Acute management of stroke in Iran: Obstacles and solutions
Background: Stroke is among the leading causes of mortality and permanent disability in the world. Iran is located in the stroke belt and has a high age-adjusted stroke incidence rate. In this multistep prospective qualitative study, we aimed at investigating the status and challenges of stroke management in Iran and explore possible solutions.
Methods: In the first and second phase, we attempted to define the status of stroke management in Iran by searching the relevant literature and conducting semi-structured interviews with health-care providers in thirteen hospitals located in seven large cities in Iran. In the third phase, we tried to recommend possible solutions based on international standards and experience, as well as interviews with stroke experts in Iran and the United States.
Results: Little public awareness of stroke symptoms and its urgency, low prioritization for stroke management, and an inadequate number of stroke-ready hospitals are some of the major obstacles toward timely treatment of stroke in Iran. Every hospital in our pool except two hospitals had guideline-based algorithms for the administration of intravenous thrombolysis. However, there was no single call activation system for stroke alert. Data from some of the centers showed that hospital arrival of stroke patients to final decision-making took 116-160 minutes. Although there were four endovascular programs in our target areas, there was no center with 24-hour coverage.
Conclusion: There are many challenges as well as potentials for improvement of stroke care in Iran. Improving public knowledge of stroke and establishing an organized and comprehensive stroke program in the hospitals will improve acute stroke management in Iran. The Iranian ministry of health should define and advocate the establishment of stroke centers, track the rate of death and disability from stroke, introduce pathways to improve the quality of stroke care through national data monitoring systems, and eliminate disparities in stroke care.
2. Azarpazhooh MR, Etemadi MM, Donnan GA, Mokhber N, Majdi MR, Ghayour-Mobarhan M, et al. Excessive incidence of stroke in Iran: Evidence from the Mashhad Stroke Incidence Study (MSIS), a population-based study of stroke in the Middle East. Stroke 2010; 41(1): e3-e10.
3. Hosseini AA, Sobhani-Rad D, Ghandehari K, Benamer HT. Frequency and clinical patterns of stroke in Iran - Systematic and critical review. BMC Neurol 2010; 10: 72.
4. Borhani Haghighi A, Karimi AA, Amiri A, Ghaffarpasand F. Knowledge and attitude towards stroke risk factors, warning symptoms and treatment in an Iranian population. Med Princ Pract 2010; 19(6): 468-72.
5. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359(13): 1317-29.
6. Bluhmki E, Chamorro A, Davalos A, Machnig T, Sauce C, Wahlgren N, et al. Stroke treatment with alteplase given 3.0-4.5 h after onset of acute ischaemic stroke (ECASS III): additional outcomes and subgroup analysis of a randomised controlled trial. Lancet Neurol 2009; 8(12): 1095-102.
7. Ringelstein EB, Chamorro A, Kaste M, Langhorne P, Leys D, Lyrer P, et al. European Stroke Organisation recommendations to establish a stroke unit and stroke center. Stroke 2013; 44(3): 828-40.
8. Xian Y, Holloway RG, Chan PS, Noyes K, Shah MN, Ting HH, et al. Association between stroke center hospitalization for acute ischemic stroke and mortality. JAMA 2011; 305(4): 373-80.
9. Wahlgren N, Ahmed N, Davalos A, Ford GA, Grond M, Hacke W, et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet 2007; 369(9558): 275-82.
10. Leifer D, Bravata DM, Connors JJ 3rd,Hinchey JA, Jauch EC, Johnston SC, et al. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42(3): 849-77.
11. Alberts MJ, Latchaw RE, Selman WR, Shephard T, Hadley MN, Brass LM, et al. Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke 2005; 36(7): 1597-616.
12. Alberts MJ, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg MR, et al. Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. JAMA 2000; 283(23): 3102-9.
13. Alberts MJ, Wechsler LR, Jensen ME, Latchaw RE, Crocco TJ, George MG, et al. Formation and function of acute stroke-ready hospitals within a stroke system of care recommendations from the brain attack coalition. Stroke 2013; 44(12): 3382-93.
