Abstract Body (Do not enter title and authors here): Abstract

Background
Stroke is a leading cause of death and disability worldwide and a significant burden on healthcare systems globally. Despite the effectiveness of tissue plasminogen activator (tPA) within 4.5 hours of the onset of acute ischemic stroke (IS), many patients arrive at the emergency department beyond the window to perform intravenous thrombolysis.
Study objectives: This study investigated factors contributing to the delayed presentation of acute patients with stroke to emergency departments across governorate hospitals in Oman and assessed neurological function at 90 days using the Modified Rankin Scale.

Methods
A prospective observational cohort multi-center study was conducted involving 512 participants with acute ischemic stroke symptoms who arrived at the emergency departments more than 4.5 hours after symptom onset. Data were collected using questionnaires administered to participants or their relatives to identify reasons for delayed arrival. Key variables included socio-demographic characteristics, symptom type, mode of arrival, and follow-up outcomes. Statistical analysis was performed to assess associations between these variables and participant outcomes.

Results
The mean age of the participants was 61.96 years, with a majority being male (65.2%) and Omani nationals (81.3%). The most common symptoms were upper limb weakness (67.8%), lower limb weakness (60.4%), and inability to speak (56.7%). The primary mode of transfer to the hospital was by a relative (62.3%). Significant findings included; Delayed Arrival: Confusion, falls, and facial weakness were associated with the fastest median arrival times, while memory loss, loss of facial sensation, and abnormal eye movements were associated with the longest delays. Reasons for Delay: Common reasons for delay included lack of awareness of stroke symptoms (36.7%), believing symptoms would self-resolve (29.7%), and not knowing the importance of timely hospital arrival (31.9%). Outcomes: At 90 days, 36.3% had mild disability, 50.0% had moderate to severe disability, and 13.7% had died.

Conclusion
Delayed hospital arrival in participants with stroke is influenced by various factors, including symptom type, mode of arrival, and socio-demographic characteristics. Enhancing public awareness about stroke symptoms and the importance of timely medical intervention could improve outcomes. This study provides valuable insights for improving stroke management and patient education in Oman.