Ignacio and colleagues reported that in-hospital strokes accounted for 10.6% of 24,039 overall strokes that occurred between Jan 1, 2018 and Dec 31, 2022 in Alberta, Canada. ^{Reference Ignacio, Abdalrahman and Kaveeta1} In-hospital strokes were more severe, required longer hospital stays and were associated with a 3-fold higher mortality (after adjusting for age, sex, comorbidities, facility type and admission year) compared with community-onset strokes. Despite the greater severity, workflow times were longer, consistent with previous studies. Patients with in-hospital strokes less frequently received intravenous thrombolysis (IVT; 2.4% vs. 9.9%) but had a similar frequency of undergoing endovascular therapy (EVT; 4.3% vs. 4.2%) compared to those with community-onset strokes. Undergoing EVT was associated with lower in-hospital mortality and risk of pneumonia. By utilizing a population-based database of all Alberta hospital discharges linked to the Quality Improvement and Clinical Research Alberta Stroke Program Registry, which captures detailed information on patients with acute ischemic stroke treated with IVT and/or EVT, the study describes current outcomes and highlights important opportunities for improvement for the treatment of in-hospital strokes.

The authors emphasized that in-hospital strokes accounted for more than 10% of all ischemic strokes, a proportion that cannot be overlooked. Notably, more in-hospital strokes occurred in non-stroke centers compared to where community-onset strokes presented (36.3% vs. 19.3%), suggesting that early detection and standardized protocols for in-hospital stroke are important for any hospitals. ^{Reference Reale, Iacovelli and Rabuffetti2,Reference Kuczynski, Freeman, Mooney, Huang, Demchuk and Khosravani3} Only a small proportion of in-hospital stroke patients were transferred to advanced stroke centers for IVT or EVT, highlighting the opportunity for early triage and transfer systems in non-stroke centers to improve the in-hospital stroke chain of survival and to lead to better outcomes. Future investigation of integrated provincial diagnostic imaging data may provide more detailed and clinically meaningful metrics. ^{Reference Shah, He and Dyck4}

Several questions remain. How frequent is it among patients with in-hospital ischemic stroke that they are potentially eligible for EVT? Previous studies suggest that large vessel occlusion (LVO) accounts for approximately 24–38% of all ischemic strokes. ^{Reference Rennert, Wali and Steinberg5} Given the severity of baseline comorbidities, patients hospitalized in advanced stroke centers may be at particularly high risk for developing LVO-related ischemic stroke. Better data on treatment patterns and outcomes in subgroups of hospitalized patients, such as those undergoing surgery or cardiac interventions, would also yield important information with implications for screening and resource allocation. Although ischemic subtype predominates, an analysis of in-hospital hemorrhagic stroke, including intracerebral hemorrhage (ICH), may add unique insight into the recent “Code ICH” paradigm. ^{Reference Li, Yakhkind and Alexandrov6}