Kinnear and colleagues should be congratulated for providing important population-level data on geographic differences in vascular imaging after ischemic stroke and Transient Ischemic attack in Manitoba. Patients presenting to rural hospitals were less likely to undergo neck Computed tomography angiography (CTA) within seven days than those presenting to urban hospitals (57.4% versus 81.6%), and urban presentation remained associated with CTA receipt after adjustment for age and sex (Odds ratio: 1.58, 95% Confidence interval: 1.15–2.18). ^{Reference Kinnear, Zahid and Avila Salas1} These findings raise concern for geographic inequity in timely vascular stroke investigations.

The reasons underlying this difference are likely multifactorial. Stroke severity differed between groups but was not included in the adjusted model. Other clinical and system-level factors, including diagnostic certainty, contrast-related limitations, transfer pathways, local CTA capability, staffing and imaging protocols, may influence the indication for, feasibility of or timing of CTA. ^{Reference Kinnear, Zahid and Avila Salas1} As the authors acknowledge, carotid ultrasound was not captured, and imaging performed after seven days did not contribute to the primary exposure definition. Thus, some patients without timely CTA may still have undergone later or alternative vascular assessment.

The exploratory revascularization analysis is informative, although only 39 patients underwent carotid revascularization, limiting precision and the ability to distinguish access barriers from differences in carotid anatomy, symptom attribution, procedural eligibility, competing illness, patient preference or referral pathways. ^{Reference Kinnear, Zahid and Avila Salas1} Associations between CTA receipt, antithrombotic use, recurrence and mortality should also not be interpreted causally and may reflect broader differences in stroke care and follow-up. ^{Reference Kinnear, Zahid and Avila Salas1}

Prior Canadian data suggest that more granular measures of geographic access may help build on these findings. In Ontario, rurality defined by community size was not associated with thrombectomy, whereas increasing driving time to a comprehensive stroke center was associated with lower odds of thrombectomy at longer distances. ^{Reference Taghdiri, Vyas and Kapral2} Broad geographic categories may identify populations at risk, while more proximal measures may better identify modifiable barriers.

Future work could extend this study by evaluating the vascular stroke pathway in a time-resolved manner. Canadian recommendations support urgent arch-to-vertex vascular imaging, with CTA first-line when feasible and Magnetic Resonance Angiography or carotid ultrasound as reasonable alternatives when CTA is not possible. ^{Reference Heran, Lindsay and Gubitz3} Patients with symptomatic ipsilateral 50–99% extracranial carotid stenosis should be evaluated without delay for potential revascularization; when carotid endarterectomy is indicated in clinically stable patients, it should be performed as early as possible and ideally within 14 days. ^{Reference Gladstone, Lindsay and Douketis4} Measuring time to appropriate vascular imaging, transfer, specialist assessment and revascularization may provide a more complete assessment of equity and identify targets for system improvement.