Use of Mechanical Thrombectomy versus Tissue Plasminogen Activator in Low–Middle-Income Countries: A Meta-Epidemiological Analysis of Treatment Options and Social Determinants of Health

Abstract

Introduction

Acute ischemic stroke (AIS) is the second leading cause of death worldwide, and the disease burden falls greatly on low- and middle-income countries (LMICs) with around 63% of the global incidence. Despite medical advancements in high-income countries, this disparity in outcomes persists in LMICs. The impact of socioeconomic factors has not been well explored on treatment accessibility for AIS.

Methods

We completed a systematic review using PubMed, Scopus, and Web of Science with the search focused on outcomes of AIS in LMICs. A pooled meta-analysis was completed with these studies correlating variables to the use of tissue plasminogen activator (TPA) and mechanical thrombectomy (MT) treatment.

Results

About 46 studies were found for the use of TPA or MT for AIS in LMICs between 2007 and 2022. The percentage of the population living below 50% of the median income correlated with TPA use. MT use correlated with the median income, population density, average life expectancy, poverty–headcount ratio, and gross national income (GNI) per capita. Meanwhile, we found that both TPA and MT use insignificantly correlated with better in-hospital mortality and poor neurological outcome rates.

Conclusion

This meta-regression analysis uniquely explores the relationship between socioeconomic parameters in LMICs and the use of specific AIS therapies. Country parameters related to wealth disparity and population density correlated with treatment use. Further research with data involving delay to treatment and the potential impact of dedicated stroke centers warranted investigating the role of treatment accessibility in improving AIS outcomes.

Keywords

acute ischemic stroke - low- and middle-income countries - social determinants of health - mechanical thrombectomy - tissue plasminogen activator

