Delivering acute stroke care in a middle-income country. The Mexican model: "ResISSSTE Cerebro"

Abstract

Introduction: Founded in 2019, the "ResISSSTE Cerebro" program is the first and only stroke network within the Mexican public health system. One advanced stroke center (ASC) and seven essential stroke centers (ESC) provide acute stroke (AS) care through a modified hub-and-spoke model. This study describes the workflow, metrics, and outcomes in AS obtained during the program's third year of operation.

Materials and methods: Participants were adult beneficiaries of the ISSSTE health system in Mexico City with acute focal neurological deficit within 24 h of symptom onset. Initial evaluation could occur at any facility, but the stroke team at the ASC took all decisions regarding treatment and transfers of patients. Registered variables included demographics, stroke risk factors, AS treatment workflow time points, and clinical outcome measures.

Results: We analyzed data from 236 patients, 104 (44.3%) men with a median age of 71 years. Sixty percent of the patients were initially evaluated at the ESC, and 122 (85.9%) were transferred to the ASC. The median transfer time was 123 min. The most common risk factor was hypertension (73.6%). Stroke subtypes were ischemic (86.0%) and hemorrhagic (14.0%). Median times for onset-to-door, door-to-imaging, door-to-needle, and door-to-groin were: 135.5, 37.0, 76.0, and 151.5 min, respectively. The rate of intravenous thrombolysis was 35%. Large vessel occlusion was present in 63 patients, from whom 44% received endovascular therapy; 71.4% achieved early clinical improvement (median NIHSS reduction of 11 points). Treatment-associated morbimortality was 3.4%.

Conclusion: With the implementation of a modified hub-and-spoke model, this study shows that delivery of AS care in low- and middle-income countries is feasible and achieves good clinical outcomes.

Keywords: acute ischemic stroke; hub-and-spoke; low- and middle-income countries; public health; stroke centers.