Table 3. Brief review on previous studies related to tele-neurology.

CBOC: community-based outpatient clinic; ISDN: integrated services digital network; ED: emergency department; AIS: acute ischemic stroke; NIHSS: National Institutes of Health Stroke Scale; IV rt-PA: intravenous recombinant tissue plasminogen activator; ICH: intracerebral hemorrhage; ECASS: European Cooperative Acute Stroke Study; CI: confidence interval; TCT: telehealth clinical technician; CVT: clinical video telehealth; TIA: transient ischemic attack; DTN: door-to-needle; UAMC: University of Arkansas for Medical Sciences; NCC: neurocysticercosis; ICP: intracranial pressure; FIM: functional independence measure.

Study, Country	Clinical conditions (Health care providers)	Sample Size and Timeline of study	Methods and Setup	Outcomes and Results
Davis et al. 2012 [9], USA	Veterans with chronic neurologic conditions like Parkinson's disease, seizure disorders etc. (CBOC personnel and Neurologists)	354 patients from April 1, 2011 to March 31, 2013	Methods: The clinical video telehealth (CVT) system enables a neurologist to directly talk to and examine a Veteran with a neurologic illness at his or her local community-based outpatient clinic (CBOC). Setup: Tandberg or Jabber camera system at different participating sites and ISDN lines transmitted the information between the two sites at 548 kilobits/s.	Outcomes: Cost analysis and Patient Satisfaction. Results: 90% Patient satisfaction equivalent in both groups in the 5-level Likert scale questions. An average time of 5 hours and 325 miles and a total of $48,000 were saved.
Mazighi et al. 2015 [22], Paris	Acute Ischemic Stroke (AIS) (ED Physicians and Neurologists)	47 patients were randomized to usual care (n = 22) and tele-thrombolysis (n = 25) arms from April 2006 to March 2010.	Methods: After evaluation by the ED physician using the National Institutes of Health Stroke Scale (NIHSS) in the hospital without stroke unit facility, the stroke neurologist at the Bichat Stroke Center was contacted by a video-conferencing system to confirm the indication to use IV rt-PA for a suspected AIS patient. After confirmation patients were included in the study and randomly assigned to a usual care arm or a tele-thrombolysis arm. Setup: Video-conferencing.	Outcomes: Excellent outcome (modified Rankin scale (mRS) 0–1 at 90 days). Favorable outcome (90-day mRS 0–2) and early neurological improvement (NIHSS score 0–1 at 24 hours or a decrease of54 points within 24 hours). Safety outcomes included symptomatic intracerebral hemorrhage (ICH) per ECASS II definition, any ICH and all-cause mortality. Results: 15 patients (32%) reached an excellent outcome. Tele-thrombolysis arm group less frequently had an excellent outcome than usual care arm (16% vs. 50%, p = 0.013). After adjustment for age and prerandomization, NIHSS score this difference remained non-significant. Pre-randomization NIHSS was significantly associated with a less excellent outcome, with a multivariate OR per point increase of 0.75 (CI, 0.60–0.93; p<0.009). The multivariate ORs were 0.51 (CI, 0.12–2.17; p=0.36) for the tele-thrombolysis group, 0.96 (CI, 0.92–1.01; p=0.09) for age and 0.83 (CI, 0.71–0.96; p=0.014) for pre-randomization NIHSS. There were no significant differences between the two groups for early neurological improvement outcome and safety outcome.
