Stroke represents a major global public health challenge due to its high morbidity, mortality, and long-term socio-economic impact. According to the World Health Organization, stroke is the second leading cause of death worldwide and the leading cause of acquired disability in adults [1][2]. This situation is particularly critical in resource-limited countries, where access to specialized care is often delayed or unavailable [1].

Rapid intervention, particularly intravenous thrombolysis within the first 4.5 hours, significantly improves the prognosis of ischemic strokes, which account for nearly 85% of cases [3]-[8]. However, many patients in developing countries arrive at the hospital after this optimal treatment window [9]. This delay constitutes a major barrier to effective treatment and compromises both vital and functional outcomes [10]-[15]. In a study conducted in Kinshasa, the delay in hospital arrival increases the risk of severe strokes by 5 times [16].

In Pointe-Noire, the economic capital of the Republic of Congo, no research had yet assessed the determinants of this delay. This study aims to identify the factors associated with the late consultation of stroke victims in order to suggest potential improvements.

We conducted a prospective cross-sectional study from July 1 to October 30, 2024, at the Loandjili General Hospital in Pointe Noire. All patients aged ≥ 18 years admitted for a stroke confirmed by CT or MRI were included. Patients who refused to answer the questionnaire were excluded. Data were collected using a questionnaire administered to the patient or accompanying person and supplemented by a review of medical records. The variables included: consultation delay, (Delayed consultation was defined as arriving at the hospital more than 3 hours after the onset of symptoms. This threshold was chosen to take into account local constraints on access to emergency imaging, so that patients arriving within the first 3 hours still have a reasonable probability of being treated within the maximum recommended window of 4.5 hours for thrombolysis), sociodemographic data, clinical signs, medical history, initial symptom perception, mode of transport, initial contact (The variable “initial contact” was defined as the first person contacted by the patient or their family after the onset of symptoms. It comprised three categories: non-specialized medical staff, family members, and direct consultation at the hospital. For the multivariate analysis, the category “direct consultation at the hospital” was used as the reference category), distance, imaging performed, and outcome. The data were entered into Excel and analyzed using R Studio (version 4.1.3). Qualitative variables were described using frequencies, and quantitative variables were described using means, standard deviations, and extremes. Bivariate comparisons used the chi-squared test for proportions and the Wilcoxon Mann Whitney test for means (significance threshold α < 0.05). To limit confounding factors, a multiple binary logistic regression was performed by including all variables with a p<0.25 in the initial model. A mixed stepwise automated method was used. The calibration of the multivariate model was verified by the Hosmer Lemeshow test, VIF (variance inflation factors) for multicollinearity, and the AUC of the ROC curve. The study was conducted in accordance with ethics, with permission from the head of the department, anonymity of data, and informed consent from participants.

The results confirm that post-stroke consultation delays are common. This frequency has been widely observed in the literature, where more than three-quarters of patients arrive late at the hospital [16]-[20]. This delay in consultation is defined as arriving at the hospital more than 3 hours after the onset of stroke symptoms [21]. This 3-hour window was chosen considering the difficulties in quickly accessing medical imaging in our reality, which would increase the chances of staying within the 4.5-hour maximum window for thrombolysis.

This delay appears to be a multifactorial phenomenon, involving geographical, temporal, and behavioral determinants. Among the main identified obstacles are the geographical distance between the patient’s home and hospital facilities, the occurrence of symptoms at night, as well as inappropriate care pathways which are significant factors of delay. This complexity is widely described in the literature. For example, authors have shown that a lack of awareness of warning signs, hesitation to call emergency services, and underestimation of symptoms by patients or their families are recurring obstacles in the care process [22][23]. We observe that, unlike in the bivariate analysis, the average socioeconomic level appears to be a protective factor in the multivariate analysis. This difference is probably explained by a confounding effect: once adjusted for distance, initial mode of referral, and time of onset, the socioeconomic level reflects the ability to quickly access hospital services more than social status itself.

The geographical distance ≥ 5 km is a major determinant of delay, as described in the literature [24].

The initial consultation with a non-specialized healthcare professional extends the care pathway, a well-documented phenomenon [5][25]-[27]. Thus, the initial reliance on non-specialized health facilities, such as general practice offices or primary care services, significantly contributes to delaying access to specialized emergency services.

The timing of symptom onset is also a well-identified factor. Indeed, nighttime occurrence often delays the recognition of symptoms and access to emergency care. This phenomenon is well described in the literature [6]. Thus, Revathi showed that the time of onset of symptoms between 7 PM and 3 AM was significantly associated with delay in seeking consultation for stroke [26]. Conversely, going directly to the hospital is a protective factor, confirming the importance of immediate orientation. In the literature, patients who arrived early went directly to the hospital [27].

The presence of dizziness, often perceived as alarming, appears to prompt earlier medical consultation. This suggests that the subjective perception of severity relies not only on the classic neurological signs of a stroke but also on less specific manifestations. This observation is in line with the literature [7]. This suggests a lack of awareness of stroke signs among the population. This lack of awareness has been widely described in the literature [8][28].

These findings highlight the importance of targeted interventions at several levels:

Awareness campaigns aimed at the general population, to enhance the rapid recognition of early stroke signs and promote an adequate response.The development and accessibility of effective emergency regulation platforms, coupled with quickly available medical transportation, especially in rural or peri-urban areas.The creation of local neurovascular care centers, aimed at reducing access delays to specialized care.Enhanced training for frontline professionals (general practitioners, paramedics, staff at primary care centers) on the rapid detection of strokes and referral to specialized pathways.

Our recommendations stem directly from these results: given that dizziness was associated with earlier consultation, awareness campaigns should include this symptom among the potential signs of stroke. Similarly, the strong association between distance ≥5 km and delay justifies the establishment of decentralized care centers or a priority medical transport system.

Delayed consultation represents a major barrier to effective stroke management in Pointe-Noire. It is associated with geographic, temporal, and behavioral factors. Awareness measures, better organization of the emergency system, and decentralization of care could significantly improve the management and prognosis of strokes.

All authors contributed to the development of this work, including study design, data collection, statistical analysis, writing, review, and editing of the manuscript.