MENA-Adapted Guidelines

We recommend establishing regional telemedicine networks to overcome the limited access to comprehensive stroke centers in many MENA countries.

Unlike high-resource settings, many MENA nations face significant geographic barriers to centralized care, requiring innovative approaches to support rapid consultation before physical transfer. Following the NICE guidelines but adapted for our regional realities, we emphasize that transfer decisions should consider holistic patient assessment rather than severity scores alone.

MENA healthcare providers should prioritize early treatment of ruptured aneurysms, ideally within 24 hours.

Our regional experts emphasize that transportation difficulties in remote areas or conflict zones require pre-established emergency transfer protocols. When immediate transfer is impossible due to geopolitical or resource constraints, we provide alternative management strategies for stabilization.

MENA neurological teams must balance securing the aneurysm against procedural risks, while considering variable expertise across the region.

Unlike high-resource settings, the availability of both endovascular and surgical expertise varies dramatically. We recommend that larger centers establish supportive relationships with smaller facilities through formal telemedicine consultation networks to optimize modality selection.

We recommend implementing standardized ICU care bundles adapted for varying resource availabilities.

Many MENA facilities operate with limited monitoring equipment, requiring protocols that prioritize the core elements applicable even in austere environments. Regional healthcare systems should develop tiered approaches that account for different capability levels, while ensuring key interventions to prevent complications.

For new-onset seizures after aSAH, we recommend treatment with anti-seizure medication for 7 days.

MENA practitioners should consider medication accessibility; levetiracetam is preferred when available, but regional shortages often necessitate alternatives. We provide guidance on older, more widely available medications while avoiding phenytoin because of its association with poorer outcomes.

We strongly recommend training nurses to detect neurological changes using standardized assessments across all MENA settings.

Where advanced monitoring is unavailable, protocols for simplified neurological monitoring with clear triggers for intervention are provided. Alternative approaches have been suggested for settings that lack specialized equipment.

We advocate early nimodipine administration to prevent delayed cerebral ischemia adapted to regional healthcare contexts.

The NICE guidelines recommend enteral nimodipine for confirmed aSAH, which we endorse when addressing regional availability challenges. Given the variable accessibility and cost of nimodipine across MENA countries, we detail contingency approaches in which supply is limited.

For symptomatic delayed cerebral ischemia, we recommend blood pressure augmentation with consideration of regional monitoring capabilities.

Many MENA facilities lack continuous arterial monitoring, requiring adaptation of protocols for intermittent non-invasive measurements. Implementation guidance addresses the variable availability of vasopressor medication.

We recommend individualized follow-up imaging protocols based on patient risk and local resource availability.

Many MENA settings face limitations in imaging accessibility, requiring prioritization strategies. Our guidelines provide direction for screening intervals and modality selection based on local capabilities, with telemedicine support for image interpretation where expertise is limited.

We advocate team-based rehabilitation approaches adapted to regional healthcare contexts.

Acknowledging that formal rehabilitation services are limited in many MENA countries, we emphasize family centered approaches incorporating home-based care. Culturally appropriate rehabilitation strategies can leverage family involvement and community resources.