Ischemic Stroke is neurologic emergency and remains a major global health problem and leading cause of mortality and morbidity. Ischemic stroke represents 85% of acute stroke. Due to ongoing demographic shifts, such as population aging and health transformations seen in developing countries, its importance is expected to increase in the future. [9, 10]. Currently, intravenous thrombolytic treatment (IVT) is considered the most effective intervention treatment for patients presenting with acute ischemic stroke (AIS). Majority of the patients come late to the hospital and miss this golden opportunity [11, 12]. In this study, we investigated the various factors influencing the early arrival of AIS patients to the emergency department in Mogadishu. Compared to other Western and developed countries, where prehospital delays typically range from 3 to 6 hours [13, 14], the median prehospital delay in this study is 14 hours, which is much longer. Of the patients, only 32 (15%) arrived at the hospital within the therapeutic window of 4.5 hours. This has negative impact on management and outcomes of patients with acute ischemic stroke. This should public health concern and therefore should become top priority for healthcare professionals. In univariate and multivariate analysis of this study, factors associated with early hospital arrival were male gender), having higher education living in city low GCS score, travel distance of less than 10km, living with family or friends, knowledge of stroke symptoms day time stroke onset, knowledge of thrombolytic treatment for acute stroke, and hemiplegic Presentation. There was not any previous study evaluating the factors contributing to the prehospital delay of acute ischemic stroke patients.
The cut-off point for classifying patients delayed and early arrival groups varied from study to study. Some studies kept 2 hours as cut-off point, considering the hospital delay [17, 18]. Two studies from India used 3 hours as the cutoff for categorizing early and late arrivals [19, 20]. In our study, the cut-off point for early arrival for ischemic stroke thrombolysis is 4 hours. The proportion of patients’ arrival in the therapeutic window varies from one study to the other. Study by Guveli et al [15] 30.7% of patients arrived the hospital within 3 hours after the onset of stroke symptoms. In another study by Kocak et al [16], 29.5% of patients came to the hospital in < 4 hours. As per study by Caroline Mithi et el, only 23.9% of patients with acute ischemic strokes arrived early to the hospital with in the therapeutic window [21]. In this study only 15% of the patient came within the therapeutic window and therefore majority of the patients missed the golden opportunity.
Male patients had shorter prehospital delays than female patients. Male patients were more likely to arrive early than female patients. Age was significant factor in terms of prehospital delay. According to a study by Jin et al, people over the age of 65 and female patients were just more likely to arrive early than younger patients and men [22]. According to univariate analysis, higher educational level and residence in the city were associated with fewer prehospital delays. However, in our analysis, age and income status had no impact on prehospital delay. Some studies showed that educational status and income level of patients had no effect on hospital arrival delays [23, 24].
According to certain prior studies (mainly from western countries), Living alone is a significant factor in the delay in getting medical treatment among stroke patients [25,26]. In our study, majority of patients were living with their families (80%). Those living with family/friend had fewer hospital delays than those living alone according to the univariate analysis. In this study, past history of stroke, TIA, other comorbidities such as hypertension, diabetes, and hyperlipidemia were not significant factors influencing early hospital arrival.
In univariate analysis, recognition of symptoms of stroke by patients/relatives was significantly associated with early hospital arrival. Patients/relatives without knowledge of stroke symptoms were more likely to arrive late. Fifty seven percent of the subjects did not know stroke symptoms. Likewise, only 16% of patients/relatives knew the availability of thrombolytic treatment for acute ischemic stroke. These findings emphasize the urgent need to educate the public about stroke and specially the patients in the risk group. In contrary, some studies revealed that identification of stroke symptoms had no appreciable impact on timely presentation at the emergency room. [27, 29]. However some previous studies showed that knowledge and awareness of stroke symptoms has substantial impact on early hospital arrival [2, 28]. In the literature, there are number of studies showing that use of ambulances can reduce prehospital delays in acute stroke patients [30, 28]. The patients who arrived the hospital via ambulance were 25% in this study. This rate is very low compared to that of the developed countries, which is 60% [6]. In Somalia, since there aren't many emergency ambulance services, patients must rely on other transportation options to get to the hospital. However 25% arrival of via ambulance is still good number, but was not significant enough to reduce prehospital delay of patients. This indicates that readily availability, quick access and organization of emergency ambulance services are not developed in the country.
In our study, the average of hospital arrival for the patients was 14 hours. This delay is almost similar in other African countries, for example, in the neighboring Kenya where patients present to the ER between 1 and 3 days from the onset [31]. Patients were significantly more likely to arrive at the hospital early if they lived in Mogadishu or its vicinity, similar to what has been found by Ashraf VV et al., where early emergency arrival was substantially related with living within 15 km of the hospital [2]. In this study, patients with day time stroke onset were more likely to arrive early to the hospital than those who had night time stroke onset. This is in contrast to a research by Haki Cemile et al., which revealed no association between the time of arrival at the hospital and the onset of symptoms as day or night [1].
Strengths and Limitations
This research is the first to be published that addresses the major challenges and barriers towards receiving acute care for acute ischemic stroke patients in Somalia. The study specifically focused the factors influencing early hospital arrival of patients with acute ischemic stroke. Our findings have implications for reducing stroke patients' prehospital delays and therefore addressing these factors will improve stroke care in the country.
The study is a single-centered study using a modest sample size. However this study provides a useful, representative picture of the current issues surrounding prehospital delay in presentation of acute stroke in this part of the world. Further studies with larger sample size nvolving various stroke centers are required to verify these conclusions. Another limitations in our study is utilization of information from the parapatients incases when the patient cannot communicate properly, which may become less representative.