Real-World Analysis of Stroke Care: Thrombolysis and Thrombectomy in a Regional Stroke Unit in Germany

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This paper could be accepted after minor revision.

Although the authors mentioned in the Limitations section that outcome data were not collected, they should explain why this happened. Is this due to a flaw in the organization and design of this study or was this work not performed due to objective circumstances? Indeed, the lack of these data severely limits the ability to assess the clinical impact of process time on patient recovery and long-term prognosis. Such data would greatly enhance the value of this work.

Author Response

Although the authors mentioned in the Limitations section that outcome data were not collected, they should explain why this happened. Is this due to a flaw in the organization and design of this study or was this work not performed due to objective circumstances? Indeed, the lack of these data severely limits the ability to assess the clinical impact of process time on patient recovery and long-term prognosis. Such data would greatly enhance the value of this work.

Thank you for this important observation. We agree that the absence of outcome data limits the clinical interpretability of our findings. However, the primary objective of this subanalysis was to evaluate organizational process data based on existing documentation within the framework of the FAST4D study. The collection of structured clinical outcome data was not part of the original study design and could not be implemented retrospectively due to ethical and logistical constraints.

“...no clinical outcome data were collected, as this subanalysis focused on organizational process variables [...]”

Reviewer 2 Report

Comments and Suggestions for Authors

Comments: 

This is a study describing the real-world analysis of stroke care in a regional stroke unit in Germany. In this observational study, authors report that different stroke practices at the center. The research question is not novel but may be important for a specific geographical region. The study design, analysis and their interpretations are appropriate. The manuscript is logically structured and easy to read. The authors need to address the following points: 

1. Introduction: The study is not novel. The authors should discuss how this is addressing a potential knowledge gap. a 

1. Methodology: As the study is based on retrospective chart review, the measures to deal with missing data should be mentioned.  

1. Methods: The neuroimaging done at the time of presentation and the protocol followed should be mentioned. The step-up of the stroke unit may also be mentioned.  

1. Results: Many clinically important factors have not been provided. E.g Stroke severity, Time to thrombolysis, Neuroimaging findings, ASPECTS score, types of stroke, risk factors for stroke. These factors influence the decision regarding EVT. 

1. Results: Reasons for ‘no IVT’ needs to be mentioned in detail. The term ‘Other contraindications’ needs to be elaborated. Which criteria were followed for the same?  

1. Results: 749 (51.5%) patients were female. I think the authors mean this percentage is of the confirmed stroke patients, not of the whole cohort of 2436 patients. The first line of the results section may be reframed. Additionally, 749 is not 51.5% of 1394.  

1. Was perfusion scanning done in patients while deciding not to proceed with IVT? 

1. General information about emergency healthcare in the particular region, their accessibility and methods of referral may be provided as the readers might not be aware of them. 

1. No attempt has been made to address the factors for delay in IVT or EVT.  

 

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The authors have prepared a manuscript that examines thrombolysis and thrombectomy rates, as well as door-in-door-out (DIDO) time and reasons for not administering intravenous thrombolysis (IVT) in a regional stroke unit in Germany. The article could be valuable for neurologists and healthcare system specialists. However, I have several recommendations, which are outlined below:

1. There appears to be a technical error, as two figures are missing from the manuscript.
2. The authors state, "Continuous variables were reported as mean ± standard deviation (SD), median and interquartile range (IQR) [Quartile 25 – Quartile 75], or as numbers and percentages, depending on data distribution." However, I did not observe any data presented as Me[Q1; Q3] apart from references to other reports (e.g., [4]).
3. It may be beneficial to add another table that breaks down the cohort by gender to examine potential sex-based differences in any of the parameters.
4. It might also be useful to mention global and Europe-wide statistics regarding DIDO time, IVT, and EVT in the Discussion section.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the comments regarding my question. The paper could be published in present form.

Author Response

Comment:
Thank you for the comments regarding my question. The paper could be published in present form.

Response:
We sincerely thank the reviewer for the positive evaluation and supportive comment. We are pleased that the revisions addressed the concerns raised and that the manuscript is now considered suitable for publication in its current form.

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have addressed most of my queries adequately. One minor correction about the % of female in the Table 1 is needed. 

Author Response

Comment:
The authors have addressed most of my queries adequately. One minor correction about the % of female in the Table 1 is needed.

Response:
We thank the reviewer for this helpful final remark. We have corrected the percentage of female patients in Table 1 to match the number provided in the text (749/1394 = 53.7%) and ensure consistency throughout the manuscript.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors successfully addressed all the points raised.