The development of the medical science and technology has led to new opportunities in treating patients, which has in turn resulted in extended life expectancy and an aging population. The aging population has resulted in an increased number of senior citizens, which implies a larger number of neurological patients, who primarily suffer from neurovascular and neurodegenerative diseases. The development of telecommunication and information technologies has brought about the development of telemedicine, which in turn has reduced limitations in the availability of health care (patients in hard-to-reach or remote areas, patients with low mobility or no mobility).

Telemedicine services in neurology can be regular ones (regular initial examination and subsequent check-ups) or emergency ones (emergency examinations of patients with a stroke, epileptic attacks, consciousness disorders and/or need for complex intervention procedures).

Regular telemedicine services are intended for outpatient treatment, monitoring and counselling of patients with chronic neurological diseases. The majority of patients suffer from neurovascular diseases and diseases of the blood vessels that supply the brain. Such patients need to be counselled and monitored in order to prevent stroke. The aging population also means more patients with neurodegenerative diseases, such as Parkinson’s disease and Alzheimer’s diseases. Both diseases are characterized by deterioration of nerve cells. In Parkinson’s diseases, there is a deterioration of nerve cells responsible for motor functions. The motor functions thus deteriorate, and there may be shaking or rigidity. In Alzheimer’s disease, nerve cells responsible for memory and learning deteriorate, and the first symptoms with such patients are forgetfulness and inability to learn new information (short-term memory is most affected, and patients remember the past, but they cannot remember recent events).

Epilepsy and multiple sclerosis are frequent with a younger population. Epilepsy is a disease characterized by occasional epileptic attacks which occur due to an uncontrolled electric discharge of a group of nerve cells. Multiple sclerosis is a disease which occurs as a result of the deterioration of insulating covers of nerve cells in the brain and/or spinal cord, which disrupts the conduct of nervous impulses and leads to the occurrence of different symptoms, depending on the place of damage (muscular weakness, disturbed senses, dizziness, vision problems etc.). 

Emergency telemedicine services are envisaged for the examination of patients with a stroke, which is an emergency condition. A stroke can be caused by obstruction of a blood vessel by a blood clot, causing the brain tissue supplied by this vessel to die: in this case, we say that the patient has cerebral infarction. Also, blood vessel rupture can occur leading to cerebral haemorrhaging. The telemedicine service provided in such a situation will depend on the level of equipment of the telemedicine access centre. If it has a CT scanner, the telemedicine service can include the initiation of specific treatment or assessment whether a complex intervention treatment is required. However, if this is not the case, the service will be limited to counselling regarding general treatment of the patient with a suspected stroke and assessment of emergency and the manner of transport to the closest neurological department for diagnostic evaluation and treatment. Emergency telemedicine services may be useful for caring for patients with an epileptic status (a condition when epileptic attacks follow one after another, and the patient does not regain consciousness), which is also an emergency condition. They can be used for assessment of other consciousness disorders, as well as to assess the need for a complex intervention. Most importantly, telemedicine services can decrease the number of unnecessary referrals to hospitals, improving the quality of treatment of patients with chronic diseases on the other hand. The application of telemedicine is nowadays included in the European guidelines for treating cerebral stroke.

High-quality video conferencing systems are recommended for examinations of patients who have suffered a stroke based on the NIHSS (National Institute of Health Stroke Scale).

High-quality video conferencing systems are recommended for examinations of patients with an acute stroke which is conducted by a stroke specialist.

Teleradiological systems (approved by the FDA or another competent organization) are recommended for the analysis of brain CT scans for patients with a suspected acute stroke.

Tha analysis of brain CT scans via teleradiological systems (approved by the FDA or another competent organization), performed by a stroke specialist or a radiologist, is useful to identify excluding factors for thrombolytic therapy.

EPILEPSY

Epileptic status is an emergency condition in neurology which is often very difficult to stop. Timely consultation with a neurologist-intensivist via a video conferencing system can reduce the duration of the status by a correct selection of treatment, as such status can sometimes last for hours and endanger the patient’s life.

The best way to diagnose epilepsy is to monitor the attack or rely on the description of the person who was near the patient at that time. This is important as it makes it possible for the neurologist to establish a diagnosis or revise it and correct the therapy. Thanks to this, the role of telemedicine is becoming increasingly important in treating epileptic patients and in communication among hospitals.

Emergency telemedicine services in caring for patients with an acute stroke and epilepsy (epileptic status) are professionally and economically founded too.

