Stroke is a serious global health problem. It is a leading cause of disability in developing countries, and second leading cause of death worldwide. According to the Global Burden of Disease (GBD) 2021 study, the global disability-adjusted life years (DALYs) of stroke have increased from 144 million in 2010 to 160 million in 2021, the increase being primarily explained by rise in life expectancy and population size1.

Early treatment of ischemic stroke with intravenous thrombolysis is most effective when administered within 4.5 hours of symptom onset; with the best results achieved when the treatment is initiated within 90 minutes, while mechanical thrombectomy is recommended within 6 hours and may be extended to 24 hours in select cases2 . However, a substantial proportion of stroke patients fail to reach healthcare facilities within this therapeutic window, reducing their eligibility for evidence-based interventions.

Pre-hospital delay refers to the time between the onset of stroke symptoms and initiation of treatment, which significantly affects patient outcomes. The Jeffrey Saver’s concept of “time is brain” highlights the need for timely intervention in acute stroke, as evidence suggests that for every minute of delay in stroke treatment, nearly 1.9 million neurons are lost, leading to worse functional outcomes3. Studies indicate that delayed hospital presentation is associated with worse neurological outcomes and higher mortality rates.

Multiple factors contribute to delays in seeking stroke care, including lack of awareness about stroke symptoms, failure to recognize the urgency of the condition, reliance on home remedies or local healthcare providers, and delayed decision-making by patients or their families. Socioeconomic barriers such as financial constraints, gender disparities, and geographic distance from tertiary care centers further contribute to these delays. Healthcare system-related factors, including limited emergency medical services (EMS), inefficient triage systems, and delayed activation of stroke teams, also play a significant role in prolonged pre-hospital delays4.

To our knowledge, the currently available data about pre-hospital delay in acute stroke patients in a rural background setting from Northern India are scarce. This study aims to identify key determinants of delay in acute stroke presentation to a tertiary care center with a rural background, which will help in formulating strategies for addressing healthcare system barriers that contribute to treatment delays, strengthening emergency medical services (EMS) for rapid patient transport, and enhancing public awareness about stroke symptoms and the urgency of medical attention.

Study design and setting

This observational cross-sectional study was conducted in the Department of Neurology of a tertiary care institute in Northern India with a rural background; over a period of 1.5 years from July 2023 to January 2025. The Hind Institute Of Medical Sciences, Safaedabad, Barabanki, Lucknow is a tertiary care Institute which serves as a referral center for all kinds of diseases and conditions for the nearest rural area. It is a multi-speciality hospital with more than 500 beds and is one of the largest private healthcare facilities in this area. The hospital has a 24/7 Neurology unit headed by a Neurophysician, where all the admitted stroke patients receive comprehensive stroke care. The dedicated stroke unit comprises of neurophysician, radiologists, physicians, medical officers, nursing officers and support staff.

Study population

A total of 120 patients with Acute Ischaemic stroke were included in the study. All adult patients with symptoms of acute ischaemic stroke were enrolled in the study if they met the following inclusion criteria: 1) age ≥ 18 years, 2) confirmed acute ischaemic stroke with a Brain scan (CT/ MRI), 3) presenting within 72 hours of onset of stroke symptoms to the emergency unit, and 4) giving a written consent to participate in the study.

Exclusion criteria included presence of transient ischaemic attack, stroke due to arterio-venous malformations or intracranial aneurysms, patients who received intravenous thrombolysis before visiting the study centre, patients with in-hospital stroke and patients presenting after 72 hours of stroke onset. 

The institutional ethics committee approved the study, and written informed consent was obtained from all participants before inclusion in the study.

Methodology

Prehospital time was defined as the time from symptom onset to the earliest documented time of presentation to the emergency department or outpatient department of the hospital. Pre-hospital delay was defined as any time greater than 4 hours and 30 minutes from the onset of symptoms to presentation to the hospital.

A structured questionnaire was completed for every stroke patient by interviewing the patient and/or accompanying family member and reviewing their medical records. In the case of patients with altered level of consciousness or dysphasia, the questionnaire was administered to the primary caregiver or attendant. The detailed questionnaire included presenting complaints & demographic data, knowledge and awareness, and contextual factors for assessing determinants of pre-hospital delay in the study group.

Statistical Analysis

SPSS version 22 (IBM Corp., Armonk, NY, USA) was used to perform the data analysis. Descriptive statistics were used to describe characteristics of study participants, which were then summarised and presented in text and tables. Categorical variables were summarised using frequencies and percentages and the results were presented in tables. Continuous variables were summarised using the mean and standard deviation if the data were normally distributed, and for non-normally distributed continuous variables, we used median and interquartile range. Categorical variables were compared with the Fisher exact test and continuous variables with the Mann Whitney test. As a measure of variance for continuous variables, we report the median and interquartile range (IQR). Variables with a P value of ≤0.2 in the univariate analysis of prehospital delay were entered into a multivariate logistic regression model with prehospital delay as the end point.

