Fast delivery of intravenous thrombolysis (IVT) and transportation to a comprehensive stroke center (CSC) are paramount for primary stroke centers (PSCs). We investigated outcomes and workflow times of patients treated with IVT at PSCs.

This is a secondary analysis of the AcT trial, a multicenter, phase-3, randomized, controlled, noninferiority trial comparing tenecteplase with alteplase in patients with acute ischemic stroke within 4.5 hours of onset. We compared baseline characteristics, imaging and clinical outcomes at 90 days, and workflow times between PSCs and CSCs.

Of 1577 patients enrolled in the trial, 99 (6.27%) were treated at PSCs and 1,478 (93.72%) at CSCs. Both groups had similar age, proportion of females, baseline NIHSS and presence of LVO. The proportion of patients achieving excellent functional outcome at 90 days was higher in PSCs compared to CSCs (mRS 0-1: 48.48% versus 35.01%, adjusted IRR, 1.42 [CI 95%, 1.04–1.95]). Patients at PSCs had longer door-to-needle times (median, 56.5 [42–70] versus 35 [27–47] minutes, p < 0.001). In the 24 patients transferred to CSCs, the needle-to-puncture time was more favorable for tenecteplase compared to alteplase (median, 35.5 [21–58] versus 52 [18–74] minutes, p < 0.001).

Our findings suggest that patients treated at PSCs may achieve outcomes comparable to those treated at CSCs, despite differences in workflow efficiency. These results should be interpreted cautiously, as this is a hypothesis-generating analysis, and observed differences may reflect multiple factors, including site-level practices, referral patterns and workflow characteristics.