Barriers to Optimal Acute Management of Stroke: Perspective of a Stroke Center in Mexico City

The first barrier is there are no protocols anywhere in stroke. This is already established in the title by 'management' instead of curing or recovery from stroke.

Barriers to Optimal Acute Management of Stroke: Perspective of a Stroke Center in Mexico City

Vanessa Cano-Nigenda¹, Enrique Castellanos-Pedroza¹, Diana Manrique-Otero¹, Beatriz Méndez², María Fernanda Menéndez-Manjarrez¹, Roberto Toledo-Treviño¹, Miguel Calderón¹ and Antonio Arauz^1*

• ¹Stroke Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
• ²Department of Endovascular Therapy, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico

Background: Stroke is a leading cause of death and disability worldwide, particularly in low- and middle-income countries. We aimed to identify the main barriers to optimal acute management of stroke in a referral center.

Methods: Demographic data was collected from patients assessed with acute stroke in the emergency department of the Instituto Nacional de Neurología y Neurocirugía (INNN) from January to June 2019. Additionally, a telephone interview was conducted with patients/primary caregiver to know which they considered the main reason for the delay in arrival at INNN since the onset of stroke.

Results: 116 patients were assessed [age 65 ± 15 years, 67 (57.8%) men]. Patients consulted other facilities prior to arrival at INNN in 59 (50.9%) cases (range of hospitals visited 1–4), 83 (71.6%) arrived in a private car, with prenotification in only 4 (3.4%) of the total sample. The mean onset-to-door time was 17 h (45 min−10 days). Telephone interviews were done in 61 patients/primary caregivers, stating that they consider the multiple evaluations in other facilities [n = 26/61 (42.6%)] as the main reason for delay in arrival at the ED, followed by ignorance of stroke symptoms and treatment urgency [n = 21/61 (34.4%)].

Conclusion: In this small, retrospective, single center study, the main prehospital barrier to optimal acute management of stroke in a developing country is multiple medical evaluations prior to the patient's transport to a specialized stroke hospital, who mostly arrived in a private car and without prenotification. These barriers can be overcome by strengthening public education and improving patient transfer networks and telemedicine.

Introduction

Stroke remains the second leading cause of disability and death worldwide (1), particularly in low- and middle-income countries (LMICs), where most of the stroke burden occurs (2). The prospective data base from the National Institute of Neurology and Neurosurgery-Stroke Registry (NINN-SR), the largest hospital-based registry in Latin America, which included information on 4,481 strokes, showed a mortality rate of 24.5% and poor outcomes [modified Rankin scale (mRs) ≥ 3] in 56.2% of patients, mainly due to cerebral hemorrhage (3). In general, the mortality rate of stroke has been cut in half in high-income countries but reduced by only 15% in LMICs (4). In ischemic stroke (IS), the frequency of intravenous thrombolysis (IVT) use in Mexican hospitals is <10%, mainly because patients continue to arrive outside the therapeutic window (5).

The quality and quantity of stroke care is not homogeneous in developing countries. As observed in previous studies, there are multiple barriers at different levels of care, including at the patient level (sociocultural, stroke education, and financial considerations), in the healthcare system (inadequate stroke care protocol and a limited number of stroke team members), at the healthcare professional level (low collaboration, limited and outdated knowledge of stroke) and regarding national health policies (6–8).

The objective of this study is to evaluate the barriers and limitations to optimal acute management of stroke in a developing country.

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