Table 2.

Summary characteristics of included studies.

Author	Year	Country	Topic	Study design	Key findings
Roth et al. [1]	2020	United States	Global Burden of Cardiovascular Diseases and Risk Factors, 1990–2019	Epidemiological study	Cerebrovascular accidents, commonly known as strokes, are a leading contributor to worldwide mortality and a substantial contributor of incapacitation. The global burden of stroke in 2019 was 143 million recorded cases
Ansari et al. [2]	2023	Iran	Telestroke: A Novel Approach for Post-Stroke Rehabilitation	An overview	Preponderantly, low- and middle-income countries bear the most substantial global burden of strokes. Swift identification and treatment of afflicted individuals, particularly in remote or rural locales, are imperative measures to mitigate ensuing complications
Akinyemi et al. [3]	2021	Nigeria	Stroke in Africa: profile, progress, prospects and priorities	Scoping review	Approximately 87% of disability arising from strokes and 70% of stroke-related fatalities occur in low-income and middle-income nations. On a global scale, an estimated one in four adults is projected to experience a stroke during their lifetime. Africa may exhibit stroke incidence rates two to three times higher than those observed in Western Europe and the United States, coupled with elevated stroke prevalence
Owolabi et al. [4]	2018	Nigeria	The epidemiology of stroke in Africa: A systematic review of existing methods and new approaches	Systematic review	Africa shoulders the predominant burden of hypertension, identified as the most robust and prevalent modifiable risk factor for strokes. In the African context, stroke emerges as a pivotal health determinant, historically deemed infrequent due to resource constraints hindering comprehensive community-based studies for accurate burden assessment
Kyei-Nimakoh et al. [5]	2017	Australia	Access barriers to obstetric care at health facilities in sub-Saharan Africa—a systematic review	Systematic review	Primary impediments to healthcare service accessibility in Africa encompass the financial outlay associated with services, the geographical distance between health facilities and the residences of service users, and prolonged waiting time at healthcare facilities
Mweemba et al. [6]	2021	Zambia	Access barriers to maternal healthcare services in selected hard-to-reach areas of Zambia: a mixed methods design	Mixed methods design	In a concurrent mixed methods investigation carried out in Zambia's challenging-to-reach districts of Kaputa and Ngabwe, findings revealed that residents had to traverse approximately 12 kilometers to reach healthcare services. The study indicated that patients were inclined to remain at home rather than seek health services when lacking transportation fares. Beyond the distance to health centers, participants raised concerns about the poor condition of roads, exacerbated during rainy seasons, rendering modes of transport such as motorcycles and cars challenging
Harahsheh et al. [7]	2022	United States	Telestroke's Role Through the COVID-19 Pandemic and Beyond	Scoping review	Telestroke is a pivotal element within stroke systems of care, offering a means to swiftly assess individuals exhibiting acute stroke symptoms in remote or underserved regions. Telestroke serves as a crucial tool in identifying optimal candidates for hospital transfer. Its application effectively limits unwarranted transfers of patients, particularly those with mild stroke syndromes or stroke mimics, who can be appropriately managed at local facilities
Jun-O'Connell et al. [8]	2023	United States	Outcomes of Telestroke Inter-Hospital Transfers Among Intervention and Non-Intervention Patients	Exploratory study	Telestroke is the use of remote information and communication technologies to enable the delivery of stroke care for patients, facilitating the remote practice of physicians as stroke patients concurrently receive care from a distance (Connell et al., [8])
Mohamed et al. [9]	2023	Canada	Is telestroke more effective than conventional treatment for acute ischemic stroke? A systematic review and meta-analysis of patient outcomes and thrombolysis rates	Systematic review	The use of telestroke for managing strokes is considered safe and demonstrates improvement in functional outcomes
Sharrief et al. [11]	2023	United States	Telehealth Trials to Address Health Equity in Stroke Survivors	A review	The integration of telestroke services into transitional and post-stroke care has significant potential to bridge critical gaps in the continuum of care for stroke survivors, who often encounter challenges distinct from those faced by individuals with other chronic conditions. Telestroke alleviates transportation challenges, particularly for patients subject to driving restrictions, thereby enhancing accessibility and continuity of care in this vulnerable population. By addressing mobility limitations and reducing dependence on specialized equipment required to access physical clinic spaces, telestroke minimizes logistical barriers to care
