Global inequities and strategies for expanding access to reperfusion therapies in acute ischemic stroke: A focus on low- and middle-income countries

Background and purpose: Acute ischemic stroke is a leading cause of mortality and long-term disability worldwide, disproportionately affecting low- and middle-income countries (LMICs). While intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) improve outcomes in high-income countries (HICs), access remains severely limited in resource-constrained regions. This review examines global disparities in reperfusion therapy and highlights strategies to expand access in LMICs. Methods: A narrative review was conducted of literature published between 1995 and 2025 across PubMed, Scopus, Web of Science, and Google Scholar. Search terms included acute ischemic stroke, IVT, MT, stroke systems of care, HICs, LMICs, telemedicine, hub-and-spoke models, and workforce capacity. Eligible sources comprised randomized trials, systematic reviews, multicenter cohort studies, registry analyses, and policy reports addressing access, infrastructure, referral networks, and implementation strategies. Evidence was synthesized narratively to identify barriers and scalable interventions. Observations: IVT is available in roughly 70 countries, while MT exists in only 33, predominantly in HICs. Barriers in LMICs include delayed hospital arrival, limited imaging and interventional resources, workforce shortages, high treatment costs, and fragmented referral pathways. Emerging strategies such as telestroke networks, hub-and-spoke referral systems, task-sharing with non-specialist providers, cost-adapted imaging protocols, and community awareness campaigns show potential to improve timely access and patient outcomes. Policy support, regional collaborations, and infrastructure investment are key enablers. Conclusions: Expanding access to IVT and MT is essential to reduce stroke-related mortality and disability in LMICs. Implementation requires coordinated policy, targeted investment, workforce development, and context-specific solutions. Further research should evaluate long-term outcomes, cost-effectiveness, and scalability of these interventions to guide sustainable improvements in stroke care delivery.