Highlights
Teleneurological ward rounds demonstrated 92% guideline adherence compared to 54% for conventional on-site consultations in subacute stroke care, representing a 38-percentage-point absolute difference. The superiority of telemedicine persisted across all six quality domains evaluated, with secondary prevention showing the most pronounced benefit. These findings support broader integration of teleneurology into routine inpatient stroke management, particularly in resource-limited settings.
Background: The Challenge of Neurological Expertise Access
Stroke remains a leading cause of mortality and long-term disability worldwide, demanding timely and expert neurological assessment throughout the care continuum. While telestroke networks have successfully extended acute stroke expertise to rural and underserved regions, most implementations have focused exclusively on emergency department consultations for acute thrombolysis and thrombectomy decision-making. The critical question of whether telemedicine can adequately support the subacute phase of inpatient stroke care has remained largely unaddressed.
The subacute period following stroke admission represents a vulnerable window where decisions regarding etiological classification, secondary prevention optimization, and discharge planning significantly influence long-term outcomes. Yet primary care hospitals frequently lack dedicated neurological staff, creating potential gaps in care quality. This study by Behrens and colleagues addresses this gap by systematically evaluating whether virtual neurological ward rounds can match or exceed conventional consultation models.
Study Design and Population
This prospective, multicenter, nonrandomized noninferiority trial enrolled patients from 15 primary care hospitals within 4 German telestroke networks between October 2022 and December 2024. The study included adults aged 18 years or older hospitalized with suspected acute ischemic stroke, hemorrhagic stroke, or transient ischemic attack. Of 1908 patients screened, 518 were enrolled, with 501 ultimately included in the final analysis.
The cohort had a median age of 71 years, comprising 222 females (44%) and 296 males (56%). Each participant received both a teleneurological ward round and a conventional on-site neurological assessment during their hospitalization. Teleneurological consultations were conducted by network neurologists via video platform, while on-site assessments were performed by local neurologists at each participating hospital. All documentation underwent blinded evaluation by external neurovascular experts to minimize assessment bias.
The study examined six guideline-based quality domains: etiological classification of stroke mechanism, comprehensive neurological examination, cardiovascular risk assessment, diagnostic recommendations, secondary prevention implementation, and recommended aftercare planning. The predefined noninferiority margin was set at a maximum difference of 5 percentage points in correct assessment rates between modalities.
Key Findings: Telemedicine’s Remarkable Superiority
The primary analysis revealed that teleneurological ward rounds achieved complete adherence to all six quality criteria in 92% of cases (95% CI, 90%-94%), compared to only 54% (95% CI, 49%-58%) for conventional on-site consultations. This 38-percentage-point absolute difference (90% CI, 34-42) substantially exceeded the predefined noninferiority threshold and demonstrated clear superiority of the telemedicine approach.
Notably, teleneurological consultations outperformed on-site assessments across every individual quality domain. The advantage was most striking for secondary prevention, where the absolute difference reached 21 percentage points (90% CI, 17-24). This finding suggests that remote neurologists with specialized stroke expertise may be more likely to implement evidence-based prevention strategies, including appropriate antiplatelet regimens, anticoagulation decisions for atrial fibrillation, statin intensification, and blood pressure optimization.
The secondary outcomes examining individual domain performance and expert quality ratings on visual analog scales reinforced the primary findings. External reviewers consistently rated teleneurological consultations as more comprehensive in addressing guideline-recommended care elements, suggesting that the observed differences reflect genuine quality gaps rather than documentation artifacts.
Expert Commentary: Interpreting the Results
These findings challenge conventional assumptions about the limitations of telemedicine in complex inpatient settings. Several factors may explain the observed superiority of teleneurological ward rounds. Network neurologists likely possessed greater experience in stroke-specific care protocols and maintained tighter alignment with current guideline recommendations. The structured nature of video consultations may have promoted more systematic evaluation of all quality domains, reducing the variability sometimes observed in traditional bedside assessments.
The study population’s characteristics—predominantly elderly patients with multiple comorbidities managed at community hospitals—represent the exact clinical scenario where teleneurology deployment is most relevant. These settings frequently lack round-the-clock neurological coverage, and local physicians may benefit from subspecialty guidance that virtual consultations provide.
Potential limitations include the nonrandomized design, which introduces possible selection bias despite prospective enrollment. The German healthcare system’s specific organizational structure may limit generalizability to other national contexts. Additionally, the study measured process measures rather than hard clinical outcomes such as mortality or functional independence; however, guideline adherence serves as a validated surrogate for care quality in stroke management.
Conclusion: Toward Broader Teleneurology Integration
This landmark study provides robust evidence that teleneurological ward rounds are not merely equivalent but actually superior to conventional on-site consultations for subacute inpatient stroke care. With 38 percentage points higher guideline adherence and consistent advantages across all quality domains, telemedicine offers a viable strategy for improving neurological care access and quality in hospitals lacking dedicated neurology departments.
The implications extend beyond stroke to other neurological conditions requiring inpatient management. Healthcare systems facing neurologist shortages, particularly in rural and suburban areas, should consider implementing teleneurology programs for ward-based consultations. Future research should examine whether these quality advantages translate into improved patient outcomes and cost-effectiveness, as well as explore optimal implementation strategies including technology requirements, workflow integration, and reimbursement models.
Funding
The study received institutional support from the participating German telestroke networks. No commercial funding sources were reported in the disclosure statements.
Reference
Behrens JR, Kaffes M, Aigner A, et al. Teleneurology vs On-Site Neurology Consultation for Postadmission Hospital Care of Stroke. JAMA neurology. 2026-04-06. PMID: 41941227.