Telestroke systems and thrombolysis decisions: diagnostic uncertainty, treatment thresholds, and stroke mimics

Telestroke expands access to specialist stroke care and is associated with increased use of intravenous thrombolysis (IVT). Whether this reflects improved access alone or also changes how clinicians act under diagnostic uncertainty remains unclear.

To review evidence on telestroke-associated thrombolysis, stroke mimics, and decision-making, and to examine the hypothesis that telestroke may influence the practical threshold for IVT.

We conducted a narrative review of studies addressing telestroke implementation, IVT utilization, stroke mimic frequency and safety, remote neurological assessment, and decision-related features of telestroke care. Evidence was synthesized around three proposed domains: risk asymmetry, information constraints and diagnostic friction, and distributed responsibility with workflow pressure.

Telestroke is consistently associated with greater thrombolysis utilization, while stroke mimics remain common among both evaluated and treated patients. Serious hemorrhagic complications after thrombolysis of stroke mimics are uncommon. However, existing studies are predominantly observational and do not directly measure clinicians' diagnostic confidence or treatment thresholds. Higher IVT rates and mimic treatment may therefore reflect improved specialist access, faster workflows, case mix, or other system-level factors rather than a lower threshold for treatment.

Current evidence does not demonstrate that telestroke lowers the thrombolysis threshold. Instead, a treatment-threshold shift should be regarded as a testable hypothesis. Future studies should directly measure diagnostic confidence, estimated stroke probability, competing diagnoses, and treatment decisions to determine how telestroke influences clinical decision-making under uncertainty.