office, Department of Neurology,
Universita¨tsklinikum Erlangen, Erlangen, Germany
3
Department of Internal Medicine, Klinikum Kulmbach,
Kulmbach, Germany
4
Department of Neurology, Klinikum Nu¨rnberg, Nu¨rnberg,
Germany
5
Department of Neurology, Klinikum Bayreuth, Bayreuth,
Germany
123
J Neurol (2015) 262:1266–1270
DOI 10.1007/s00415-015-7702-y

2. assistance 24 h 7 days a week. Theoretically these spe-
cialists could assist also in other neurological diseases,
but currently there is no adequate framework for to
utilize a telestroke service therefore. However, within
existing telestroke services patients with other neurologic
conditions are already seen by telemedical consultation,
whether they suffer from stroke mimics or are presented
by the spoke hospital alienating the telestroke service.
Thus there is no systematic information if these tele-
medical consultations produce the same results than that
reported from telestroke networks. To explore the value
of a telestroke service in general neurology, we con-
ducted an analysis of such cases within a well estab-
lished stroke care network.
Methods
The Stroke Care Network using Telemedicine in Northern
Bavaria (STENO) is one of the world’s largest telemedical
stroke care networks. It consists of three tertiary stroke
centers at Erlangen University Hospital as well as
Nuremberg and Bayreuth City General Hospital and at the
time of this study 11 local or regional hospitals serving as
primary and secondary care facilities in the German state of
Bavaria, caring for about 4,500 acute stroke patients per
year. The network was initiated in 2007/2008 based on a
preceding pilot study [13]. STENO is fully reimbursed by
the Bavarian state government and the German health in-
surance system. Local hospitals are district hospitals re-
sponsible for primary and comprehensive care primarily in
the fields of general medicine and surgery. They differ in
size, ranging from about 180 to 450 beds. In ten hospitals,
the departments of internal medicine were responsible for
treatment of stroke, while in one there was a staff neu-
rologist available. All hospitals have a consulting neu-
rologist on demand at least once weekly. Telemedicine
service is provided on a 24/7 basis by live audiovisual
communication. Remote clinical examination is based on
National Institutes of Health Stroke Scale (NIHSS) that is
adopted to the needs of telemedicine and is provided by
experienced neurologists. Details of STENO methodology
are described elsewhere [14].
The cases were analyzed over a time period of
12 months from October 2008 to September 2009, after the
initiation period when teleconsultation service was fully
operated. Every teleconsultation case that was requested
for a non-stroke diagnosis or at least a non-stroke differ-
ential diagnosis was included. We analyzed neurological
examination, the (tele-)consultant’s diagnosis, the dis-
charge diagnosis as well as the therapeutic recommenda-
tions. In cases with a second neurological consultation at
bedside, this was also included in the analysis. It should be
noted that the distinction between stroke and non-stroke
cases for further analysis is determined by teleconsultation
diagnoses.
Statistical analysis was done by two-tailed t tests for
continuous variables and by Chi-square tests for catego-
rical variables.
Results
Out of 1500 teleconsultations with full-scale audiovisual
remote examination, there were 352 cases with a non-
stroke diagnosis (23.5 %). The mean age of patients was
69.8 years (19–88 years) 51.2 % were male. In 128 of
these cases there was a non-stroke diagnosis suspected
even before consultation (36.4 %). Only in 228 out of these
cases (64.8 %) a clear diagnosis could be given after
consultation. Frequency of diagnosis documented by tele-
consultants is shown in Fig. 1, consultation and discharge
diagnoses of stroke and non-stroke cases are listed in
Table 1. In 212 (60.2 %) cases therapeutic recommenda-
tions were possible. In 172 cases (48.9 %) consultation
diagnosis and discharge diagnosis were not identical,
compared to 12.5 % in all stroke cases. In 81.3 % of all
352 non-stroke teleconsultations cases other parts of the
neurological examination were added to the standard set
based on the NIHSS such as: deep tendon reflexes, gait
Non stroke Diagnoses in Teleconsultation (n = 352 / 100%)
59, / 16,7%
48/ 13,6%
6/ 1,7%
31/ 8.8%
19/ 5.3%26 / 7.4%
39/ 11.0%
124 / 35,5%
Seizure
Inflammatory
peripheral nerve
cranial nerve
Vertigo
other neurological
non-neurological
unclear
Fig. 1 Distribution of
diagnostic categories in all non-
stroke teleconsultation
diagnoses
J Neurol (2015) 262:1266–1270 1267
123

3. analysis, Babinski sign, rapid alternating movements (di-
adochokinesia) or Romberg’s test. In 105 cases a bedside
neurological consultation was provided after the telecon-
sultation (time delay teleconsultation—bedside consulta-
tion 29.3 h, range 4–65 h.). Initial diagnosis was upheld in
62.8 % of the non-stroke cases, compared to 90.8 % of 261
stroke cases receiving bedside neurological exam
(p 0.05). Figure 2 displays the number of correct and
incorrect diagnoses in stroke and non-stroke cases when
comparing telemedical and bedside neurological consulta-
tion. There was no difference in in-hospital mortality be-
tween non-stroke cases with correct or incorrect diagnosis
(4.6 vs. 5.0 %), but length of hospital stay (LOS) was
slightly longer in incorrect (8.3 days) than in correctly
diagnosed cases (7.6 days, p = 0.56). For all stroke cases
mortality rate was 6.7 % and mean LOS was 8.1 days.
