Abstract Body: Introduction:
Telestroke has the potential to revolutionize acute stroke treatment by improving access to optimal stroke care, including time-sensitive care such as thrombolysis. Yet few studies have compared acute stroke treatment metrics and outcomes in patients treated using telestroke versus standard in-person stroke evaluation.

Methods:
This was a retrospective cohort study of acute ischemic stroke patients age ≥18 presenting to 53 Paul Coverdell Michigan hospitals between 2022 and 2023 who were potentially eligible for thrombolysis (i.e., presented ≤ 4 hours of last known well, no contraindications to thrombolysis). The primary exposure was telestroke (vs non-telestroke), and primary outcomes were receipt of thrombolysis and door-to-needle (DTN) time. Secondary outcomes included discharge ambulatory status and door-in-door-out (DIDO) time in transferred patients. Multivariable hierarchical models evaluated associations between the telestroke (vs. non-telestroke) activation and outcomes, sequentially adjusted for demographics, medical history, presenting/arrival, and hospital characteristics.

Results:
Among the 4974 stroke patients potentially eligible for thrombolysis (mean age 69.2 [SD: 14.6], 48.3% female), 1078 (21.7%) were evaluated using telestroke and 3896 (78.3%) without telestroke. Telestroke patients were more commonly at primary stroke centers (71.1% vs 39.0%) and less at comprehensive stroke centers (13.3% vs 53.9%; P<0.001). Thrombolysis was administered to 56.8% of telestroke patients (at the site of telestroke initiation) versus 54.7% of patients without telestroke (P=0.23). Telestroke patients had longer DTN times (55 vs. 47 minutes, P<0.001), longer DIDO times (166 vs. 142 minutes, P<0.001), and a lower likelihood of ambulating independently at discharge (P<0.001). After adjusting for patient demographics, medical history, and presenting/arrival factors, telestroke patients had significantly longer DTN times (8.1 minutes longer, 95% CI 1.9, 14.3). This difference was attenuated after adjustment for hospital characteristics, including stroke center status.

Discussion:
Acute stroke treatment metrics, including DTN and DIDO times, were significantly worse in telestroke vs. non-telestroke cases from the Paul Coverdell Michigan stroke registry. Differences in DTN were partially explained by hospital-level systems factors, such as stroke center status, which may serve as targets for future studies and quality improvement initiatives.