Iranian Journal of Neurology 2017. 16(2):.

Acute management of stroke in Iran: Obstacles and solutions
Shima Shahjouei, Reza Bavarsad-Shahripour, Farhad Assarzadegan, Reza Rikhtegar, Masoud Mehrpour, Babak Zamani, Georgios Tsivgoulis, Andrei Alexandrov, Anne Alexandrov, Ramin Zand


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.


Stroke; Thrombolytic Therapy; Tissue Plasminogen Activator; Hospital Rapid Response Team; Quality Improvement; Iran

Full Text:



Lozano R, Naghavi M, Foreman K, 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. Elsevier; 2013;380(9859):2095–128.

Azarpazhooh MR, Etemadi MM, Donnan G a., 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):3–11.

Hosseini A a, Sobhani-Rad D, Ghandehari K, et al. Frequency and clinical patterns of stroke in Iran - Systematic and critical review. BMC Neurol. 2010;10:72.

Borhani Haghighi A, Karimi AA, Amiri A, et al. Knowledge and attitude towards stroke risk factors, warning symptoms and treatment in an Iranian population. Med Princ Pract. 2010;19(6):468–72.

Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. N Engl J Med. 2008;359(13):1317–29.

Bluhmki E, Chamorro A, Dávalos A, 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 [Internet]. Elsevier Ltd; 2009 Dec [cited 2014 Oct 12];8(12):1095–102. Available from:

Ringelstein EB, Chamorro A, Kaste M, et al. European stroke organisation recommendations to establish a stroke unit and stroke center. Stroke. 2013;44(3):828–40.

Xian Y, Holloway RG, Chan PS, et al. Association between Stroke Center Hospitalization for Acute Ischemic Stroke and Mortality. JAMA. 2012;29(6):997–1003.

Wahlgren N, Ahmed N, Dávalos A, 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 [Internet]. 2007 Jan 27;369(9558):275–82. Available from:

Leifer D, Bravata DM, Connors JJ, 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 A. Stroke. 2011;42(3):849–77.

Alberts MJ, Latchaw RE, Selman WR, et al. Recommendations for comprehensive stroke centers: A consensus statement from the brain attack coalition. Stroke. 2005;36(7):1597–616.

Alberts MJ, Hademenos G, Latchaw RE, et al. Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. JAMA. 2000;283(23):3102–9.

Alberts MJ, Wechsler LR, Jensen MEL, et al. Formation and function of acute stroke-ready hospitals within a stroke system of care recommendations from the brain attack coalition. Stroke [Internet]. 2013;44(12):3382–93. Available from:

Mehrdad R. Health system in Iran. Japan Med Assoc J. 2009;52(1):69–73.

M Taghvaei AS. Spatial distribution of health services in Iranian Cities. Soc Welf Q. 2011;39:33–54.

Nikkhah K, Avan A, Shoeibi A, et al. Gaps and Hurdles Deter against Following Stroke Guidelines for Thrombolytic Therapy in Iran: Exploring the Problem. J Stroke Cerebrovasc Dis [Internet]. Elsevier Ltd; 2015;24(2):408–15. Available from:

Ministry of Health and Medical Education [Internet]. 2015 [cited 2015 Oct 6]. Available from:

Centers for Disease Control and Prevention. Primary Stroke Center Policy in the United States. 2011;

Schwamm LH, Pancioli A, Acker JE, 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.

Xu J, Kochanek KD, Murphy SL. National Vital Statistics Reports Deaths : Final Data for 2007. Natl Vital Stat Reports [Internet]. 2010;58(3):1–136. Available from:

Gropen TI, Gagliano PJ, Blake CA, et al. Quality improvement in acute stroke: The New York State Stroke Center Designation Project. Neurology. 2006;67(1):88–93.

Goldstein LB. February 8 Highlight and Commentary: Criteria for stroke centers. Neurology. 2005;64(3):403–403.

E. Bernd Ringelstein, Markku Kaste, Werner Hacke DL. Stroke Care in Europe – The Role of Stroke Units. Cerebrovasc Dis. 2007;24–7.

Ringelstein EB, Busse O, Ritter MA. Current concepts of stroke units in Germany and Europe. Schweizer Arch fur Neurol und Psychiatr. 2011;162(4):155–60.