Publikationsverlauf

Artikel online veröffentlicht:
19. Juli 2025

• References

• 1 Feigin VL, Brainin M, Norrving B. et al. World Stroke Organization (WSO): Global Stroke Fact Sheet 2022. Int J Stroke 2022; 17 (01) 18-29
• 2 Feske SK. Ischemic stroke. Am J Med 2021; 134 (12) 1457-1464
• 3 Punchak M, Mukhopadhyay S, Sachdev S. et al. Neurosurgical care: Availability and access in low-income and middle-income countries. World Neurosurg 2018; 112: e240-e254
• 4 Reshetnyak E, Ntamatungiro M, Pinheiro LC. et al. Impact of multiple social determinants of health on incident stroke. Stroke 2020; 51 (08) 2445-2453
• 5 Skolarus LE, Sharrief A, Gardener H, Jenkins C, Boden-Albala B. Considerations in addressing social determinants of health to reduce racial/ethnic disparities in stroke outcomes in the United States. Stroke 2020; 51 (11) 3433-3439
• 6 Yadav RS, Chaudhary D, Avula V. et al. Social determinants of stroke hospitalization and mortality in United States' counties. J Clin Med 2022; 11 (14) 4101
• 7 Covell MM, Naik A, Shaffer A. et al. Social determinants of health impact spinal cord injury outcomes in low- and middle-income countries: A meta-epidemiological study. Neurosurgery 2024; 94 (05) 893-902
• 8 Sarraj A, Savitz S, Pujara D. et al. Endovascular thrombectomy for acute ischemic strokes: Current US access paradigms and optimization methodology. Stroke 2020; 51 (04) 1207-1217
• 9 Bambauer KZ, Johnston SC, Bambauer DE, Zivin JA. Reasons why few patients with acute stroke receive tissue plasminogen activator. Arch Neurol 2006; 63 (05) 661-664
• 10 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372 (71) n71
• 11 Patel A, Vieira MMC, Abraham J. et al. Quality of the development of traumatic brain injury clinical practice guidelines: A systematic review. PLoS ONE 2016; 11 (09) e0161554
• 12 Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010; 25 (09) 603-605
• 13 Hilbrich L, Truelsen T, Yusuf S. Stroke and cardiovascular diseases: the need for a global approach for prevention and drug development. Int J Stroke 2007; 2 (02) 104-108
• 14 Naik A, Bederson MM, Detchou D. et al. Traumatic brain injury mortality and correlates in low- and middle-income countries: A meta-epidemiological study. Neurosurgery 2023; 93 (04) 736-744
• 15 Niklasson A, Herlitz J, Jood K. Socioeconomic disparities in prehospital stroke care. Scand J Trauma Resusc Emerg Med 2019; 27 (01) 53
• 16 Abilleira S, Lucente G, Ribera A, Permanyer-Miralda G, Gallofré M. Patient-related features associated with a delay in seeking care after stroke. Eur J Neurol 2011; 18 (06) 850-856
• 17 Asif KS, Otite FO, Desai SM. et al.; Global Executive Committee of the MT-GLASS Study. Mechanical Thrombectomy Global Access For Stroke (MT-GLASS): A Mission Thrombectomy (MT-2020 Plus) Study. Circulation 2023; 147 (16) 1208-1220
• 18 Kleinig TJ, McMullan P, Cloud GC, Bladin PC, Ranta A. Hyper-acute stroke systems of care and workflow. Curr Neurol Neurosci Rep 2024; 24 (10) 495-505
• 19 Child N, Fink J, Jones S, Voges K, Vivian M, Barber PA. New Zealand National Acute Stroke Services Audit: Acute stroke care delivery in New Zealand. N Z Med J 2012; 125 (1358): 44-51
• 20 Rahbar MH, Medrano M, Diaz-Garelli F. et al. Younger age of stroke in low-middle income countries is related to healthcare access and quality. Ann Clin Transl Neurol 2022; 9 (03) 415-427
• 21 Virani SS, Alonso A, Benjamin EJ. et al.; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2020 Update: A report from the American Heart Association. Circulation 2020; 141 (09) e139-e596
• 22 Krishnamurthi RV, Feigin VL, Forouzanfar MH. et al.; Global Burden of Diseases, Injuries, Risk Factors Study 2010 (GBD 2010), GBD Stroke Experts Group. Global and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990-2010: Findings from the Global Burden of Disease Study 2010. Lancet Glob Health 2013; 1 (05) e259-e281
• 23 Ramphul K, Ramphul Y, Sombans S. et al. Incidence and mortality rates of acute ischemic stroke in hospitalized patients in the United States. Arch Med Sci Atheroscler Dis 2021; 6: e132-e134
• 24 Kelly DM, Feld J, Rothwell PM, Reinecke H, Koeppe J. Admission rates, time trends, risk factors, and outcomes of ischemic and hemorrhagic stroke from German nationwide data. Neurology 2022; 99 (23) e2593-e2604
• 25 D'Anna L, Abu-Rumeileh S, Merlino G. et al. Safety and outcomes of mechanical thrombectomy in acute ischemic stroke attributable to cardiological diseases: A scoping review. J Am Heart Assoc 2024; 13 (17) e034783
• 26 Almallouhi E, Zandpazandi S, Anadani M. et al. Outcomes of mechanical thrombectomy in stroke patients with extreme large infarction core. J Neurointerv Surg 2024; 16 (12) 1268-1274
• 27 Romoli M, Princiotta Cariddi L, Longoni M. et al. Mechanical thrombectomy in ischemic stroke with a large infarct core: A meta-analysis of randomized controlled trials. J Clin Med 2024; 13 (15) 4280
• 28 Boulanger JM, Lindsay MP, Gubitz G. et al. Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018. Int J Stroke 2018; 13 (09) 949-984
• 29 Knauss S, Stelzle D, Emmrich JV, Korsnes MS, Sejvar JJ, Winkler AS. An emphasis on neurology in low and middle-income countries. Lancet Neurol 2019; 18 (12) 1078-1079
• 30 Lauinger AR, Naik A, Bah MG. et al. Letter: Trends in in-hospital mortality and neurological deficit rates following ischemic stroke in low- and middle-income countries. Neurosurgery 2024; 94 (01) e9-e12
• 31 Prust ML, Forman R, Ovbiagele B. Addressing disparities in the global epidemiology of stroke. Nat Rev Neurol 2024; 20 (04) 207-221