Advantages and Challenges of Telestroke Implementation in Low- and Middle-income Countries: A Systematic Review
Joao Moreira Nogueira1, Enzo Parente1, Marina Maia1, Aline Vasconcelos1, Letícia Barros1, André Gomes1, Álissa Moura1
1Centro Universitário Christus
Objective:
To synthesize and evaluate evidence on the effectiveness, safety, and operational feasibility of Telestroke implementation in low- and middle-income countries, with special emphasis on its applicability to the Brazilian healthcare context.
Background:
Acute ischemic stroke remains a leading cause of mortality and disability worldwide, especially in low-resource settings. Limited access to neurologists and specialized stroke centers delays reperfusion therapy, worsening outcomes. Telestroke enables remote neurological evaluation, diagnostic confirmation, and treatment decisions, potentially reducing inequities in care delivery.
Design/Methods:
This systematic review followed PRISMA guidelines. Searches were performed in PubMed, Embase, and LILACS databases using combinations of “Stroke,” “Telestroke,” “Telemedicine,” “Developing Countries,” “Pre-hospital care,” and “Thrombolysis therapy.” Inclusion criteria comprised primary studies comparing Telestroke-assisted versus conventional in-person acute stroke management. Nineteen studies published between 2006 and 2024 were included after independent screening by two reviewers using the Rayyan® platform. Data extracted included study design, population, intervention, outcomes, and country of origin.
Results:
Telestroke networks expanded access and sped up care. After implementation, IV thrombolysis rose from 8% to 26% (~3×) and the odds of receiving rt-PA doubled (OR≈2.0). Door-to-needle fell from 66→55 min; <60-min treatments increased 13%→32%. Onset-to-needle shortened 211→169 min. Functional outcomes held: 45% achieved mRS 0–1 at 90 days, with safety preserved (ICH 2.4% and ~6.1% vs 6.3%). In bridging cases, early recanalization was 15.8% vs 2.2% (≈7.2×) and ΔNIHSS −2 vs 0. Economics: US$2,449/QALY (lifetime); the network projects +45 thrombolyses and +20 thrombectomies/year, with ~US$358k annual savings across regional scenarios.
Conclusions:
Telestroke is a feasible and cost-effective strategy to expand equitable access to acute stroke care in low-resource regions. Evidence shows comparable clinical outcomes to conventional care, with operational gains in networked systems - including marked improvements in door-to-needle times and higher IV thrombolysis rates. Future prospective studies should quantify long-term clinical and economic impacts to guide national implementation frameworks.
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