Presidency of I.R.I M and P organization. Population statistics [Internet]. Statistical Center of Iran. 2016 [cited 2016 Jul 3]. Available from:

Ayromlou H, Soleimanpour H, Farhoudi M, et al. What are the most important barriers for thrombolytic therapy in ischemic stroke patients? Int J Stroke [Internet]. 2013;8(4):E7–E7. Available from:

Ghandehari KÃ, Zahed AP, Taheri M, et al. Estimation of Iranian stroke patients eligible for intravenous thrombolysis with tPA. Int J Stroke. 2009;4(August):236.

Oveisgharan S, Sarrafzadegan N, Shirani S, et al. Stroke in Isfahan, Iran: Hospital admission and 28-day case fatality rate. Cerebrovasc Dis. 2007;24(6):495–9.

Ghandehari K, Foroughipour M, Pourzahed A. Thrombolysis in stroke patients: Problems and limitations. Iran J Med Sci. 2010;35(2):145–8.

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.

Ayromlou H, Soleimanpour H, Farhoudi M, et al. Eligibility assessment for intravenous thrombolytic therapy in acute ischemic stroke patients; evaluating barriers for implementation. Iran Red Crescent Med J [Internet]. 2014;16(5):e11284. Available from:

Hatamabadi HR, Mansourifar H, Asarzadegan F, et al. Barriers to On Time Delivery of Thrombolytic Therapy for Patients with Acute Stroke. J Maz Univ Med Sci. 2013;23(102):107–10.

Evenson KR, Foraker R, Morris DL, et al. A Comprehensive Review of Prehospital and In-hospital Delay Times in Acute Stroke Care. Int J Stroke. 2009;4(3):187–99.

Pontes-neto M, Silva GS, Feitosa MR, et al. Stroke Awareness in Brazil Alarming Results in a Community-Based Study. 2008;292–7.

Menon B, Swaroop JJ, Deepika HKR, et al. Poor Awareness of Stroke—A Hospital-Based Study from South India: An Urgent Need For Awareness Programs. J Stroke Cerebrovasc Dis [Internet]. Elsevier Ltd; 2014;23(8):2091–8. Available from:

Nordanstig A, Jood K, Rosengren L. Public stroke awareness and intent to call 112 in Sweden. Acta Neurol Scand. 2014;130(6):400–4.

Fassbender K, Balucani C, Walter S, et al. Streamlining of prehospital stroke management : the golden hour. Lancet Neurol [Internet]. Elsevier Ltd; 2013;12(6):585–96. Available from:

Smolderen KG, Spertus JA, Nallamothu BK, et al. Health care insurance, financial concerns in accessing care, and nonelective readmissions following acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2011;4(6).

Jauch EC, Saver JL, Adams HP, 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;

Karbakhsh M, Zandi NS, Rouzrokh M, et al. Injury epidemiology in Kermanshah: The National Trauma Project in Islamic Republic of Iran. East Mediterr Heal J. 2009;15(1):57–64.

Zargar M, Modaghegh MHS, Rezaishiraz H. Urban injuries in Tehran: Demography of trauma patients and evaluation of trauma care. Injury. 2001;32(8):613–7.

Derakhshanfar H, Mahmoudi H, Noori S, et al. Studying the efficiency triage at Shahid Beheshti Hospitals, Tehran, Iran. HealthMED. 2015;9:307–15.

Mirhaghi AH, Roudbari M. A Survey on Knowledge Level of the Nurses about Hospital Triage. Iran J Crit Care Nurs. 2011;3(4):165–70.

Mojdeh S, Memarzadeh M, Isfahani MA, et al. Problems in the emergency department of Al-Zahra educational medical center, Isfahan. IJNMR. 2009;14(4):180–4.

Mellon L, Doyle F, Rohde D, Williams D, et al. Stroke warning campaigns : delivering better patient outcomes ? A systematic review. 2015;61–73.

Hodgson C, Lindsay P, Rubini F. Can Mass Media Influence Emergency Department Visits forfor Stroke ? 2007;

Dianati M, Mosavi GA, Hajibagheri A, et al. 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.

Mohammadian-hafshejani A, Salehiniya H. Letter to the Editor Some Facts about Case Fatality of Acute Myocardial Infarction in. 2015;44(12):1718–9.

Meretoja A, Roine RO, Kaste M, Linna M, et al. Effectiveness of primary and comprehensive stroke centers: PERFECT stroke: A nationwide observational study from Finland. Stroke. 2010;41(6):1102–7.


  • There are currently no refbacks.

Creative Commons Attribution-NonCommercial 3.0

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly.