Geographic Accessibility to Acute Stroke Care in Egypt: A Population-Level GIS Analysis With Hub-and-Spoke Network...

Egypt faces a disproportionate acute stroke burden, but geographic accessibility to intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) has not been systematically quantified using modality-specific treatment windows. The objective of the current work is to measure population-level geographic accessibility to IVT and MT across Egypt's 27 governorates, characterize access inequality determinants, and model the clinical impact and cost-effectiveness of targeted hub-and-spoke network expansion.

We verified 29 IVT-capable hospitals and 13 MT-ready centers through a 3-phase protocol. Onset-to-treatment time was computed for 120 settlements representing 89.3% of the national population (108.3 million). MT eligibility was based on noncontrast CT for ASPECTS scoring and CT angiography for large-vessel occlusion confirmation. Treatment windows were classified as optimal (<180 min), within-window (IVT 180 to 270 min; MT 180 to 360 min), or denied (IVT >270 min; MT >360 min). A maximum-coverage location problem model identified the optimal deployment for 3 new MT hubs and 4 IVT spokes. Cost-utility analysis expressed outcomes in quality-adjusted life years over 10 years using Egypt's GDP per capita of $3800.

IVT optimal access was 71.8% nationally (77.0 million), while MT optimal access was only 56.2% (60.9 million), with 20.4% denied MT under the 6-hour threshold. Nine of 13 MT-ready centers (69.2%) concentrated in Cairo/Giza (19.2% of the population). Hub-and-spoke deployment improved MT optimal access from 56.2% to 75.8% nationally. Probabilistic sensitivity analysis demonstrated 73.2% and 91.4% probabilities of cost-effectiveness at 3× and 4× GDP thresholds, respectively.

Egypt's MT access crisis reflects infrastructure maldistribution rather than patient ineligibility. A hub-and-spoke model using NCCT+CTA-based MT selection within the 6-hour window is clinically sound, operationally feasible, and probabilistically cost-effective.