Study Profile

A total of 120 patients with acute ischaemic stroke were included in this study. The majority of patients were between 60 – 70 years of age (45%) followed by 50-60 years (30%). There was a higher number of male participants (65%) compared to female participants (35%) in the study, with most of the patients being married (66.7%), as compared to single and widowed. Overall, 33.3% of the patients were illiterate, while 45% of the patients received education only up to the primary school. Most of the study participants were either unskilled (30%) or agricultural farmers (40%), and approximately 67.5% of the study population lived in the rural areas (Table 1). This demographic factor may influence the time it takes for individuals to present to the hospital, with rural residents possibly facing more barriers to timely healthcare access.

 Table 1: Demographic variables and their association with pre-hospital delay time

Demographic factors and their association with prehospital delay

The average time to hospital presentation for males was 7.12 hours (95% confidence interval (CI) = 4.7-11.24 hours), while for the female patients, it was 7.42 hours (95% CI = 4.56-10.23 hours). The mean time to hospital presentation in the illiterate population (8.43±2.14 hours) and patients with primary education (8.80±2.92) was more as compared to patients with higher education and graduates, and the results were statistically significant. Similarly, people residing in the urban areas had significantly less pre-hospital delay time (5.46±2.16); as compared to patients from the nearby rural areas (8.86±3.18). No statistically significant association was observed between variables such as gender, age group, socioeconomic status, and occupation, with mean time to hospital admission (Table 1). The risk factors for acute stroke presentation in our study population included diabetes mellitus (35%), hypertension (26.7%), coronary artery disease (15%), previous stroke ( 10%) and substance abuse in 6.7 % patients; none of the risk factors had statistically significant association with pre-hospital delay time.

Stroke symptoms, severity and their association with pre-hospital delay

With regards to stroke awareness, 84.2% of study participants had previously heard of stroke, which indicates a fairly high level of general awareness in the community. However, 15.8% were not aware of stroke, potentially influencing their response to stroke symptoms. The most common stroke symptom at presentation was motor weakness (81.6%), followed by speech disturbances (68%) and altered level of consciousness (26.7%). The other less common symptoms at presentation included facial palsy (19.16%), seizure (18.3%), vertigo (11.6%), visual disturbances (11.6%), sensory disturbance (10%) and ataxia (9.15%). The discussion with the patients and their family members revealed that though the understanding of motor symptoms, facial weakness, altered level of consciousness as presenting features of acute stroke was present; they underestimated the other clinical features of stroke including sensory alterations, ataxia, vertigo, visual disturbances and seizures. The patients with motor weakness and altered level of consciousness had a statistically significant (P<0.001) less pre-hospital delay as compared to other stroke symptoms (Table 2). 

Table 2: Association of stroke symptoms and severity with pre-hospital delay time

Contextual factors contributing to pre-hospital delay in acute stroke

Majority of patients had onset of symptoms at home (81.6%) with a presence of bystander at the onset of stroke (85%), however the association with pre-hospital delay time was not significant. The majority of patients 124/143 (87.4%) visited lower-level facilities prior to referral to the tertiary facility. 26.7% of patients had a wake-up stroke, with onset during sleep which contributed to a greater delay in presentation to the study hospital. The distance from our tertiary care centre had a significant contribution (P<0.001) to pre-hospital delay time; with patients living >60 km far from the study centre, presenting later to the hospital as compared to patients living within 30 km from the hospital (Table 3). The patients who travelled with their private vehicles (31%) took the least time to present to study hospital (4.68±0.08 hours), while patients who took a public vehicle (48%) or waited for ambulance services (20%) took more time to travel (P<0.001). A common pattern with significant pre-hospital delay time emerged: many patients first visited general practitioners (17%), or presented to the nearby local hospitals (35%), only to be referred to the study hospital later - by which time their symptoms had worsened (Table 3).

TABLE 3: Association of contextual factors with pre-hospital delay in acute stroke

Stroke and its associated disabilities are a well recognized global public health concern. Despite the recent advances in stroke management, many acute stroke patients do not receive timely medical attention, especially in middle-income countries 5. As recommended by the American Heart Association (AHA), intravenous thrombolysis for acute ischaemic stroke is most effective when administered within four and a half hours, with the best outcomes observed within 90 minutes. However, due to significant pre-hospital delay, only a small number of acute ischaemic stroke patients manage to receive thrombolytic therapy 6. This study examines the factors associated with pre-hospital delay in patients of acute ischaemic stroke admitted at a tertiary care centre in Northern India with a rural background.

