OBJECTIVES Egypt faces a disproportionate acute stroke burden, but geographic accessibility to intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) has not been systematically quantified using modality-specific treatment windows. The objective of the current work is to measure population-level geographic accessibility to IVT and MT across Egypt's 27 governorates, characterize access inequality determinants, and model the clinical impact and cost-effectiveness of targeted hub-and-spoke network expansion. METHODS We verified 29 IVT-capable hospitals and 13 MT-ready centers through a 3-phase protocol. Onset-to-treatment time was computed for 120 settlements representing 89.3% of the national population (108.3 million). MT eligibility was based on noncontrast CT for ASPECTS scoring and CT angiography for large-vessel occlusion confirmation. Treatment windows were classified as optimal (<180 min), within-window (IVT 180 to 270 min; MT 180 to 360 min), or denied (IVT >270 min; MT >360 min). A maximum-coverage location problem model identified the optimal deployment for 3 new MT hubs and 4 IVT spokes. Cost-utility analysis expressed outcomes in quality-adjusted life years over 10 years using Egypt's GDP per capita of $3800. RESULTS IVT optimal access was 71.8% nationally (77.0 million), while MT optimal access was only 56.2% (60.9 million), with 20.4% denied MT under the 6-hour threshold. Nine of 13 MT-ready centers (69.2%) concentrated in Cairo/Giza (19.2% of the population). Hub-and-spoke deployment improved MT optimal access from 56.2% to 75.8% nationally. Probabilistic sensitivity analysis demonstrated 73.2% and 91.4% probabilities of cost-effectiveness at 3× and 4× GDP thresholds, respectively. CONCLUSIONS Egypt's MT access crisis reflects infrastructure maldistribution rather than patient ineligibility. A hub-and-spoke model using NCCT+CTA-based MT selection within the 6-hour window is clinically sound, operationally feasible, and probabilistically cost-effective.
Objectives: Egypt faces a disproportionate acute stroke burden, but geographic accessibility to intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) has not been systematically quantified using modality-specific treatment windows. The objective of the current work is to measure population-level geographic accessibility to IVT and MT across Egypt’s 27 governorates, characterize access inequality determinants, and model the clinical impact and cost-effectiveness of targeted hub-and-spoke network expansion. Methods: We verified 29 IVT-capable hospitals and 13 MT-ready centers through a 3-phase protocol. Onset-to-treatment time was computed for 120 settlements representing 89.3% of the national population (108.3 million). MT eligibility was based on noncontrast CT for ASPECTS scoring and CT angiography for large-vessel occlusion confirmation. Treatment windows were classified as optimal (<180 min), within-window (IVT 180 to 270 min; MT 180 to 360 min), or denied (IVT >270 min; MT >360 min). A maximum-coverage location problem model identified the optimal deployment for 3 new MT hubs and 4 IVT spokes. Cost-utility analysis expressed outcomes in quality-adjusted life years over 10 years using Egypt’s GDP per capita of $3800. Results: IVT optimal access was 71.8% nationally (77.0 million), while MT optimal access was only 56.2% (60.9 million), with 20.4% denied MT under the 6-hour threshold. Nine of 13 MT-ready centers (69.2%) concentrated in Cairo/Giza (19.2% of the population). Hub-and-spoke deployment improved MT optimal access from 56.2% to 75.8% nationally. Probabilistic sensitivity analysis demonstrated 73.2% and 91.4% probabilities of cost-effectiveness at 3× and 4× GDP thresholds, respectively. Conclusions: Egypt’s MT access crisis reflects infrastructure maldistribution rather than patient ineligibility. A hub-and-spoke model using NCCT+CTA-based MT selection within the 6-hour window is clinically sound, operationally feasible, and probabilistically cost-effective.
Objectives: The diagnostic yield of neuroimaging in patients with nonindex seizures, defined as those with established epilepsy presenting to the emergency department with a recurrent seizure, remains uncertain. Although head computed tomography (CT) is frequently performed, its impact on clinical decision-making is often limited. This study aimed to assess the frequency of neuroimaging use, its diagnostic yield, and the clinical factors associated with acute findings leading to management changes. Methods: We conducted a retrospective observational study of adult patients with epilepsy presenting with nonindex seizures to a tertiary public hospital in Bogotá, Colombia, between February 2023 and February 2024. Sociodemographic, clinical, and neuroimaging data were extracted from electronic medical records. Descriptive and bivariate analyses were performed. Results: A total of 307 patients were included (median age: 39 y; 58.6% male). Head CT was performed in 79.8% (n=245), revealing structural abnormalities in 43.6% (n=107). Only 3.7% (n=9) showed acute pathologic findings requiring changes in management. Most abnormalities were chronic and did not influence clinical decisions. The only variable significantly associated with acute CT findings was seizure-related traumatic brain injury (33.3% vs. 0%, P <0.001; OR=26.6, 95% CI: 11.2-62.8). Conclusions: The diagnostic yield of head CT in patients with nonindex seizures is low despite its widespread use in emergency settings. Routine neuroimaging may be unnecessary without clinical red flags such as trauma, new focal deficits, or atypical presentations. Evidence-based tools are needed to guide neuroimaging use and optimize resource utilization.
Objectives: Stroke is a leading cause of mortality and disability worldwide, particularly acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Although endovascular intervention has proven effective, individual outcomes vary considerably. This study aimed to identify key prognostic factors and develop a predictive model for neurological recovery in patients with LVO-AIS following endovascular thrombectomy (EVT). Methods: A total of 191 LVO-AIS patients who underwent EVT at the Neurosurgery Department of Zhejiang University Shaoxing Hospital from January 2022 to June 2023 were included in the analysis. Prognostic factors collected included demographic information, premorbid characteristics, initial laboratory data, neurological evaluation, and others. The 90‑day modified Rankin Scale (mRS) score served as the primary clinical outcome. A multilevel prognostic (MLP) model and an associated nomogram were developed to identify significant predictors and visualize their individual contributions to the outcome. Results: The Zhejiang University Shaoxing Hospital (ZJUSXH) model was developed, incorporating 11 key predictors: the National Institutes of Health Stroke Scale (NIHSS) score, symptom onset‑to‑recanalization (OTR) time, fasting blood glucose (FBS), hemoglobin (HGB), serum albumin (ALB), symptomatic intracerebral hemorrhage (sICH), the Controlling Nutritional Status (CONUT) score, the prognostic nutritional index (PNI), swallowing function, and the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification. The overall predictive accuracy of the model was 86.2%. Conclusion: The NIHSS score and OTR time emerged as the most critical prognostic factors. FBS, HGB, ALB, sICH, swallowing function, and TOAST classification were also significant predictors. In addition, the CONUT score and PNI showed a significant association with neurological outcomes. Both the developed ZJUSXH model and its corresponding nomogram demonstrated high predictive accuracy.