Schreiber et al. 2018 [26], USA	Veterans with chronic neurologic conditions like Parkinson's disease, seizure disorders etc. (Neurologists and telehealth clinical technician (TCT))	745 encounter that included 570 unique patients between November 2011 and December 2014.	Methods: Teleneurology encounters were performed through clinical video telehealth (CVT), the teleneurologist assessed mental status, cranial nerves (motor functions), abnormal movements, coordination, and gait. The TCT assisted with evaluation of sensory function, muscle strength, tone, and tendon reflexes. In a random sampling of veterans, they were asked to complete a patient satisfaction survey. The survey was developed by the Teleneurology program and followed a Likert-like format. Setup: Community based outpatient clinic (COBC's) equipped with GlobalMed Mobile Telemedicine Station (GlobalMed, Scottsdale, AZ) with codec, camera, with pan/tilt/zoom capability remotely controlled by the provider, and two 21.5″ touchscreen monitors (resolution: 1,920 × 1,080). The provider site equipped with a Cisco TelePresence EX90 (Cisco Systems, San Jose, CA) with codec, camera, and 24-inch LCD monitor (resolution: 1,920 × 1,200, bandwidth capacity 386 kilobits per second).	Outcomes: To assess the feasibility (patient satisfaction and cost analysis) of applying telehealth modality to patients with chronic neurological disorders living in an urban setting. Results: The average age was 62.6 years and 3.5% were female. Greater than 90% of the respondents were satisfied with the care they received. 84% of the respondents preferred to have a CVT encounter at the CBOC rather than travel to the medical center. 86% would recommend a telehealth encounter with other veterans. 7% of respondents preferred a face-to-face encounter with a neurologist. There were an average cost savings of $6,276 during the study period.
Patterson et al. 2001 [28], UK and Bangladesh	Neurological disorders (Neurologists in UK and Local staff and doctors at Bangladesh)	Twelve consultations within 12 months	Methods: A small team of dedicated local staff were trained in the use of the equipment and how to send email referrals to a series of UK specialists. The use of a numbering system ensured patient confidentiality. Setup: Two digital cameras (CI400XL) and accessories, two tripods and a laptop.	Outcomes: Store and Forward Teleneurology method efficacy for delivering expert neurological advice. Results: Two cases were completed in one day, five in one week and 10 in three weeks. The neurologist would have preferred a video-link in eight of the 12 cases which he perceived as extremely complicated. The local doctors found the advice beneficial in 6 of these 8 cases as well as in the four more straightforward cases.
Cutting et al. 2013 [34], USA	Neurologic disorders (ED physicians and vascular fellowship trained neurologists)	498 patients were evaluated by Telestroke between March 2011 and March 2013.	Methods: Four urban hospitals (4 spokes) were included. Prior to Telestroke initiation, Emergency department (ED) protocols and rate of tPA administration were reviewed with an administrator and Neurologists practising at these spoke hospitals. When suspected AIS patients presented to a spoke, the ED physician called a central number, linked to the phone of the neurologist on-call. After video patient evaluation and review of imaging, recommendations regarding tPA were communicated to the ED and followed the American Heart Association/American Stroke Association guidelines. Setup: InTouch Health products and services.	Outcomes: Patient characteristics, time to initiation of the consult, and treatment decisions. Results: The mean age was 64.5 years, and 60.4% were female. Median time from initial emergency room call to start of Teleconsult was 5 (range, 1–51) minutes. The average length of Teleconsult was 30 minutes. 281 Telestroke patients (56.4%) were determined by Teleconsult to have an AIS or TIA. The tPA was recommended for 72 patients (14.5% overall; 25.6% of ischemic stroke/TIA patients). Transfer to the hub hospital occurred in 75 patients.
Kramer et al. 2014 [12], USA	Acute neurologic conditions (Resident Physicians, fellows and Neurologists)	36 trainees and 10 faculty members worked from July 2009 through November 2011. invited to participate via email	Methods: Resident physician and fellow trainees and faculty at a single institution who provided service over 29 months were surveyed. Responding participants answered 10 questions using a 5-point Likert scale or ranking. Setup: Surveys via email.	Outcomes: The survey compared experiences using the supervisory methods of telephone, robotic telepresence (RTP), and in-person interaction. Results: Surveys were received from 20 of the trainees (55.5%) and 8 of the faculty members (80%). 85% of both trainees and faculty preferred in-person supervision most, with robotic telepresence RTP ranked second and telephone being least favored. 38% of faculty and 70% of trainees reported telephone method was unsatisfactory for patient data review.
