Golden hours at risk: Prehospital delays in acute ischemic stroke and their impact on public awareness and emergency response

Abstract

Background: Timely intervention is essential in the management of acute ischemic stroke, as delays in treatment initiation can significantly worsen clinical outcomes. Despite advancements in stroke care, prehospital delays remain a major barrier to accessing reperfusion therapies. This study aimed to investigate the sociodemographic, clinical, and cognitive factors contributing to prehospital delays and to assess their impact on treatment accessibility and outcomes.

Methods: This prospective observational study was conducted at the Emergency Department of Eskişehir Osmangazi University, a regional stroke center, between March 2018 and February 2019. Adult patients (≥18 years) presenting with a first-time suspected ischemic stroke were enrolled. Data were collected through structured interviews with patients and/or their relatives and supplemented by official emergency medical service records. Variables analyzed included sociodemographic characteristics, symptom recognition time, mode of transport, and awareness of stroke symptoms.

Results: A total of 436 patients were included. Most patients (78.6%) resided in urban areas, while 19.7% lived alone. The majority (72%) experienced sudden symptom onset. Intravenous rtPA was administered to 26.4%, and mechanical thrombectomy was performed in 12.4% of patients. Ambulance use was significantly higher among rural residents (p < 0.001). The mean time from symptom onset to hospital arrival (symptom-to-door) was 362 ± 400 minutes. Key contributors to prehospital delays included delayed symptom recognition and delayed contact with emergency services. Higher educational attainment of the first responder was significantly associated with shorter recognition-to-arrival times. Patients with typical stroke symptoms (e.g., unilateral weakness, speech impairment) reached the hospital faster than those with non-specific symptoms like imbalance. Patients or relatives who correctly identified stroke symptoms had significantly shorter delays in all key time intervals (p < 0.001). Those educated through public seminars, healthcare professionals, or social media showed faster recognition and response times compared to those informed by friends or with no prior knowledge.

Conclusion: Prehospital delay remains a key obstacle to timely stroke management. Factors such as education level, living situation, symptom awareness, and the source of stroke-related information significantly influence early hospital presentation. Public health strategies should emphasize stroke education, particularly for high-risk populations, through both digital media and community outreach. Improved coordination between emergency services and stroke centers is also critical for enhancing access to timely, life-saving interventions.