Abstract Background and aims Acute ischemic stroke requires rapid specialized care. Intravenous rt-PA within 4.5 hours and thrombectomy for large-vessel occlusion improve outcomes. This study explores barriers to timely rt-PA use Methods This retrospective study included 167 acute ischemic stroke patients treated with intravenous rt-PA within 4.5 hours per ECASS III criteria, using data from Al-Azhar and Al-Maadi Military Hospitals (May 2014–April 2021). Early improvement was a ≥4-point NIHSS reduction or complete resolution within 24 hours, while early deterioration was a ≥2-point NIHSS increase, new symptoms, hemorrhagic transformation, or death within 24 hours post-rt-PA. Results The study included 167 patients (mean age 62.6 ± 9.9 years; 56.2% males). rt-PA was given within 0–3 hours in 52.6% and 3–4.5 hours in 47.3%. Lack of awareness of emergency thrombolysis was reported in 27.5%. Among those treated at 3–4.5 hours, 40.5% arrived within 2 hours. Early improvement occurred in 76.0%, early deterioration in 17.3%. Door-to-needle ≤60 minutes was achieved in 32.8% arriving within 0–2 hours versus 48.7% arriving within 2–3.5 hours. Complications included symptomatic ICH (10.7%), asymptomatic ICH (2.9%), angioedema (1.2%), and hematuria (2.3%). No rt-PA–related deaths; 8.9% died from COVID-19 pneumonia. Conclusions The low utilization of rt-PA in developing countries is mainly due to limited public awareness and restricted access to emergency medical services, particularly during the COVID-19 pandemic. Establishing multidisciplinary stroke teams and implementing prehospital code stroke protocols with priority dispatch, pre-notification, and rapid transfer are essential to reduce prehospital and door-to-needle delays. Conflict of interest Nothing to disclose
Elsayed Abed (2026) studied this question.