Regular telemedicine and supervisory telemedicine services have an important role in monitoring and treating patients with chronic neurological diseases, such as neurodegenerative diseases (e.g. Parkinson’s disease), demyelinating diseases (e.g. multiplesclerosis), paroxysmal diseases (e.g. epilepsy), neuromuscular diseases, headaches and various chronic pain syndromes. They also have a significant professional foundation in an increasing number of professional papers.

It is important to emphasize that neurological patients often have a varying degree of disability, which is a debilitating factor in their everyday activities, including their visits to a specialist doctor, especially if they live in remote rural areas or on islands. The cost-effectiveness of using telemedicine in neurology is evident, especially taking into consideration the fact that his group of patients often has to come to check-ups from remote areas. We must bear in mind that the use of telemedicine in neurology and medicine in general enables equal availability of health services for all patients.

International recommendations
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 Conclusion - This new statement provides a comprehensive and evidence-based review of the scientific evidence supporting the use of telemedicine for stroke care delivery organized by the stroke systems of care model. Stroke. 2009;40:2616.)
© 2009 American Heart Association, Inc.

Class I recommendations 
Level of Evidence A 1. High-quality videoconferencing systems are recommended for performing an NIHSS-telestroke examination in nonacute stroke patients, and this is comparable to an NIHSS-bedside assessment. Similar recommendations apply for the European and Scandinavian Stroke scales (Class I, Level of, Evidence A). 2. The NIHSS-telestroke examination, when administered by a stroke specialist using high-quality videoconferencing, is recommended when an NIHSS-bedside assessment by a stroke specialist is not immediately available for patients in the acute stroke setting, and this assessment is comparable to an NIHSS-bedside assessment (Class I, Level of Evidence A). 3. Teleradiology systems approved by the FDA (or equivalent organization) are recommended for timely review of brain CT scans in patients with suspected, acute stroke (Class I, Level of Evidence A). 4. Review of brain CT scans by stroke specialists or radiologists using teleradiology systems approved by the FDA (or equivalent organization) is useful for identifying exclusions for thrombolytic therapy in acute stroke patients (Class I, Level of Evidence A).

Class I recommendations 
Level of Evidence B 5. When implemented within a telestroke network, teleradiology systems approved by the FDA (or equivalent organization) are useful in supporting rapid imaging interpretation in time for thrombolysis decision making (Class I, Level of Evidence B). 6. It is recommended that a stroke specialist using high-quality videoconferencing provide a medical opinion in favor of or against the use of intravenous tPA in patients with suspected acute ischemic stroke when on-site stroke expertise is not immediately available (Class I, Level of Evidence B). 7. When the lack of local physician stroke expertise is the only barrier to the implementation of inpatient stroke units, telestroke consultation via high-quality videoconferencing is recommended (Class I, Level of Evidence B). 8. Assessment of occupational, physical, or speech disability in stroke patients by allied health professionals via high-quality videoconferencing systems using specific standardized assessments is recommended when in-person assessment is impractical, the standardized rating instruments have been validated for high-quality videoconferencing use, and administration is by trained personnel using a structured interview (Class I, Level of Evidence B). 9. Telephonic assessment for measuring functional disability after stroke is recommended when in-person assessment is impractical, the standardized rating instruments have been validated for telephonic use, and administration is by trained personnel using a structured interview (Class I, Level of Evidence B). Class II recommendations 1. High-quality videoconferencing is reasonable for performing a general neurological examination by a remote examiner with interrater agreement comparable to that between different face-to-face examiners (Class IIa, Level of Evidence B). 2. Implementation of telestroke consultation in conjunction with stroke education and training for healthcare providers can be useful for increasing the use of intravenous tPA at community hospitals without access to adequate onsite stroke expertise (Class IIa, Level of Evidence B). 3. Compared with traditional bedside evaluation and use of intravenous tPA, the safety and efficacy of intravenous tPA administration based solely on telephone consultation without CT interpretation via teleradiology are not well established (Class IIb, Level of Evidence C). 4. Prehospital telephone-based contact between emergency medical personnel and stroke specialists for screening and consent can be effective in facilitating enrollment into hyperacute neuroprotective trials (Class IIa, Level of Evidence B). 5. Delivery of occupational or physical therapy to stroke patients by allied health professionals via high-quality videoconferencing systems is reasonable when in-person assessment is impractical (Class IIa, Level of Evidence B).