Factors Associated With Delayed Hospital Arrival in Acute Ischemic Stroke: Insights from a Middle-income Country
Presley Gruezo1, David Guizado Herrera1, Naomi Mora1, Fiorella Rodríguez1, Sunny Sanchez1, Danny Japon2, Carlos Rodriguez Alarcon3
1Instituto Nacional de Investigación en Salud Pública Dr. Leopoldo Izquieta Pérez, 2Universidad Catolica Santiago de Guayaquil, 3Neurology Department, University of Miami / Jackson Health System
Objective:
Determine clinical and sociodemographic factors associated with prehospital delay among patients with acute ischemic stroke.
Background:
In middle-income countries, delayed hospital arrival for acute ischemic stroke arises from a multifactorial interaction of individual, social, and health system determinants. Limited recognition of symptoms and treatment urgency, combined with socioeconomic, cultural, and geographic barriers, often delays medical consultation. These challenges, together with restricted access to emergency transport and low levels of health literacy, contribute to missed opportunities for timely reperfusion therapy.
Design/Methods:
A retrospective, cross-sectional, and analytical study was conducted at two tertiary referral centers in Ecuador. Patients with confirmed acute ischemic stroke were analyzed. Sociodemographic and clinical variables were evaluated using chi-square and ANOVA tests to identify associations with prehospital delay, defined as hospital arrival more than 4.5 hours after symptom onset.
Results:
A total of 62 patients with confirmed acute ischemic stroke were included. The mean age was 67±15.8 years, and 53.2% were male. Overall, 80.6% of patients (50) arrived more than 4.5 hours after symptom onset, rendering them ineligible for fibrinolysis. Dysarthria (p = 0.016), type 2 diabetes mellitus (p = 0.016), and cardioembolic etiology (p = 0.047) were significantly associated with longer prehospital delays. Although not statistically significant, insurance affiliation (p = 0.067) demonstrated a relevant trend, as most patients arriving outside the therapeutic window were uninsured (56%). Notably, all patients who presented within the therapeutic window were accompanied by a family member.
Conclusions:
Most patients presented beyond the therapeutic window for reperfusion. Dysarthria, type 2 diabetes, and cardioembolic etiology were associated with longer prehospital delays, suggesting that specific clinical features and comorbidities may delay care-seeking. Conversely, family accompaniment facilitated earlier hospital arrival, highlighting the importance of caregiver support. Public education on stroke recognition and improved emergency response systems are crucial to reducing prehospital delays and enhancing access to timely stroke treatment.
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