14. Mehrdad R. Health system in Iran (Short 1. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380(9859): 2095-128.
15. Taghvaei M, Shahivandi A. Spatial distribution of health services in Iranian cities. Social Welfare 2011; 10(39): 33-54.
16. Nikkhah K, Avan A, Shoeibi A, Azarpazhooh A, Ghandehari K, Foerch C, et al. Gaps and hurdles deter against following stroke guidelines for thrombolytic therapy in Iran: exploring the problem. J Stroke Cerebrovasc Dis 2015; 24(2): 408-15.
17. Shafaonline. Treatment of stroke, of priorities of health ministry in 2015/ allocating 2200 ICU bed. No, 53138 [Online]. [cited 2015]; Available from: URL: http://shafaonline.ir/fa/news/53138
18. National Center for Chronic Disease Prevention and Health Promotion. A summary of primary stroke center policy in the United States [Online]. [cited 2011]; Available from: URL: https://www.cdc.gov/dhdsp/pubs/docs/primary_stroke_center_report.pdf
19. Schwamm LH, Pancioli A, Acker JE 3rd, Goldstein LB, Zorowitz RD, Shephard TJ, et al. Recommendations for the establishment of stroke systems of care: Recommendations from the American Stroke Association's task force on the development of stroke systems. Circulation 2005; 111(8): 1078-91.
20. Xu J, Kochanek KD, Tejada-Vera B. Deaths: Preliminary Data for 2007. Natl Vital Stat Rep 2009; 58(1): 1-52.
21. Gropen TI, Gagliano PJ, Blake CA, Sacco RL, Kwiatkowski T, Richmond NJ, et al. Quality improvement in acute stroke: The New York State Stroke Center Designation Project. Neurology 2006; 67(1): 88-93.
22. Goldstein LB. February 8 Highlight and Commentary, Criteria for stroke centers. Neurology 2005; 8(3): 403.
23. Ringelstein EB, Kaste M, Hacke W, Leys D. Stroke Care in Europe-The Role of Stroke Units. Eur Neurol Rev 2007; (2): 24-6.
24. Ringelstein EB, Busse O, Ritter MA. Current concepts of Stroke Units in Germany and Europe. Schweiz Arch Neurol Psychiatr 2011; 162(4): 155-60.
25. Population statistics, Statistical Center of Iran. Presidency of I.R.I M and Plan and Budget Organization [Online]. [cited 2016]; Available from: URL:
26. Hatamabadi HR, Mansouri H, Asarzadegan F, Shojaee M. Barriers to on time delivery of thrombolytic therapy. J Mazandaran Univ Med Sci 2013; 23(102): 107-10. [In Persian].
27. Aboutalebi S, Moghadasian M, Moradi A, Pazki R. The knowledge assessment of stroke in over age 25 years old habitants of Bushehr port 2005. Iran South Med J 2006; 9(1): 59-65.
28. Yarmohammadi A. Awareness of stroke risk factors among inpatient in teaching hospitals of Shahid Beheshti Medical University, Tehran, Iran 2011. Neurology 2016; 80(7 Suppl): P04-072.
29. Ayromlou H, Soleimanpour H, Farhoudi M, Sadeghi-Hokmabadi E, Rajaei Ghafouri R, Sharifipour E, et al. What are the most important barriers for thrombolytic therapy in ischemic stroke patients? Int J Stroke 2013; 8(4): E7.
30. Ghandehari K, Pour Zahed A, Taheri M, Abbasi M, Gorjestani S, Moghaddam Ahmadi A, et al. Estimation of Iranian stroke patients eligible for intravenous thrombolysis with tPA. Int J Stroke 2009; 4(4): 236.
31. Oveisgharan S, Sarrafzadegan N, Shirani S, Hosseini S, Hasanzadeh P, Khosravi A. Stroke in Isfahan, Iran: hospital admission and 28-day case fatality rate. Cerebrovasc Dis 2007; 24(6): 495-9.
32. Ghandehari K, Pourzahed A, Foroughipour M, Taheri M, Abbasi M, Gorjestani S, et al. Thrombolysis in Stroke Patients; Problems and Limitations. Iran J Med Sci 2010; 35(2): 145-8.
