Door-to-needle performance and areas for improvement of reperfusion therapy in acute ischaemic stroke

Introduction Door-to-needle (DTN) time and timely transfer for mechanical thrombectomy (MT) are key modifiable determinants of outcome in acute ischaemic stroke. We assessed reperfusion pathway performance and variables affecting DTN and door-to-departure (DTD) times in MT patients to identify areas for improvement. 

Method We retrospectively reviewed 239 consecutive patients directly admitted to Northampton General Hospital, University Hospitals of Northamptonshire NHS Trust, who underwent reperfusion therapy (rtPA, referred for MT, or both) between January 2025 and May 2026. Time intervals and clinical parameters, including working versus off-hours presentation, pre-alert Code Stroke activation and large vessel occlusion (LVO) presence, were analysed. 

Results Of 239 patients, 198 received rtPA and 92 underwent MT (61.5% rtPA only, 23.4% MT only, 15.1% both). Median DTN was 46 minutes (71.3% <60 mins; 12.3% <30 mins). Median door-to-CT was 19 minutes. DTN was significantly shorter during working hours than off-hours (43 vs 52.5 mins, p=0.0009). Code Stroke activation was less frequent in LVO-positive versus LVO-negative patients (53.2% vs 72.7%, p=0.033), and in MT-only versus rtPA-only patients (33.3% vs 69.3%, p=0.0014), despite higher initial NIHSS in MT-only patients (16 vs 6). Code Stroke in LVO-positive patients trended towards faster door-to-CT (14 vs 27.5 mins, p=0.09) but unaffected DTD. Scan-to-needle interval correlated strongly with overall DTN (ρ=0.73, p<0.0001). Median DTD for MT patients was 121.5 minutes, unaffected by bridging. CTA-to-transport request interval (median 41 mins) correlated strongly with total DTD (ρ=0.60, p<0.0001) and was prolonged off-hours (39 vs 48 mins, p=0.047). Total DTD trended longer off-hours (109 vs 132.5 mins, p=0.058). 

Conclusions Reperfusion treatment is significantly faster during working hours. Code Stroke activation is mainly used for thrombolysis patients. We identified areas of improvement, such as scan-to-needle interval for thrombolysis, and the CTA-to-transport request interval for necessary mechanical thrombectomy transfers.