The current model highlighted strength points and detected some gaps by using the WSO roadmap within the Matrouh governorate. Along with the following content and through a problem-solving analytical approach the current model aimed at dealing with the gaps so as to customize and implement a stroke service based on the WSO roadmap.

Matrouh was a good example of implementing a stroke service as it had the basic hospitals and ambulance services yet it was deficient in stroke units, availability of thrombolysis, trained physicians, code stroke, awareness, telestroke, and database analysis (Table 3).

The current model found 2 out of 7 hospitals within Matrouh governorate namely (El Alamein Typical Hospital and Mersa Matrouh General Hospital) to be approaching the term essential healthcare stroke providers as they had the needed diagnostic capabilities and were located at a distance that made them capable of covering a broad area of the governorate (Fig. 2).

Yet, both hospitals are deficient in dedicated stroke beds. According to the estimated numbers in the current model, a total of 11 beds were needed to serve stroke cases within the governorate.

Another gap found in the current model is the deficiency of neuroscience specialty within Matrouh. According to the World Health Organization (WHO), neurology atlas low-income countries have 0.03 neurologists per 100,000 population while low-middle-income countries have 0.13 [19].

Based on Kissani and colleagues; neurologists in Egypt up to 2020 were 3108 [13] and in another study conducted by Roushdy and colleagues in 2022 neurologists were 4500 this makes the neurology specialty not scarce in Egypt [20] with 4.31 neurologists per 100,000 population [21].

The main obstacle is the inequality in the distribution of branches of medicine including neurology along different governorates, most of the specialties are concentrated in Cairo and major cities. Another important obstacle is the failure to retain physicians within Egypt, most physicians find salaries unsatisfactory, suffer from verbal abuse and physical assaults, and do not have a proper job description with an overall dissatisfaction [22,23,24].

So, one important goal is to improve salary and working conditions to retain specialists more generally [24], reallocating trainees/neurologists during summer to help deliver the service at the beginning and also to offer training to local staff [25], and improving stroke knowledge of the teams that work on the ground and training them on the different major stroke scales to implement in-hospital acute stroke pathway [26,27,28].

According to the WSO roadmap, the first step in stroke management is recognition of stroke and calling for help at healthcare services [4]. For such a step to occur raising awareness and linking patients and their caregivers to EMS is a must. Despite code stroke is still not active in Egypt. Yet, it is mandatory for any successful stroke service as it eventually reduces onset to door which reflects on onset to needle time [29, 30].

Matrouh was found to have 60 ambulance units so activating code stroke is reachable. By activating code stroke patients who usually seek private transportation to reach hospitals will find a more professional way that can minimize any potential delay from symptom onset to hospital admission [31].

According to Saini and colleagues in 2016; 13.7 million new stroke cases were encountered globally with approximately 87% ischemic strokes yet less than 5% received thrombolysis [32].

The low thrombolysis rate could be partially attributed to non-eligibility yet it reflects more the failure of the utilization of thrombolytics which could be a result of a lack of awareness about time is brain concept and the face, arm, speech, and time (FAST) criteria.

Raising awareness is a crucial aspect to consider in any stroke service implementation plan. The Angels Initiative, together with the WSO, has introduced the FAST Angels Heroes Initiative which aims at increasing public awareness in general and increasing the awareness of stroke precisely in the young age group within schools [33] making use of such an initiative will be of great value in the situation of Matrouh and in any similar condition where grandchildren are left with grandparents for a proportion of the time in summer season.

Translation of FAST Heroes’ Western names to Arabic ones that reflect the cultural background of Egypt and Arabic-speaking countries so as to achieve brain imaging for such heroes and for the FAST criteria along with school children could increase stroke awareness in the region.

The translated material could be presented to school children in their classrooms through a combined campaign held by the stroke chapter within the Egyptian Society of Neurology, Neurosurgery, and Psychiatry which is the main umbrella of Neurologists along entire Egypt and the MOH as well as the Ministry of Education.

Thrombolysis is a must in any successful stroke service implementation. In Egypt, thrombolysis, as well as thrombectomy, are totally endorsed by the government [14]. Yet, this is not the case in most developing countries [20]. rtPA ought to be obtainable for any hospital to be considered an essential healthcare stroke provider and to be called a stroke unit this could be achieved through advocacy with the aid of WSO as was done in Latin America [34].

The funds for higher transportation costs due to the unavailability of stroke units and reduced thrombolysis rates leading to higher lifelong costs can be translated into mobilizing rtPA in the chosen hospitals and building a stroke unit from existing basic resources.

