AUTHOR=Nasreldein Ahmed , Walter Silke , Mohamed Khaled O. , Shehata Ghaydaa Ahmed , Ghali Azza A. , Dahshan Ahmed , Faßbender Klaus , Abd-Allah Foad 

TITLE=Pre- and in-hospital delays in the use of thrombolytic therapy for patients with acute ischemic stroke in rural and urban Egypt

JOURNAL=Frontiers in Neurology

VOLUME=Volume 13 - 2022

YEAR=2023

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2022.1070523

DOI=10.3389/fneur.2022.1070523

ISSN=1664-2295

ABSTRACT=Background: Reducing pre- and in-hospital delays play an important role in increasing the rate of intravenous thrombolysis (IVT) in patients with acute ischemic stroke. In Egypt, the IVT rate has increased steadily but is still far away from an ideal rate. 
Aim: To investigate factors associated with pre- and in-hospital delays of IVT among acute ischemic stroke patients coming from urban and rural communities.
Methods: This prospective, multi-center, observational cohort study was conducted from January 2018 to January 2019. Patients with acute ischemic stroke, who did not receive IVT, were included in the study. Patients were recruited in three large University stroke centers in Egypt, Assiut (south of Egypt), Tanta (north of Egypt), both serving urban and rural patients and the University Hospital in Cairo (capital city), only serving an urban community. All participants underwent NIHSS and full neurological assessment, urgent laboratory investigations and computed tomography or magnetic resonance imaging to confirm the stroke diagnosis.  The patients were subjected to a structured questionnaire which was designed to determine the parameters and time metrics for the pre- and in-hospital delays among patients from rural and urban regions.
Results: A total of 618 patients were included in the study. 364 patients (58.9%) lived in rural regions and 254 (41.1%) in urban regions. General demographic characteristics were similar between both groups. 73.3% of patients arrived within the therapeutic time window were urban patients. The time from symptom onset till hospital arrival (onset to door time, ODT) was significantly longer among rural patients (738 ± 690 min) than urban patients (360 ± 342 min). Delayed onset to alarm time (OAT), initial misdiagnosis and presentation to non-stroke ready hospitals were the most common causes of pre-hospital delay and were significantly higher in rural patients. For patients arriving within the time window, the most common causes of in-hospital delays were prolonged laboratory investigations and imaging duration.
Conclusion: The limited availability of stroke-ready hospitals in rural Egypt leads to delays in stroke management, with subsequent treatment inequality of rural acute stroke patients.