Belt et al. 2016 [35], USA	Epilepsy in Children	89 Stroke patients evaluated by in-transit Telestroke (ITTS) from January 2015 through March 2016.	Methods: ALS Units are easily clamped onto BLS ambulance stretchers and transmitted images during patient transport. Paramedics, trained for neurological emergencies assisted remote teleneurologists in obtaining a simplified history and examination, then coordinating care with the receiving emergency department. Setup: 4 ALS units were provided with an InTouch Xpress device, a portable unit incorporating a high-definition camera, microphone, and screen allowing transparent bidirectional communication.	Outcomes: Door-to-needle (DTN) and last-known-well-to-needle (LKWTN) times for all intravenous alteplase–treated stroke patients were assessed and compared in with and without in-transit Telestroke. Results: All alteplase-treated strokes brought to the ED had ITTS. Mean DTN time was 28 minutes (95% CI, 23–35) in ITTS patients, 41 in controls (95% CI, 36–47; P=0.02). Mean LKWTN time was 30 minutes less, 92 with ITTS (95% CI, 69–115), and 122 without (n=71; 95% CI, 109–135; P=0.037. Among non-ITTS patients evaluated by telemedicine (n=36), DTN was 12 minutes longer than with in-person assessment (n=48; P<0.001).
Bashiri et al. 2016 [36], USA	Neurological disorders (Neurologists)	Surveyed all patients at UAMC Neurology Clinic between March 2011 and December 2012.	Methods: The questionnaire was composed of the following four main questions- 1. Do you travel more than 1 hour by car to get to the neurology clinic? 2. Does your neurological condition make driving or travel difficult? 3. Have you missed appointments due to travel-related problems? 4. Does travel to the clinic create a financial hardship for you? Setup: Surveys	Outcomes: To assess patient interest in participating in Teleneurology for routine follow-up visits as well as demographic and medical factors associated with interest. Results: Of 1,441 respondents, 52.4% were interested in telemedicine. Of those interested versus uninterested in telemedicine, respectively, 68.9% versus 36.32% traveled more than 1 h to the clinic (p < 0.001), 64.7% versus 35.3% had difficulty secondary to neurological conditions (p < 0.001), 22.6% versus 6.8% had missed medical appointments due to travel problems (p < 0.001), and 43.1% versus 9.4% had travel-imposed financial hardship (p < 0.001).
Al Kasab et al. 2017 [13], USA	Acute Ischemic Stroke (Neurologists)	A total of 7,694 stroke consults at Medical University of South Carolina (MUSC) from May 1, 2008, through April 6, 2016	Methods: Retrospective Data was collected which included National Institutes of Health Stroke Scale (NIHSS) on presentation, number of IV alteplase administrations, number of patients transferred to MUSC, number of mechanical thrombectomies performed on transferred patients, the rate of symptomatic intracerebral hemorrhages (sICHs), and discharge location. Setup: Web conferencing.	Outcomes: To assess how the Telestroke program had developed and the rate and safety of (IV) alteplase administration through Telestroke. Results: Over the study period, the number of participating sites increased from 6 to 19 sites. The percentage of transfers decreased from 48% to 16%. Of the 7694 total, 3,795 (49.2%) patients were diagnosed with ischemic stroke, of those 1,324 (34.8%) received IV alteplase. The sICH occurred in 33 patients who received alteplase, and in 5 patients receiving a combination of IV and intra-arterial thrombolysis. The number of rtPA administered over Telestroke increased from 28 cases in 2008 to 336 cases in 2015. Average door-to-needle times decreased from 98.8 min in 2008 to 66.5 min in 2015.
Elson et al. 2018 [11], USA	Neurological disorders (Primary Care Physicians and Neurologists)	183 local clinicians surveyed, 89 completed the survey (43 among those in the usual care group and 46 in the intervention group) between March 2014 and August 2016.	Methods: Clinicians whose patients with Parkinson’s disease had participated in a national randomized controlled trial of video visits were Surveyed. Setup: Videoconferencing Polycom software on Dell notebook computers.	Outcomes: To determine whether clinicians received recommendations from remote specialists; recommendations were implemented; what barriers to speciality care local clinicians perceived; and recommend video visits. Results: Among respondents in the intervention group, 19 (44%) reported receiving the consultation note from the remote specialist. Sixteen (84%) of these implemented recommendations and 13 (81%) reported that the recommendations improved their patient’s condition. Thirty-six (40%) local clinicians would recommend video visits to their other patients with Parkinson’s disease. Thirty-two (37%) were unsure, and 12 (13%) would not recommend them. There was no difference in responses between those clinicians whose patients were in the usual care or the intervention group, nor between primary care physicians, neurologists, and Parkinson’s disease specialists.
