Beyond the golden hour: prehospital delay and in-hospital stroke mortality in an elderly cohort reaching a national emergency-medicine center in Kazakhstan.
Abduldayeva A, Omarbek A, et al. • Frontiers in neurology • 2026
Within this hospital-admitted elderly cohort, in-hospital mortality appears governed by neurological severity and cardiac comorbidity rather than transport time, with baseline NIHSS (penalized OR 1.22 per point) and cardiac arrhythmia (penalized OR 5.51) as the significant predictors of death.
Key Findings
Results
The median onset-to-door time was 9.5 hours, far exceeding the 4.5-hour thrombolysis window, with only 36.5% of patients arriving within that window.
Median onset-to-door time was 9.5 h (IQR 3.0–48.3 h; range 25 min to 264 h).
Only 36.5% of patients arrived within the 4.5-hour thrombolysis window.
Delays were longest in hemorrhagic stroke, with a median of 24.8 h.
The cohort comprised 149 elderly patients aged 57–75 years admitted to a national emergency medicine center in Astana, Kazakhstan in 2025–2026.
Results
Ischemic stroke predominated, accounting for 81.9% of cases, while reperfusion therapy was administered to only 24.6% of ischemic-stroke patients.
122 of 149 patients (81.9%) had ischemic stroke.
Reperfusion therapy reached 24.6% of ischemic-stroke patients.
Thrombolysis was used in 9.0% and thrombectomy in 15.6% of ischemic-stroke patients.
67.2% of ischemic-stroke patients were managed conservatively.
Results
In-hospital mortality was low at 6.8% despite the substantial prehospital delays.
Overall in-hospital mortality was 6.8% across the 149-patient cohort.
The authors note a crude mortality contrast of 29.4% vs. 3.8% (described as descriptive and hypothesis-generating).
The low overall mortality is interpreted in the context of survivor bias, as only patients who survived to reach the center were included.
Results
Onset-to-door time did not predict in-hospital death or discharge functional status.
Adjusted OR for in-hospital death per hour of onset-to-door time was 1.00 (p = 0.99).
Spearman correlation between onset-to-door time and modified Rankin Scale at discharge was r = −0.013 (p = 0.87).
These associations were assessed using logistic regression and Spearman correlation analyses.
Results
Baseline NIHSS score was a significant independent predictor of in-hospital mortality in the Firth penalized logistic regression model.
Penalized OR for death per NIHSS point was 1.22 (95% profile-likelihood CI 1.12–1.37; p < 0.001).
A Firth penalized model was used due to the small number of deaths (pre-specified).
Higher NIHSS at admission indicated greater neurological severity.
Results
Cardiac arrhythmia was a significant independent predictor of in-hospital mortality.
Penalized OR for death associated with cardiac arrhythmia was 5.51 (95% CI 1.07–29.71; p = 0.041).
This was identified in the same Firth penalized logistic regression model as NIHSS.
The finding supports the importance of arrhythmia detection in stroke triage.
Results
Later-presenting patients had lower baseline neurological severity, indicating a severity-time selection effect.
Baseline NIHSS was inversely correlated with onset-to-door time (r = −0.193; p = 0.019).
This indicates that patients who arrived later were less severely affected.
The authors interpret this as reflecting who reaches the center rather than a causal relationship, consistent with survivor and referral bias.
Methods
The study population was elderly patients in Kazakhstan, a country with low population density and limited prehospital infrastructure, where data on stroke outcomes are scarce.
Kazakhstan has an area of approximately 2.72 million km² with a population density of roughly 7 inhabitants per km².
149 patients aged 57–75 years were retrospectively analyzed.
Patients were admitted to the National Coordination Center for Emergency Medicine in Astana in 2025–2026.
Transient ischemic attacks were excluded; all cases were neuroimaging-confirmed acute stroke.
Prehospital time, transport mode, reperfusion, NIHSS, comorbidity, and in-hospital mortality were assessed.
What This Means
This research suggests that among elderly stroke patients admitted to a major emergency center in Kazakhstan, how long it took to reach the hospital did not meaningfully predict whether a patient died or how well they recovered. The study tracked 149 patients aged 57–75 years and found that the typical patient arrived nearly 10 hours after stroke onset — far beyond the 4.5-hour window when clot-dissolving drugs are most effective — and that only about one-third arrived in time for reperfusion therapy. Despite these long delays, the in-hospital death rate was relatively low at 6.8%. Instead of transport time, the factors that predicted death were how neurologically severe the stroke was at admission (measured by the NIHSS score) and whether the patient had a cardiac arrhythmia (irregular heartbeat).
The research also found that patients who arrived later tended to have less severe strokes — suggesting that the sickest patients either died before reaching the hospital or arrived faster, while those with milder strokes were more likely to wait. This 'survival bias' means the results reflect who makes it to the hospital, not the full picture of stroke outcomes in the region. The findings apply specifically to this admitted cohort and should not be interpreted as showing that delays do not matter at the population level.
This research suggests that in settings like Kazakhstan — with vast geography, sparse population, and limited emergency infrastructure — improving stroke outcomes may require approaches beyond just reducing transport time, such as better detection and management of cardiac arrhythmias, risk-based triage to prioritize the most severely affected patients, and investment in regionalized care and air ambulance capacity. At the same time, efforts to shorten the time from stroke onset to hospital arrival remain important, especially to increase the proportion of patients who can benefit from reperfusion treatments.
Abduldayeva A, Omarbek A, Doszhanova G, Adilbekov Y, Safonov N, Iskakova S. (2026). Beyond the golden hour: prehospital delay and in-hospital stroke mortality in an elderly cohort reaching a national emergency-medicine center in Kazakhstan.. Frontiers in neurology. https://doi.org/10.3389/fneur.2026.1916069