Missing Clot-Busting Drug, Not Missing Scanners, Blocks Stroke Care in Honduras

At the largest public hospital in Honduras, not a single patient with acute ischemic stroke received clot-dissolving therapy over a 61-day period, and the reason was not a lack of scanners, protocols, or trained neurologists. It was the absence of the drug itself. A new study from Hospital Escuela Universitario in Tegucigalpa, published in Frontiers in Stroke, documents with unusual precision how a supply failure can render an entire reperfusion system clinically inert, even when most of the surrounding infrastructure is technically in place.

The research team, led by Jesús Antonio Rodríguez Santos and colleagues at the National Autonomous University of Honduras, conducted a retrospective, consecutive case series of every acute ischemic stroke presentation to the hospital’s Internal Medicine Emergency Service between 1 October and 30 November 2025. Because they screened all arrivals rather than a selected sample, the cohort functions as a census for the period: 23 patients, median age 70 years, 14 of them male, and none thrombolyzed. The institutional thrombolysis rate for those two months was therefore exactly zero percent.

The clinical picture of the cohort was stark. Extreme poverty, defined as two or more unsatisfied basic needs in the household, affected 14 of the 23 patients, or 60.9 percent. Hypertension was nearly universal, present in 95.7 percent of patients, and diabetes in roughly a third. Most patients arrived with moderately severe deficits, with 82.6 percent falling in the middle range of the National Institutes of Health Stroke Scale, between scores of 5 and 25. These are precisely the patients in whom timely reperfusion can mean the difference between independent living and permanent disability.

Timing, however, had already eliminated most of them before any treatment decision could be made. The median onset-to-door time was 10 hours, with an interquartile range of 7 to 15 hours and individual delays stretching to 96 hours. Only one of the 22 patients with a recorded onset time arrived within the 4.5-hour window in which intravenous thrombolysis is standard. This pattern of prehospital delay is well documented in low- and middle-income countries, where stroke awareness, ambulance access, and geographic barriers conspire to consume the most treatment-responsive hours of the illness.

What makes the Honduran data distinctive is what happened next. The researchers constructed a thrombolysis eligibility cascade, a stepwise accounting of how many patients remain potentially treatable as each barrier is applied. Of 23 patients, the pool collapsed to a single individual after the time window criterion. That patient had no absolute contraindication to thrombolysis under the 2019 American Heart Association and American Stroke Association guidelines. Yet the drug, recombinant tissue plasminogen activator, was unavailable. Not scarce, not rationed, but entirely absent. The cascade terminated at zero treated patients, with the final and decisive loss attributable to supply alone.

The contrast with other system components is the study’s most consequential finding. Neuroimaging was available for 95.7 percent of patients, with a median door-to-imaging time of 3 hours. An institutional stroke protocol and trained personnel existed for the same proportion. In other words, the diagnostic and organizational machinery of acute stroke care was largely operational. The bottleneck was neither knowledge nor equipment but the physical presence of a vial of alteplase, a drug that has been standard of care worldwide since the mid-1990s.

The authors are careful about interpretation, and rightly so. With a single group and a constant outcome, no statistical hypothesis about why patients went untreated can be tested, and the study explicitly avoids causal claims. The 61-day window may have coincided with a particular shortage episode, so the findings cannot be generalized to all Honduran hospitals or all time periods. Data came from retrospective records, symptom onset times were often self-reported, and the admission stroke severity was captured in broad categories rather than as a continuous score. These are honest limitations, and the researchers document their data corrections transparently, including one entry error in a discharge severity score that was identified and fixed during chart review.

Even without thrombolysis, the natural history of untreated arterial occlusion played out in the cohort. In-hospital complications occurred in just over half of patients, most frequently hemorrhagic transformation of the index infarct, which affected four patients and was confirmed by computed tomography, since magnetic resonance imaging was not operational during the study period. Two patients died, an in-hospital mortality rate of 8.7 percent, consistent with figures from other Latin American stroke-unit registries. Among survivors, the median discharge stroke severity remained at 11 on the NIHSS, and only five of the 20 patients with an assessable modified Rankin Scale score achieved a good functional outcome, defined as a score of 0 to 2. The rest left the hospital with residual disability that timely reperfusion might have prevented or attenuated.

The study’s exploratory analyses reinforce a familiar prognostic principle: early neurological severity tracks with eventual disability. The NIHSS score at 24 to 72 hours correlated strongly with discharge modified Rankin Scale score, with a Spearman correlation coefficient of 0.79. But the authors emphasize that these hypothesis-generating findings, like the rest of the study, describe the cohort rather than estimate the effect of any single factor on treatment probability.

The practical implication is unusually direct. In a center where imaging capacity and trained staff already exist, securing an uninterrupted thrombolytic supply is the single most consequential intervention, and investments in stroke pathways or public awareness campaigns cannot translate into treatment until that prerequisite is met. Reducing prehospital delay through community education and emergency prenotification would enlarge the pool of window-eligible patients, but only once the drug is on the shelf. Quality-improvement programs elsewhere in Latin America have demonstrated that adherence to acute stroke therapies can improve within public systems, suggesting that organizational gains are achievable once the structural barrier falls. For the researchers, the path forward includes prospective, multicenter registries that capture both treated and untreated strokes, routine monitoring of drug supply, and longer-term evaluation of access to endovascular thrombectomy. Until then, the study stands as a patient-level illustration of a supply-side gap that regional reviews have described in the abstract: in much of Central America, the limiting reagent in stroke care is not expertise or equipment, but the drug itself.

Subject of Research: Barriers to intravenous thrombolysis in acute ischemic stroke at a Honduran national referral hospital

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

Article References: Barriers to intravenous thrombolysis in acute ischemic stroke: a retrospective case report series from Honduras. (n.d.). https://doi.org/10.3389/fstro.2026.1946997

Image Credits: AI Generated

DOI: 10.3389/fstro.2026.1946997

Keywords: stroke, thrombolysis, acute ischemic stroke, Honduras, health systems, low- and middle-income countries, reperfusion, alteplase, health equity, stroke care barriers, Latin America, drug availability