Studying long-term trends of stroke events and case fatality rates is essential for assessing whether patient outcomes have improved as a result of better prevention and treatment in our stroke systems. Setayeshgar et al.’s study presents trends from stroke events and mortality from 2002 to 2022 in British Columbia. ^{Reference Setayeshgar, Zhou and Hennawy1} This study is unique compared to previous studies because it includes data from pre-admission stroke deaths, which includes patients who died outside of a hospital where stroke is recorded as the underlying cause on the death certificate and patients who died in the emergency department due to stroke prior to admission. One of these previous studies presented stroke admission and in-hospital mortality trends from 2003 to 2012 based only on hospital admissions. ^{Reference Kamal, Lindsay, Côté, Fang, Kapral and Hill2} Another study counted the number of stroke events across Canada in 2017 based on hospital admission and emergency department presentations due to stroke with projections where the data did not exist. ^{Reference Holodinsky, Lindsay, Amy, Ganesh, Joundi and Hill3}

The findings from this study show that stroke events and mortality are declining in British Columbia. These results reassuringly demonstrate that there is improvement in patient outcomes due to both stroke prevention and reperfusion therapies with intravenous thrombolysis and endovascular thrombectomy (EVT). Furthermore, not surprisingly, the results show that there is continued disparity in stroke events and mortality between urban and rural locations as well as income levels. This provides us with an imperative to improve access to primary/secondary stroke prevention clinics in areas outside of the urban centers; additionally, it is equally important to improve utilization of thrombolysis at primary stroke centers and increase efficient transfers for EVT to EVT-capable centers.

However, the most concerning aspect of these data is the high number of pre-admission stroke deaths, which has not been estimated in previous studies that presented trends and numbers of stroke events and mortality. This study showed that 21% of all stroke events were a result of deaths prior to hospital admission, which is concerning as early death due to stroke typically occurs 24 hours to 72 hours after onset, and stroke mortality more commonly occurs several days after onset. This may be due to the inclusion of deaths due to stroke in the emergency department, or it could be an issue with attribution to stroke in the death certificate. Nevertheless, if British Columbia is indeed seeing such a large number of pre-admission stroke deaths, it warrants a deeper dive into the causes.