The median time taken by the patients to reach our tertiary care centre was 7.12 hours in males and 7.42 hours in females. This is particularly concerning, given that timely medical intervention is essential for optimizing stroke outcomes. The delays observed in our study are consistent with the findings from studies conducted in other middle and low income countries 7,8. These delays can be attributed to several factors, including a lack of public awareness about the symptoms of stroke, failure to recognize the urgency of situation, inadequate emergency response systems. Many patients and their families hesitate to seek help due to uncertainty about the symptoms and logistic challenges, such as transportation difficulties and the time required to locate and reach an appropriate stroke care facility. This pattern was also evident in our study, as reflected by the interviews conducted with patients.

As compared to previous studies, our findings revealed a direct relationship between age and pre-hospital delay time; with younger patients presenting early to stroke care facilities 9. A plausible explanation could be ignorance or misinterpretation with other serious health issues in old age. They might also underestimate the urgency required for treatment, leading to delays in accessing healthcare facility. These age-related differences in seeking health-care services underscore the importance of tailored strategies to address the age- specific barriers.

The literacy level of the patients enrolled in our study had a significant correlation with pre-hospital delay time. The patients who were educated upto high school or above had a significantly less delay to hospital presentation, compared to those with primary education. Similarly patients living in the rural areas took significantly more time to present to the study hospital as compared to the urban population. These findings were consistent with the other studies from developing countries, emphasizing the role of stroke awareness campaigns and strengthening the emergency referral services in the rural areas to improve the functional outcomes 10.

The stroke symptoms associated with statistically significant early presentation to the study hospital included motor weakness and altered level of consciousness. The other symptoms including facial weakness, vertigo, ataxia, speech and sensory disturbances had a delayed hospital presentation. The patients with NIHSS at presentation ≥ 16 had a significantly less pre-hospital delay time as compared to those with lesser NIHSS scoring. The understanding of typical stroke symptoms is lacking, especially in the rural population, which leads to misjudgement and underestimation of severity of symptoms. Also, in some cases, individuals wait for additional symptoms to appear before seeking medical attention, leading to significant delays to hospital presentation 11.

Patients who stayed more than 60 km from the study hospital had significantly more pre-hospital delay time than those residing within 30 km. This is similar to other studies that found increased distance from the tertiary hospital as a predictor of pre hospital delay12. The inefficient road systems including traffic jam and lesser availability of transport facilities could contribute to delays for stroke patients travelling from farther areas. Patients who used public modes of transport or ambulances services had a greater pre-hospital delay as compared to those who used personal private vehicles. This is in contrast to other studies, where using the ambulance services was associated with a less pre-hospital delay 13. In this study, it can be postulated that patients residing in rural areas might have limited access to emergency ambulance services or experience delays in getting authorisation from the hospital administration.

Furthermore, the patients who came directly to the tertiary hospital had significantly less pre-hospital delay as compared to those who consulted a general practitioner or visited a lower-level facility hospital. This is also supported by other studies where coming directly to the tertiary-care hospital was associated with a lesser pre hospital delay 14. Immediately after the onset of stroke, only 49% patients presented directly to the study hospital, while others wasted their golden window period in visiting local hospitals, nursing homes or general practitioners where specialist neurology services are still lacking. These delays can be attributed to a lack of awareness among patients and their family members about nearby acute stroke care facilities, and insufficient infrastructure for managing acute stroke cases. This approach emphasizes the need to improve stroke care facilities in the rural areas, so that patients can be benefitted with timely interventions for acute ischaemic stroke.

LIMITATIONS

This study was conducted at a single tertiary care centre, which limits the generalization of the results to a broader Indian population. Patients who passed away before reaching the hospital, or received stroke care at local hospitals were excluded from the study. Since the study focused only on pre-hospital factors, delays and treatments that occurred during the hospital stay were not recorded. Furthermore, we did not analyze bystander-related factors that might have influenced the timing of alerting the emergency medical services. All these limitations need to be addressed in further studies in order to better understand the underlying factors that preclude the stroke patients from receiving Intravenous thrombolysis in rural India.

This study highlights significant challenges in timely access to acute stroke care in rural areas in Northern India. The median delay of more than 7 hours is particularly concerning, given the critical importance of early intervention in reducing stroke-related mortality and disability. Factors such as age, education level, residing in rural areas were significantly associated with these delays, underscoring systemic barriers that need to be addressed. Additionally, underestimation of symptoms, inadequate transportation facilities to nearby stroke care centres,  and insufficient stroke care infrastructure at local nursing homes; further contributed to delayed hospital arrival. Improving stroke outcomes requires targeted educational initiatives to enhance public awareness of stroke symptoms and the urgency of seeking immediate care. Streamlining referral processes and ensuring rapid access to appropriate healthcare facilities are also essential steps in reducing prehospital delays and improving patient outcome.

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