Incidence of prehospital delay in people with ischemic stroke: a meta-analysis

BACKGROUND: Intravenous thrombolysis for ischemic stroke can significantly improve neurological outcomes. However, prehospital delay is associated with failure to receive timely treatment and poorer patient outcomes. OBJECTIVE: To systematically review the incidence of prehospital delay among patients with ischemic stroke. METHODS: Nine databases were searched from inception to January 30, 2026. Two researchers independently completed the screening, data extraction, and risk-of-bias assessment. Incidence rates and 95% confidence intervals (CIs) were pooled. Heterogeneity among results was assessed using the I² statistic. Sensitivity analysis was conducted using the leave-one-out method, and Egger's regression test and funnel plots were used to detect publication bias. RESULTS: A total of 27 studies involving 266,336 participants across 14 countries were included. The overall pooled incidence was 67.7% (95%CI: 59.2%-75.6%). The pooled incidence of prehospital delay was 65.0% (95%CI: 59.8-70.0%) at the 2-hour cut-off, 77.2% (95%CI: 70.2-83.5%) at 3 hours, 68.6% (95%CI: 56.2-79.9%) at 3.5 hours, 73.8% (95%CI: 60.4-85.3%) at 4 hours, and 60.6% (95%CI: 42.8-77.1%) at 4.5 hours. The 5- and 6-hour cut-offs were each reported by only one study, with incidences of 29.7% and 53.1%, respectively. Subgroup analyses revealed significant moderators, including continent, education level, stroke knowledge, stroke symptom recognition, transportation and study quality. The certainty of evidence was low. CONCLUSION: Prehospital delay was common among patients with ischemic stroke, with an overall pooled incidence of 67.7%. Regional estimates varied, but the limited evidence outside Asia and substantial heterogeneity make these comparisons exploratory. Targeted stroke education and improved emergency medical services (EMS) are needed, together with geographically diverse studies using standardized delay definitions.