Lazarus et al. [13]	2020	Indonesia	Telestroke strategies to enhance acute stroke management in rural settings: A systematic review and meta-analysis	Systematic review	A systematic review that assessed 19 studies with a collective participation of 28,496 subjects, inclusive of prehospital and in-hospital telestroke interventions, revealed a notable increase in the proportion of patients treated within a 3-h window (OR 2.15; 95% CI 1.37–3.40; I2 = 0%) and improved three-month functional outcomes (OR 1.29; 95% CI 1.01–1.63; I2 = 44%) without a concurrent rise in the rate of symptomatic intracranial hemorrhage (OR 1.27; 0.65–2.49; I2 = 0%). Moreover, telestroke interventions were associated with a reduction in onset-to-treatment time (mean difference −27.97 min; 95% CI −35.51, −20.42; I2 = 63%) and a decreased in-hospital mortality rate (OR 0.67; 95% CI 0.52–0.87; I2 = 0%)
Nathaniel et al. [10]	2019	United States	The telestroke and thrombolysis therapy in diabetic stroke patients	Retrospective study	Telestroke could potentially facilitate prompt consultations by stroke neurologists to determine the appropriateness of administering thrombolysis therapy. Such an approach may enhance the utilization rates and efficiency of the thrombolysis administration timeline in the management of stroke in diabetic patients
Chen et al. [14]	2022	China	Telestroke for the Treatment of Ischemic Stroke in Western China During the COVID-19 Pandemic: A Multicenter Observational Study	Multicenter observational study	In an observational study conducted in western China, encompassing 11,449 admissions primarily diagnosed with ischemic stroke, the percentage of patients undergoing intravenous thrombolysis rose from 6.7% to 7.4% following the integration of telestroke. Moreover, the mean door-to-needle time (DNT) exhibited a significant reduction after the implementation of the telestroke network (63.76 ± 13.50 vs. 52.66 ± 25.49 min; p < 0.001)
Worthmann et al. [15]	2023	Germany	Telestroke networks for area-wide access to endovascular stroke treatment.	Narrative review	Telestroke networks address the critical need for time-sensitive decisions regarding intravenous thrombolysis (IVT) in acute ischemic stroke patients, particularly in hospitals without on-site neurologists. A study in Germany reported a 14.9% IVT rate within telestroke networks, highlighting the positive impact of such networks
Evans et al. [16]	2022	United Kingdom	Hyperacute stroke thrombolysis via telemedicine: a multicentre study of performance, safety and clinical efficacy	Multicentre study	In a prospective observational study examining the utilization and effectiveness of the East of England Stroke Telemedicine Partnership in delivering hyperacute stroke care, findings revealed an increase in thrombolysis rates from 38.8% in 2014 to 45.9% in 2019 following the implementation of telestroke. The median (interquartile range) time for thrombolysis decreased from 10 h (prethrombolysis) to 6 h
Poongkunran et al. [12]	2023	United States	Diagnostic accuracy of telestroke consultation: a Louisiana-based tele-network experience	Retrospective study	Telestroke has demonstrated a high diagnostic accuracy in discerning between stroke and its mimics. In a retrospective analysis encompassing all evaluations within Ochsner Health's Telestroke program from April 2015 to April 2016 in the United States, accurate diagnoses were achieved through telestroke consultations in 85% of the 874 evaluations conducted. The sensitivity, specificity, positive predictive value, and negative predictive value were determined to be 97.8%, 82.5%, 93.7%, and 93.4%, respectively. These findings affirm the assertion of elevated diagnostic accuracy in telestroke consultations
Ali et al. [17]	2020	United States	Role of Artificial Intelligence in Telestroke: An Overview.	An overview	Telestroke services offer patients residing in medically underserved regions a higher likelihood of accessing prompt and consistent healthcare. This mitigates challenges associated with a relative scarcity of physicians, which frequently results in delayed diagnoses and treatment. Additionally, telestroke aids in enhancing continuity of care by minimizing unnecessary patient transfers and redundant testing
Kissi et al. [18]	2023	Ghana	Telehealth services for global emergencies: implications for COVID-19: a scoping review based on current evidence	Scoping review	In India, despite only 2.67% of neurologists and neurosurgeons residing in rural areas, serving a population of 84.59 million, the introduction of telemedicine, including telestroke, has been instrumental in mitigating the critical shortage of healthcare professionals. Commercially deployed video conferencing (VC) systems are effectively utilized to facilitate teleconsultation sessions for patients with stroke conditions (Kissi et al., [18]).
Lyerly et al. [19]	2021	United Kingdom	Provider Communication and Telepresence Enhance Veteran Satisfaction with Telestroke Consultations.	Qualitative study	In a study that assessed the satisfaction of 186 telestroke users over an 18-month period, 142 (76%) participants expressed high satisfaction with telestroke. Factors significantly correlated with patient contentment included elevated technology ratings (p < 0.0001), favorable telepresence evaluations (p < 0.0001), and positive provider communication assessments (p < 0.0001). Of the 142 patients reporting full satisfaction with the telestroke service, an impressive 97% expressed their willingness to recommend telestroke to other patients experiencing stroke symptoms. Intriguingly, among the 44 patients expressing less than full satisfaction with the consultation, 69% still indicated their inclination to recommend the service
Truitt et al. [20]	2023	United States	Patient Satisfaction and Perception of Physician Empathy in Outpatient Community General Neurology Telemedicine	Prospective cohort study	69 patients engaged in neurology follow-up visits via telestroke, the Telestroke Patient Satisfaction Measure indicated a mean score of 55, with an average of 94% of responses showing agreement. The Consultation and Relational Empathy score averaged 44, with an impressive 90% of responses rated as “very good” or “excellent.” Participating neurologists acknowledged the significant enhancement of work-life balance through reduced travel time, effectively bridging the gap between patients' local care needs and physicians' need for improved equilibrium
Kjelle and Myklebust [21]	2022	Norway	Implementation of a telemedicine, stroke evaluation service; a qualitative study	Qualitative study	The implementation of telestroke CT services ensures equitable access to high-quality stroke healthcare. According to findings from a qualitative study conducted in Hallingdal, Norway, participants expressed a sense of safety and reassurance with the telestroke CT service. They felt secure knowing that medical assistance was readily available in close proximity in case they or their loved ones experienced a stroke
Naqvi et al. [22]	2022	United States	TASC (Telehealth After Stroke Care): a study protocol for a randomized controlled feasibility trial of telehealth-enabled multidisciplinary stroke care in an underserved urban setting	Parallel two-armed feasibility randomized controlled trial	Improvement in acute care treatments and prevention of strokes using telestroke have contributed to decreased mortality among stroke survivors, taking stroke from the third to the fifth leading cause of death in the United States
Shea et al. [23]	2018	United States	Telestroke Adoption among Community Hospitals in North Carolina: a Cross-sectional Study	Cross-sectional study	The adoption of telestroke services is significantly correlated with both external factors, such as market competition and critical access hospital status, and internal hospital factors, including payer mix, patient volume, and hospital profitability
Busti et al. [24]	2021	Italy	Telestroke: Barriers to the Transition	Narrative review	Africa may draw insights from the efforts of US healthcare authorities in advancing regulatory science for digital health. This commitment is elucidated in the 2017 Digital Health Innovation Action Plan and was further reinforced in 2020 with the establishment of the Digital Health Center of Excellence (DHCoE)
Patil et al. [25]	2022	Ireland	Detection, Diagnosis and Treatment of Acute Ischemic Stroke: Current and Future Perspectives	Narrative review	CT scanners and MRI machines are vital for the early detection and accurate diagnosis of strokes within telestroke systems, but their high costs often limit their accessibility and widespread use in many African healthcare facilities. Devices such as the Strokefinder MD100, transcranial Doppler ultrasound, and Lucid represent portable CT and MRI solutions that are relatively less expensive, enabling the detection of hemorrhages, measurement of cerebral blood flow velocity, and identification of patients with large vessel occlusions (LVOs), respectively. These imaging devices must be integrated with telestroke platforms to facilitate the instantaneous sharing and analysis of essential medical data, thereby ensuring that patients receive appropriate treatment without undue delays
Chitungo et al. [26]	2021	Zimbabwe	Utility of telemedicine in sub-Saharan Africa during theCOVID-19 pandemic. A rapid review	Rapid review	Successful telestroke implementation requires comprehensive network coverage, reliable internet connectivity, and affordable data bundles. In Africa, these technological prerequisites are often hindered by limited network infrastructure, inconsistent internet access, and the high cost of data services, particularly in rural areas. These challenges significantly impede the adoption and effective utilization of telestroke solutions across the continent
Dodoo et al. [27]	2022	Ghana	The development of telemedicine programs in Sub-Saharan Africa: Progress and associated challenges	Systematic review	The implementation of telestroke in Africa has been significantly hindered by the absence of a robust framework to harmonize the interests of diverse stakeholders. Existing telestroke initiatives have encountered persistent sustainability challenges, particularly following the conclusion of project funding cycles. Moreover, the heavy reliance on external financial support has highlighted a critical deficiency in strategic planning for long-term viability, with minimal integration of key stakeholders, including governmental bodies, private sector entities, non-governmental organizations, and local communities, to ensure sustained impact and operational continuity
Muyunda and Mpundu [28]	2023	Zambia	Mapping the Regulatory Framework for Telemedicine in Zambia: A Content Analysis	Content analysis	Lessons can be drawn from Zambia's “Guidelines for the Quality Assurance of Telemedicine Services,” issued by the Health Professions Council. These guidelines offer comprehensive instructions for both provider-to-provider and client-to-provider telestroke interactions while maintaining the established scopes of practice for all health professionals. Additionally, the guidelines require telestroke providers to hold valid licenses and accreditation certificates, ensuring that only qualified and authorized individuals deliver these essential services
Dodoo et al. [29]	2021	Ghana	Telemedicine use in Sub-Saharan Africa: Barriers and policy recommendations for COVID-19 and beyond	Systematic review	Skilled healthcare professionals capable of operating telestroke systems are essential for their effective implementation. However, most medical facilities in Africa lack professionals with the necessary hybrid (physical and electronic) expertise to utilize telestroke medical equipment. For instance, there is insufficient initial telestroke buy-in from clinicians in countries such as Ghana, Nigeria, and Mali, further hindering the adoption and success of telestroke initiatives across the continent
Ayo-Farai et al. [30]	2023	Nigeria	Telemedicine in Health Care: A Review of Progress and Challenges in Africa	A review	Diverse regulatory frameworks across African countries create significant ambiguity, impeding the establishment of uniform telestroke standards. The absence of clear, cohesive guidelines discourages healthcare providers from adopting and integrating telestroke services into routine practice
Mbunge et al. [31]	2022	Eswatini	Are we there yet? Unbundling the potential adoption and integration of telemedicine to improve virtual healthcare services in African health systems	Systematic review	The deployment of telestroke services raises significant ethical concerns, particularly with respect to doctor-patient privacy, confidentiality, informed consent, and data security, which are critical factors contributing to the potential failure of digital health interventions like telestroke. Also, the virtualization of patient care is often perceived as a form of dehumanization, which may hinder the adoption and integration of telestroke services within many health systems