Table 1 Distribution of
teleconsultation diagnosis and
discharge diagnosis for stroke
and non-stroke cases (stroke vs.
non-stroke is determined by
consultation diagnosis) and
percentage of correct
teleconsultation diagnosis in
each diagnostic category
Teleconsultation diagnosis Discharge diagnosis
n/% (n/% incorrect) n/%
Non-stroke cases n = 352, mean age 69.8 years, male 51.2 %
Seizure 59/16.8 (17/28.8) 72/20.5
Inflammatory 48/13.6 (17/35.4) 67/19.0
Peripheral nerve/spinal cord 6/1.7 (2/33.3) 16/4.5
Cranial nerve 31/8.8 (10/32.3) 39/11.1
Vertigo 20/5.7 (6/30.0) 17/4.8
Other neurological (non-stroke) 25/7.1 (8/32.0) 46/13.1
Non-neurological 39/11.1 (17/43.6) 42/11.9
Unclear 124/35.2 (95/76.6) 41/11.6
Stroke 12/3.4
Teleconsultation diagnosis Discharge diagnosis
n/% n/%
Stroke cases n = 1148, mean age 74.8 years, male 48.8 %
Cerebral ischemia 721/62.8 630/54.9
Transient ischemic attack 285/24.8 308/26.8
Intracerebral hemorrhage 121/10.5 121/10.5
Subarachnoid hemorrhage 22/1.9 21/1.8
Non-stroke neurological 49/4.3
Other non-stroke 19/1.7
Change of diagnosis: Teleconsultation => Bedside consultation
Diagn.changed
Diagn. changed
Diagn. Identicall
62.8%
Diagn. Identicall
90.8%
0
50
100
150
200
250
300
non stroke stroke
No.ofcases
Fig. 2 Change of diagnoses
from teleconsultation to bedside
neurological consultation
1268 J Neurol (2015) 262:1266–1270
123

4. The duration of one teleconsultation was 26.5 min
(8–46 min) for non-stroke cases compared to 14.3 min
(6–38 min) for stroke cases (p 0.05).
83 patients were transferred to a neurological depart-
ment (23.6 %) especially cases with diagnostic uncertainty
or a possible inflammatory cause, whereas in stroke cases
17.3 % were transferred to one of the stroke centers.
Using two cases we want to illustrate how a telecon-
sultation service may help in the clinical course:
Case 1
An 85-year-old woman was found unresponsive on the
floor at the nursing home, a left-sided hemiparesis was
recognized. On admission and in the video-based telecon-
sultation the patient was awake but disoriented and showed
a slight weakness in her left arm. History revealed a brain
trauma with right-sided subdural hematoma 4 months ago.
Consultation diagnosis was focal seizure that was con-
firmed at discharge 4 days after admission while cerebral
imaging did not show any new abnormality.
Case 2
A 76-year-old man was shown in video consultation with
suspected right-sided hemiparesis and stupor. On remote
video examination he showed right-sided weakness and
was not fully responsive. Onset of symptoms was not
known. Teleconsultation suspected a left-sided cerebral
ischemia. Brain MRI did not reveal any acute ischemia but
diffuse white matter lesions of vascular origin. When
bedside neurological consultation found the patient 4 days
later in a state of akinesia and suffering from pneumonia,
the diagnosis of a Parkinson’s syndrome was documented.
