Introduction

Telestroke consultation facilitates remote evaluation, diagnosis and management of acute stroke, including assessment of reperfusion candidacy. Examining recent Canadian data, Barrette et al. (2026) found that, in patients receiving endovascular therapy (EVT), telestroke-evaluated patients had longer symptom-to-treatment times and worse outcomes compared to those evaluated without telestroke. ^{Reference Barette1} However, these differences attenuated after adjustment for clinical and radiological factors.

The data reveal helpful information to guide further quality improvement. First, “telestroke” was only a marker for initial presentation to a primary stroke centre (PSC) and did not cause delays itself: in a subanalysis limited to PSC patients, telestroke vs. non-telestroke management did not differ in workflow delays or outcomes. Second, telestroke patients transferred to comprehensive stroke centres (CSCs) had longer overall onset-to-CSC times due to longer delays in arriving at PSCs and then CSCs. Their door-to-groin puncture times at CSCs were actually faster, likely due to pre-notification, and, in some cases, thrombolysis, prior to arrival.

Thus, worse functional outcomes in telestroke patients reflect baseline stroke severity and transport times, not the assessment modality. Each reperfusion delay of 30 minutes reduces the likelihood of a good outcome by 10–15%. ^{Reference Saver, Goyal and van der Lugt2,Reference Khatri, Yeatts and Mazighi3} Therefore, the real leverage points for improvement lie not within telestroke use but in door-in-door-out (DIDO) workflows at PSCs, and logistics accelerating arrival to treatment-capable centres.

Despite stroke systems improvements, interhospital transfer remains complex, with dozens of identified process steps and associated barriers. ^{Reference Ng, Low and Andrew4} Emerging evidence suggests that a 45-minute DIDO, rather than the current Canadian median of 120–180 minutes, could increase EVT use and improve outcomes. ^{Reference Kamal, Baradaran-Noveiri, Barrie, Holodinsky, St Louis and Demchuk5} Geographic proximity to CSCs also appears to facilitate faster DIDOs, likely reflecting more established transfer pathways and logistical familiarity.

Evidence-based processes to improve DIDOs are emerging, ^{Reference Kamal, Baradaran-Noveiri, Barrie, Holodinsky, St Louis and Demchuk5,Reference Prabhakaran, Gonzalez and Zachrison6} and ongoing quality improvement work and accountability measures will be needed to improve performance at slower sites. To speed transfer to PSCs and CSCs when distances are vast is an even more complex task, and stroke patients compose only a proportion of those needing transfer for higher level of care. Contemporary modelling strategies will need to account for other demands on the system beyond distances alone, including overall demands on regional ground and air transport resources and how these may vary with geography, weather and demand from other emergent scenarios including trauma and obstetrics. Ideally, gaps may be filled by judicious addition of new EVT-capable sites in the future to match the growing demand for optimal acute stroke care.