When Door-to-Needle Includes Any Injection: Interpreting Digital Stroke Prenotification Outcomes (Preprint)

UNSTRUCTURED This letter comments on a pilot quasi-experimental study of a digital prehospital notification app for suspected stroke. Because the study defined "needle" as the start of any parenteral treatment, including osmotic agents or diuretics, its door-to-needle outcome is not equivalent to the standard time to intravenous thrombolysis. I ask the authors to report separate estimates for time to thrombolysis, endovascular treatment, and supportive injection; to provide a patient-level sensitivity analysis for the many-to-many matched generalized estimating equation models; and to address differential ascertainment of onset times between groups. These clarifications would separate operational gains from demonstrated improvements in stroke-specific treatment.