Dopaminergic medication was started and the patient
showed substantial improvement until discharge on day 11
after admission.
Discussion
Our study aimed to investigate the use of a telestroke
service for remote support in non-stroke cases. Telemedical
support was already tested in general neurological care for
advising general practitioners by experienced neurologists
[2] and for treatment of Parkinson’s disease [1, 15] or in
patients with epileptic seizures [16]. However, most ex-
tensive use of telemedicine in clinical neurosciences is for
acute stroke care and after proof of this concept telestroke
networks are in routine service in many places all over the
world [17]. It is not clear to date whether telemedicine that
is well validated for evaluating stroke patients is also suf-
ficient for other neurological cases. Examination of patients
via telemedicine utilizing stroke scales is validated in
various studies especially for the NIHSS [8, 17], while
there is only one study evaluating the telemedical appli-
cation of a general neurological examination [18]. The data
from our retrospective survey indicate that remote expert
advice by means of a telemedicine service is also feasible
in non-stroke neurological conditions. In the majority of
cases a diagnosis was stated and therapeutic recommen-
dations were given. However, the diagnostic accuracy
seems to be lower in non-stroke cases compared to stroke
cases as the change in diagnosis between remote and
bedside consultation and between remote consultation and
discharge was more frequently than in stroke consultations.
In a prior randomized trial there were also more investi-
gations in the telemedicine group [6], which might also
serve as a hint for a higher diagnostic uncertainty. Other
outcome data like length of stay and in-hospital mortality
did not show significant differences between stroke and
non-stroke cases. Also there was no significant difference
between non-stroke cases with correct and incorrect diag-
nosis in these parameters. Thus misdiagnosis in telecon-
sultation might not have a strong influence on the course of
the patient despite a slightly longer stay in hospital. The
mean duration of teleconsultation was longer in non-stroke
cases indicating a more complex investigation. It may also
highlight a less structured telemedical evaluation and far
less experience with various other neurological problems
presenting on the video screen compared to the acute stroke
setting. However, stroke specialists in the STENO network
are all experienced neurologists with also long training and
experience in general neurology. In a telestroke service
with more specialized stroke physicians performance of
stroke and non-stroke consultations may differ even more.
Our findings suggest the need for a different organiza-
tional approach such as expanding or reorganizing the
clinical examination. Other parts of the neurological ex-
amination apart from established stroke scales are not yet
validated in a telemedicine setting. Furthermore, there was
a broad range of various neurological problems in our
sample. A more differentiated approach for different neu-
rological diseases such as seizures or movement disorders
may be more suitable. We analyzed only telemedical
support using audiovisual connection, that was already
found to be superior [13], and more cost effective than
telephone advice [19]. However, a telephone connection,
possibly supported by additional data transmission like
EEG data, may be sufficient for special neurological
problems such as headache or seizures.
To summarize, our small retrospective survey indicates
that telemedical consultation may also be feasible in general
neurology, but experiences from telestroke services cannot
be generalized to various other clinical conditions. From our
data telemedicine based neurological examination cannot
J Neurol (2015) 262:1266–1270 1269
123

5. properly substitute neurological expertise at the bedside and
should be restricted to emergency cases. Further studies are
needed to examine the value of telemedicine in general
neurological care and to define the prerequisites of teleneu-
rology service for different problems in clinical neurology.
Acknowledgments We are very grateful to Dr. Heike Schmolck for
proof-reading the manuscript. The STENO-Network is funded by the
Health Insurances in Bavaria and by the Bavarian State Ministry of
Health.
Conflicts of interest None of the authors has any conflict of interest
or any financial relationship to companies or products named in this
article.
Ethical standard This was a retrospective study from routine data
out of the STENO network and does not contain clinical studies data.
However, it was conducted according to all common ethical standards
governed by the University of Erlangen and according to the rules of
the STENO contract.
References
1. Hubble JP, Pahwa R, Michalek DK, Thomas C, Koller WC
(1993) Interactive video conferencing: a means of providing in-
terim care to Parkinson’s disease patients. Mov Disord 8:380–382
2. Paiva T, Coelho H, Arau´jo MT, Rodrigues R, Almeida A,
Navarro T, Cruz M, Carneiro G, Belo C (2001) Neurological
teleconsultation for general practitioners. J Telemed Telecare
7:149–154
3. Wechsler LR, Tsao JW, Levine SR, Swain-Eng RJ, Adams RJ,
Demaerschalk BM, Hess DC, Moro E, Schwamm LH, Steffensen
S, Stern BJ, Zuckerman SJ, Bhattacharya P, Davis LE, Yurkie-
wicz IR, Alphonso AL, American Academy of Neurology Tele-
medicine Work Group (2013) Teleneurology applications: report
of the Telemedicine Work Group of the American Academy of
Neurology. Neurology 80:670–676
4. Rubin MN, Wellik KE, Channer DD, Demaerschalk BM (2013)
Systematic review of teleneurology: neurohospitalist neurology.