Telestroke was first introduced in 1999, it aims at providing stroke expertise to hospitals that lack physicians well-trained in dealing with stroke. In our model and until solving the problem of neurologist allocation and other specialties training, telestroke will be of reasonable value [35]. Since thrombolysis is of great value in stroke recovery, yet, it ought to be administered by trained and qualified physicians to avoid any possible adverse effects. Telestroke provides an opportunity for inexperienced clinicians to be supported through assessment, decision-making, and follow-up and has been shown to improve outcomes and reduce the length of stay within hospitals [35].

In Egypt, telemedicine and telestroke units are newly introduced with the telemedicine unit at Ain Shams University Hospitals and the treat and teach initiative of Ain Shams Virtual Hospital [36,37,38,39].

The implementation of a telemedicine unit in stroke management can be realized through either a distributed model or a hub and spoke model. In both cases, the patient can be remotely assessed, and decisions regarding intravenous thrombolysis can be made [35].

In situations where a patient requires further management as intervention through thrombectomy or coiling procedures, the patient could be transferred to the nearest hospital with such capabilities which would be located in Alexandria in case of patients within Matrouh general hospital coverage area (245 km from Alexandria rather than 500 km from Cairo). As for patients within El Alamein coverage area (107 km from Alexandria or 261 km from Cairo), it is possible to be transferred to either Alexandria or Cairo based on availability and proper coordination.

It is preferable that patients with suspected large vessel occlusion (LVO) that are candidates for thrombectomy be transferred to El Alamein typical hospital for drip and then shipped to the nearest center, besides El Alamein typical hospital is equipped with an Angio suite so if re-allocation of trained interventional neurologists took place then by the time El Alamein typical hospital could be the center providing advanced stroke therapies for the entire north coast of Matrouh governorate and this will save the time of patient’s transfer for a distance that might extend for 2 h.

Suspicion of LVO requires training of EMS on the NIHSS or using a pre-hospital stroke scale as well as raising the awareness of the targeted population about the major signs of stroke which is provided through the Angels FAST Heroes initiative [35].

Once establishing a stroke unit, the model recommends self-monitoring with a database and documentation of cases presented to the two chosen hospitals with the use of quality assessment registries that are approved worldwide and already being used in different stroke units in Egypt as the safe implementation of treatments in stroke (SITS) or the Stroke care quality registry (RESQ) so as to follow up any drawbacks in the stroke implementation service with self-monitoring and self-correction [14].

Once stroke recognition takes place and acute management is provided the inpatient care step begins which includes searching for an etiological diagnosis of stroke, rehabilitation, and early mobilization [4].

Rehabilitation and early mobilization although not highlighted in the current model yet, it is present along the entire 7 hospitals of the governorate. Yet, the current model analysis found only 7 physical medicine and 16 physical therapists serving within the governorate so it is recommended to increase this number in the future government plans and this highlights that for a successful stroke service not only neurologists are needed but multidisciplinary team is needed as well [34, 35].

Comprehensive stroke management extends beyond acute management to include the identification of risk factors and secondary prevention intervention. Services addressing stroke recurrence risk are well established in Egypt where there is access to internal medicine and cardiology clinics; medications management of hypertension, diabetes, dyslipidemia; and antiplatelet and anticoagulant therapies. The two chosen hospitals in our study have these secondary prevention capabilities. This is not the case in other developing countries with a corrective plan needed to achieve availability of screening for modifiable vascular risk factors and endorsement of related medications [20].

For successful stroke management, the WSO roadmap identified the importance of dysphagia screening and this is achievable through different approaches from the very simple drinking water test to the more accurate laryngoscope assessment [4]. Initiating dysphagia screening for all stroke patients reduces hospital stays and aids in the bed turnover cycle as it reduces the risk of aspiration pneumonia and other related complications [20].

Community reintegration and recovery is one of the important points that are recommended in the roadmap and still deficient in most developing countries including Egypt and this is achievable only through an entire country development system approach with cooperation between governmental and non-governmental sectors of the community [20, 35].

The current study has certain limitations that should be acknowledged. Firstly, it remains a theoretical framework and has not yet been implemented in real-world settings. Therefore, its actual feasibility or effectiveness cannot be fully assessed without practical application, second there were not any epidemiological studies on stroke incidence in Matrouh so the current model used the nearest suitable example that was conducted in the New Valley governorate to estimate the number of stroke cases that to be encountered annually in Matrouh, third the liability of population density variability along the year yet this condition is present along different countries with touristic backgrounds and is of value to be highlighted and analyzed. Despite these limitations, the study possesses several strengths. It offers a unique approach by transforming the algorithms of the WSO roadmap into a stepwise analytical study. This allows for a comprehensive evaluation of stroke service implementation within a specific context. The choice of Matrouh governorate as a study site provides a representative example of a region with a combination of rural and urban areas, bordering characteristics, and a population that is increasing in nature. By focusing on a realistic problem-solving situation, the study offers practical insights and potential solutions for stroke service implementation.