Association of Telestroke Implementation with Onset-to-Admission Time and Clinical Outcomes in Patients with Acute Ischemic Stroke: A Retrospective Cohort Study in Bandung, Indonesia

Background: Telestroke may improve access to specialist stroke assessment in regions where neurological expertise is not immediately available. However, evidence regarding its implementation in low- and middle-income settings remains limited. This study explored the association between the Bandung Telestroke Activation System and onset-to-admission time and short-term clinical outcomes among patients with acute ischemic stroke. Methods: This retrospective cohort study included patients with acute ischemic stroke treated within the Bandung Telestroke referral network during the study period. Patients were categorized into Telestroke and Non-Telestroke groups according to whether their clinical management involved the Bandung Telestroke Activation System. The Telestroke group consisted of patients initially assessed at participating spoke hospitals and managed through remote neurological consultation before referral to Dr. Hasan Sadikin General Hospital, whereas the Non-Telestroke group consisted of patients who presented directly to the hub hospital without Telestroke support. Outcomes included onset-to-admission time, intravenous thrombolysis administration, and changes in National Institutes of Health Stroke Scale (NIHSS) scores during hospitalization. Results: The Telestroke group had a substantially shorter median onset-to-admission time than the Non-Telestroke group (3.5 vs. 20.0 h; p < 0.001) and a higher proportion of patients presenting within 4.5 h (59.0% vs. 8.3%; p < 0.001). After multivariable adjustment, Telestroke-supported care remained strongly associated with presentation within 4.5 h (aOR 11.20, 95% CI 4.16–30.11; p < 0.001). This association remained consistent after propensity score matching and residual adjustment (aOR 13.53, 95% CI 4.48–40.86; p < 0.001). Thrombolysis was more frequent in the Telestroke group in both the original and matched cohorts. Although the Telestroke group showed greater unadjusted ΔNIHSS, Telestroke was not independently associated with neurological improvement of ≥4 NIHSS points after multivariable adjustment (aOR 0.74, 95% CI 0.27–2.06; p = 0.564) or after propensity score matching (aOR 0.61, 95% CI 0.18–2.03; p = 0.419). Conclusions: The Bandung Telestroke Activation System was consistently associated with more timely hospital presentation and a higher proportion of thrombolysis administration. However, an independent association with early neurological improvement was not demonstrated after adjustment. These findings support the potential role of Telestroke in improving timely access to acute stroke care but should be interpreted cautiously given the retrospective design, different referral pathways, residual confounding, and limited sample size.