AbstractIntroductionWhether the coronavirus disease‐2019 (COVID‐19) pandemic is associated with a long‐term negative impact on acute stroke care remains uncertain. This study aims to compare the timing of key aspects of stroke codes between patients before and after the COVID‐19 pandemic.MethodsThis retrospective cohort study was conducted at an academic hospital in Shanghai, China and included all adult patients with acute ischemic stroke hospitalized via the emergency department (ED) stroke pathway during the 24 months since the COVID‐19 outbreak (COVID‐19: January 1, 2020–December 31, 2021). The comparison cohort included patients with ED stroke pathway visits and hospitalizations during the same period (pre‐COVID‐19: January 1, 2018–December 31, 2019). We compared critical time points of prehospital and intrahospital acute stroke care between patients during the COVID‐19 era and patients during the pre‐COVID‐19 era usingttest, χ2, and Mann–WhitneyUtest where appropriate.ResultsA total of 1194 acute ischemic stroke cases were enrolled, including 606 patients in COVID‐19 and 588 patients in pre‐COVID‐19. During the COVID‐19 pandemic, the median onset‐to‐hospital time was about 108 min longer compared with the same period of pre‐COVID‐19 (300 vs 192 min,p= 0.01). Accordingly, the median onset‐to‐needle time was 169 min in COVID‐19 and 113 min in pre‐COVID‐19 (p= 0.0001), and the proportion of patients with onset‐to‐hospital time within 4.5 h was lower (292/606 [48.2%] vs 328/558 [58.8%],p= 0.0003) during the pandemic period. Furthermore, the median door‐to‐inpatient admission and door‐to‐inpatient rehabilitation times increased from 28 to 37 h and from 3 to 4 days (p= 0.014 and 0.0001).ConclusionsDuring the 24 months of COVID‐19, a prolongation of stroke onset to hospital arrival and to intravenous rt‐PA administration times were noted. Meanwhile, acute stroke patients needed to stay in the ED for a longer time before hospitalization. Educational system support and process optimization should be pursued in order to acquire timely delivery of stroke care during the pandemic.