title: Gaps and hurdles deter against following stroke guidelines for thrombolytic therapy in Iran: exploring the problem.
abstract: BACKGROUND
  Insufficient information is available on the barriers that explain low rates of thrombolytic therapy for acute ischemic stroke (AIS) in developing countries compared with rates in developed societies. By the present study, we aimed to assess the implementation of thrombolytic therapy in the northeast of Iran to explore the gaps and hurdles against thrombolysis as the generally accepted treatment for AIS.
  
  
  METHODS
  In a 1-year cohort study among AIS patients admitted to the second largest tertiary neurologic referral center in Iran, those who met the prespecified selection criteria were treated with intravenous recombinant tissue plasminogen activator (rtPA).
  
  
  RESULTS
  Among 1,144 patients admitted with AIS, only 14 (1.2%) were treated with rtPA. The mean onset-to-needle and door-to-needle times were 172 and 58 minutes, respectively; 980 (85.6%) patients were initially excluded from the study because of late arrival. Additionally, 60 patients in total were omitted because of either their high age (3.7%) or passing the gold standard time limit for rtPA therapy after preliminary evaluations (1.6%), and 90 more patients (7.9%) were considered not suitable for thrombolysis because of the severity of the symptoms or the higher risk of bleeding on rtPA.
  
  
  CONCLUSIONS
  Access to thrombolytic therapy for AIS in Iran is less than in most developed countries but comparable with other developing countries. Awareness campaigns are needed to minimize barriers and improve access to thrombolysis and specialized stroke care in Iran.
authors.affiliation: Department of Neurology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
authors.forename: Karim
authors.initials: K
authors.lastname: Nikkhah
authors.affiliation: Department of Neurology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Abolfazl
authors.initials: A
authors.lastname: Avan
authors.affiliation: Department of Neurology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
authors.forename: Ali
authors.initials: A
authors.lastname: Shoeibi
authors.affiliation: Dental Research Institute, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada; Clinical Epidemiology Program, Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Amir
authors.initials: A
authors.lastname: Azarpazhooh
authors.affiliation: Department of Neurology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
authors.forename: Kavian
authors.initials: K
authors.lastname: Ghandehari
authors.affiliation: Department of Neurology, Goethe-University, Frankfurt am Main, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Foerch
authors.affiliation: The Division of Neurology, Department of Medicine, Stroke Outcomes Research Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Gustavo
authors.initials: G
authors.lastname: Saposnik
authors.affiliation: Department of Neurology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
authors.forename: Payam
authors.initials: P
authors.lastname: Sasannejad
authors.affiliation: Department of Community and Preventive Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
authors.forename: Veda
authors.initials: V
authors.lastname: Vakili
authors.affiliation: Department of Radiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
authors.forename: Parvaneh
authors.initials: P
authors.lastname: Layegh
authors.affiliation: Department of Neurology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
authors.forename: Mohammad Taghi
authors.initials: MT
authors.lastname: Farzadfard
authors.affiliation: Comprehensive Stroke Center, Department of Neurology, University of Alabama, Birmingham, Alabama.
authors.forename: Reza
authors.initials: R
authors.lastname: Bavarsad Shahripour
authors.affiliation: Department of Neurology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
authors.forename: Mohammad Reza
authors.initials: MR
authors.lastname: Hosseini
authors.affiliation: Department of Neurology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Electronic address: azarpazhoohmr@mums.ac.ir.
authors.forename: Mahmoud Reza
authors.initials: MR
authors.lastname: Azarpazhooh
mesh_terms: D000328:Adult; D000368:Aged; D002545:Brain Ischemia / Q000188:drug therapy*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000627:therapeutic use; D019983:Guideline Adherence; D006801:Humans; D007492:Iran; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000592:standards*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Stroke; cohort study; developing countries; stroke facilities; thrombolysis; treatment