Konanki et al. 2018 [15], India	Neurocysticercosis (NCC) and seizures ( Pediatrics Neurologist resident trainee)	402 children attending Neurocysticercosis (NCC) clinic between January –June 2011	Methods: The parents of children aged between 2–15 years with mild NCC burden (1–5 ring-enhancing lesions) and seizures, not receiving cysticidal drugs currently (Not eligible for cysticidal therapy or have completed cysticidal treatment), were contacted by a Pediatric Neurology Resident on Telephone before the scheduled hospital visit and were seen next day at the hospital by different Pediatric Resident. Setup: Structured Questionnaire.	Outcome: The primary objective was to estimate the diagnostic accuracy of telephone consultation to identify Critical Clinical Events compared with the Face-to-Face consultation (gold standard), in children with NCC and symptomatic seizures following the completion of cysticidal therapy. Results: Among 228 consultations, a total of 55 events were identified in 43 patients by Face-to-Face consultation (gold standard). Overall, 43 out of 228 consultations had Critical Events (18.8%). Among the individual groups of Critical Events, telephone consultation accurately identified seizures in all 18 children (sensitivity 100%), and raised ICP in all eight children (sensitivity 100%).
Dallolio et al. 2008 [37], Italy	Spinal Cord Injury (medical and nursing staff, physiotherapists, and occupational therapists)	137 study participants were recruited at 4 spinal cord units between November 2003 and February 2006. Randomized: 65 in telemedicine group and 68 in the control group	Methods: All patients received standard care from the spinal cord unit. In addition, patients randomized in the telemedicine group received 8 telemedicine weekly sessions in the first 2 months, followed by biweekly telemedicine sessions for 4 months. Telerehabilitation was performed by use of a dedicated videoconferencing platform. Setup: 1 central unit (set-top box), 1 webcam, 1 microphone with noise and echo cancellation, 1 remote controller, 1 universal serial bus electronic security key, 1 audio/video television connection cable and the related adapter, 1 power cable, 2 audio interconnection cables, 1 untwisted cable to connect to the integrated services digital network socket or to the asymmetric digital subscriber line modem, and 1 system reference manual.	Outcomes: To compare the Functional status at 6 months, clinical complications during the postdischarge period, and patient satisfaction of telerehabilitation intervention with those of standard care for spinal cord injury (SCI). Results: A higher improvement of functional scores in the telemedicine group was found only at the Italian site. FIM total score 3.38±4.43 (controls) versus 7.69±6.88 (telemedicine group), FIM motor score 3.24±4.38 (controls) versus 7.55±7.00 (telemedicine group) P .05 satisfaction with care was reported by patients in the telemedicine group across all sites.
Winter et al. 2019 [38], Germany	Stroke symptoms mimicked by actors (Paramedics and Neurologists)	40 Scenarios each group of 3G and 4G were used.	Methods: Trained actors presented stroke symptoms and paramedics assisted the remotely guided extended National Institutes of Health Stroke Scale (eNIHSS) assessment on the mobile stroke unit. Setup: Unit with camera, microphone and screen allowing use of bilateral communication.	Outcomes: To compare technical parameters of 4G and 3G connections, assessed the audio-visual quality of examination, and analyzed the reliability of neurological assessment and treatment decisions made by the remote neurologist versus the mobile stroke unit neurologist. Results: The remote examiners graded audio and video quality in 4G better than in 3G with slightly shorter assessment duration in 4G (mean: 9 (SD:5) vs. mean 11 (SD:3) min, p = 0.10). Reliability of the eNIHSS sum scores was high with intraclass correlation coefficients of 0.99 (95% CI: 0.987-1.00) for 4G and 0.98 (95% CI: 0.96-0.99) for 3G. None of the remote treatment decisions differed from onsite decisions.