Ossama Yassin Mansour, Mohamad Ezzeldin, May Nour, Ameer Hassan, Syed Kashif Zaidi, Mouhammad A. Jumaa, Farid Aladham, Ibrahim Alnaami, Hosam Maher Al-Jehani, Abdulrahman Alshamy, Faisal Alghamdi, Atilla Ozcan Ozdemir, Tamer Hassan, Hany Zaki Eldeen, Hany El Hamadani, M. Shazam Hussain, Ehsan Sharifipour, Erdem Gurkas, Mohamed Alaa Habib, Nadia Hammami, Hosam Salah, Farouk Hassan, Syed I. Hussain, Yahia Imam, Seby John, Adnan Qureshi, Amina El Khamlichi, Amr Mahmoud, Ahmed Ossama, Mostafa Mahmoud, Ehab S. Mohamed, Nada Nasr, Umair Rashid, Salma Said, Abdulmonem I. Saied, Maher Saqqur, Khalid Sobh, Mohammed Wasay, Mohammed Ghorbani, Jeyaraj Pandian, Adnan Siddiqui, A. Shuaib
BACKGROUND: Stroke remains a leading cause of mortality and long-term disability in the Middle East and North Africa (MENA) region. The substantial burden of stroke in low- and middle-income countries, where 75% of stroke-related deaths and 81% of disability-adjusted life years occur, underscores the critical need for region-specific adaptations of acute stroke care guidelines to address critical regional challenges while maintaining evidence-based core principles of care. METHODS: We adapted evidence from multiple international guidelines (AHA/ASA 2019-2023, ESO 2021-2023, NICE 2019-2022, Chinese Stroke Association 2022) and recent meta-analyses using MENA-SINO's systematic seven-step framework including comprehensive evidence review, multidisciplinary expert panel input from 45 experts across 22 MENA countries, regional implementation barrier assessment, and formal modified Delphi consensus procedures achieving > 85% agreement. Recommendations employ modified Class of Recommendation, Level of Evidence, Resource-Limited designations, and Expert Opinion statements following AGREE II standards. KEY RECOMMENDATIONS: Our regional roadmap emphasizes ten cornerstone concepts: (1) tiered stroke care systems with telemedicine networks; (2) rapid reperfusion protocols for IV thrombolysis within 4.5 hours and mechanical thrombectomy within 6-24 hours based on imaging; (3) resource-stratified care; (4) culturally sensitive decision-making frameworks; (5) aggressive secondary prevention targeting regional risk factor patterns; (6) standardized quality metrics across diverse systems; (7) comprehensive workforce development programs; (8) appropriate technology integration; (9) region-specific emergency response systems;and (10) sustainable phased implementation strategies. CONCLUSION: These guidelines provide the first comprehensive, resource-stratified framework for acute ischemic stroke management across the MENA region, with practical adaptations addressing diverse healthcare settings while preserving essential evidence-based care components.