33. Ghandehari K. Design of a standard Iranian protocol of Intravenous thrombolysis with tissue plasminogen activator: A national project. Iran J Neurol 2013; 12(2): 72-4.
34. Ayromlou H, Soleimanpour H, Farhoudi M, Taheraghdam A, Sadeghi HE, Rajaei GR, et al. Eligibility assessment for intravenous thrombolytic therapy in acute ischemic stroke patients; evaluating barriers for implementation. Iran Red Crescent Med J 2014; 16(5): e11284.
35. Evenson KR, Foraker RE, Morris DL, Rosamond WD. A comprehensive review of prehospital and in-hospital delay times in acute stroke care. Int J Stroke 2009; 4(3): 187-99.
36. Pontes-Neto OM, Silva GS, Feitosa MR, de Figueiredo NL, Fiorot JA Jr, Rocha TN, et al. Stroke awareness in Brazil: Alarming results in a community-based study. Stroke 2008; 39(2): 292-6.
37. Menon B, Swaroop JJ, Deepika HK, Conjeevaram J, Munisusmitha K. Poor awareness of stroke-a hospital-based study from South India: an urgent need for awareness programs. J Stroke Cerebrovasc Dis 2014; 23(8): 2091-8.
38. Nordanstig A, Jood K, Rosengren L. Public stroke awareness and intent to call 112 in Sweden. Acta Neurol Scand 2014; 130(6): 400-4.
39. Fassbender K, Balucani C, Walter S, Levine SR, Haass A, Grotta J. Streamlining of prehospital stroke
management: the golden hour. Lancet Neurol 2013; 12(6): 585-96.
40. Smolderen KG, Spertus JA, Nallamothu BK, Krumholz HM, Tang F, Ross JS, et al. Healthcare insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction. JAMA 2010; 303(14): 1392-400.
41. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44(3): 870-947.
42. Karbakhsh M, Zandi NS, Rouzrokh M, Zarei MR. Injury epidemiology in Kermanshah: The National Trauma Project in Islamic Republic of Iran. East Mediterr Health J 2009; 15(1): 57-64.
43. Zargar M, Modaghegh MH, Rezaishiraz H. Urban injuries in Tehran: Demography of trauma patients and evaluation of trauma care. Injury 2001; 32(8): 613-7.
44. Derakhshanfar H, Mahmoudi H, Noori S, Vafai A, Bozorgi F. Studying the efficiency triage at Shahid Beheshti Hospitals, Tehran, Iran. HealthMED 2015; 10: 307.
45. Mirhaghi AH, Roudbari M. A survey on knowledge level of the nurses about hospital triage. Iran J Crit Care Nurs 2011; 3(4): 167-74.
46. Mozhdeh S, Memarzadeh M, Abdar-Esfahani M, Gholipour F. Problems in the emergency department of Al-Zahra educational medical center, Isfahan. Iran J Nurs Midwifery Res 2009; 14(4): 180-4.
47. Mellon L, Doyle F, Rohde D, Williams D, Hickey A. Stroke warning campaigns: delivering better patient outcomes? A systematic review. Patient Relat Outcome Meas 2015; 6: 61-73.
48. Hodgson C, Lindsay P, Rubini F. Can mass media influence emergency department visits for stroke? Stroke 2007; 38(7): 2115-22.
49. Dianati M, Mosavi GA, Hajibagheri A, Alavi NM. The pre-hospital delay in seeking treatment in patients with acute myocardial infarction referring to a central hospital in Kashan, Iran. Indian J Med Sci 2010; 64(10): 448-54.
50. Mohammadian-Hafshejani A, Salehiniya H, Khazaei S. Some facts about case fatality of acute myocardial infarction in Iran. Iran J Public Health 2015; 44(12): 1718-9.
51. Meretoja A, Roine RO, Kaste M, Linna M, Roine S, Juntunen M, et al. Effectiveness of primary and comprehensive stroke centers: PERFECT stroke: a nationwide observational study from Finland. Stroke 2010; 41(6): 1102-7.