Neurohospitalist 3:120–124
5. Craig J, Patterson V, Russell C, Wootton R (2000) Interactive
videoconsultation is a feasible method for neurological in-patient
assessment. Eur J Neurol 7:699–702
6. Chua R, Craig J, Wootton R, Patterson V (2001) Randomised
controlled trial of telemedicine for new neurological outpatient
referrals. J Neurol Neurosurg Psychiatry 71:63–66
7. Craig J, Chua R, Russell C, Wootton R, Chant D, Patterson V
(2004) A cohort study of early neurological consultation by
telemedicine on the care of neurological inpatients. J Neurol
Neurosurg Psychiatry 75:1031–1035
8. Shafqat S, Kvedar CJ, Guanci MM, Chang EC, Schwamm LH
(1999) Role for telemedicine in acute stroke: feasibility and re-
liability of remote administration of the NIH stroke scale. Stroke
30:2141–2214
9. Wiborg A, Widder B (2003) Teleneurology to improve stroke
care in rural areas: the telemedicine in stroke in Swabia (TESS)
Project. Stroke 34:2951–2956
10. Audebert HJ, Schenkel J, Heuschmann PU, Bogdahn U, Haberl
RL (2006) Effects of the implementation of a telemedical stroke
network: the Telemedic Pilot Project for Integrative Stroke Care
(TEMPiS) in Bavaria, Germany. Lancet Neurol 5:742–748
11. Audebert HJ, Kukla C, Clarmann von Clarnau S et al (2005)
Telemedicine for safe and extended use of thrombolysis in stroke:
the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS)
in Bavaria. Stroke 36:287–291
12. Bruno A, Lanning KM, Gross H, Hess DC, Nichols FT, Switzer
JA (2013) Timelines of intravenous thrombolysis via telestroke in
Georgia. Stroke 44:2620–2622
13. Handschu R, Scibor M, Willaczek B, Nu¨ckel M, Heckmann JG,
Asshoff D, Belohlavek D, Erbguth F, Schwab S, for the STENO
Project (2008) Telemedicine in acute stroke: remote video ex-
amination compared to simple telephone consultation. J Neurol
255:1792–1797
14. Handschu R, Scibor M, Wacker A, Stark DR, Ko¨hrmann M,
Erbguth F, Oschmann P, Schwab S, Marquardt L (2014) Feasi-
bility of certified quality management in a comprehensive stroke
care network using telemedicine: STENO project. Int J Stroke
9:1011–1016
15. Samii A, Ryan-Dykes P, Tsukuda RA, Zink C, Franks R, Nichol
WP (2006) Telemedicine for delivery of health care in Parkin-
son’s disease. J Telemed Telecare 12:16–18
16. Rasmusson KA, Hartshorn JC (2005) A comparison of epilepsy
patients in a traditional ambulatory clinic and a telemedicine
clinic. Epilepsia 5:767–770
17. Schwamm LH, Holloway RG, Amarenco P, Audebert HJ, Bakas
T, Chumbler NR, Handschu R, Jauch EC, Knight WA 4th, Levine
SR, Mayberg M, Meyer BC, Meyers PM, Skalabrin E, Wechsler
LR, American Heart Association Stroke Council; Interdisci-
plinary Council on Peripheral Vascular Disease (2009) A review
of the evidence for the use of telemedicine within stroke systems
of care: a scientific statement from the American Heart Asso-
ciation/American Stroke Association. Stroke 40:2616–2634
18. Craig JJ, McConville JP, Patterson VH, Wootton R (1999)
Neurological examination is possible using telemedicine.
J Telemed Telecare 5:134–136
19. Handschu R, Scibor M, Nu¨ckel M, Asshoff D, Willaczek B,
Erbguth F, Schwab S, Daumann F (2014) Teleneurology in stroke
management: costs of service in different organizational models.
J Neurol 261:2003–2008
1270 J Neurol (2015) 262:1266–1270
123