Barriers to intravenous thrombolysis in acute ischemic stroke: a retrospective case report series from Honduras

Background and purpose Intravenous (IV) thrombolysis for acute ischemic stroke (AIS) is time-dependent and frequently underused in resource-limited settings. We aimed to characterize patients with AIS who did not receive IV thrombolysis at a national referral center in Honduras and to document the barriers to treatment. Methods We conducted a retrospective, single-center, consecutive case report series of all eligible patients with AIS who were not thrombolyzed at Hospital Escuela Universitario between 1 October and 30 November 2025. We gathered demographics, socioeconomic status, admission severity, process-of-care intervals, contraindications, neuroimaging and thrombolytic availability, complications, and discharge outcomes. Contraindications were classified as absolute or relative according to the 2019 American Heart Association and American Stroke Association (AHA/ASA) guidelines. A thrombolysis eligibility cascade was the principal analysis. The study was approved by the institutional review board. Results A total of 23 patients were included (median age 70 years; 14 [60.9%] male). Extreme poverty (≥2 unsatisfied basic needs [UBN]) was present in 14 patients (60.9%). All 23 AIS presentations screened during the period were included, and no patient received thrombolysis (institutional thrombolysis rate 0%). The median onset-to-door time was 10.0 h (IQR 7.0–15.0), and only 1 of 22 patients with a recorded time (4.5%) arrived within 4.5 h. Late or unknown onset was the most frequent absolute contraindication (21 [91.3%]); neuroimaging was available in 22 (95.7%) patients, but the thrombolytic agent was unavailable in every patient (availability 0%). In the eligibility cascade, the single patient within the window had no absolute contraindication and could not be treated because no thrombolytic agent was available. The in-hospital mortality rate was 2 (8.7%), and a good functional outcome (modified Rankin Scale [mRS] score 0–2) occurred in 5 of 20 patients with an assessable score. Conclusion Non-administration of thrombolysis reflected late presentation and, above all, the complete unavailability of the thrombolytic agent, whereas imaging and organizational capacity were largely in place. Drug supply was the proximate, modifiable obstacle to reperfusion in this setting.