Pre-Hospital and In-Hospital Delay in Acute Ischemic Stroke Patients in Indonesia: A Multi-center Study

  • Rizqi Haqqum Minalloh Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
  • Abdulloh Machin
  • Wida Mardiana
  • Thanarat Suansanae
  • Suvatna Chulavatnatol
  • Surakit Nathisuwan Faculty of Pharmacy, Mahidol University
Keywords: Fibrinolysis, Stroke, Indonesia


Introduction: Little is known regarding pre-hospital and in-hospital delays in acute ischemic stroke (AIS) patients in Indonesia. This study aimed to evaluate the nature of these delays and identify factors causing pre-hospital delays among AIS patients in Indonesia.
Methods: This was a prospective, observational study conducted among adult AIS patients in 3 hospitals in Surabaya during March–August 2019. Baseline characteristics along with time intervals both pre- and post-arrival of patients to the study sites were collected and analysed. Multiple logistic regression analyses with a stepwise forward model were performed to evaluate the factors contributing to the pre-hospital delay.
Results: A total of 126 patients were recruited in this study. Mean age ± S.D. was 58.56 ± 10.71 years old. The mean ± S.D. time of pre-hospital delay and mean ± S.D. time to computerized tomography scan were 1,004±1,116.09 and 189±166.44 minutes, respectively. Only 18 out of 126 patients (14.29%) presented to the hospitals within 4.5-hour of intravenous thrombolysis (IVT) time window. However, only 3 patients (2.38%) ultimately received IVT. Wake-up stroke (OR=17.865; p=0.019), unawareness of the gravity of symptoms (OR=11.025; p=0.007), unawareness of stroke symptoms (OR=7.880; p=0.003) and referral patient (OR=7.819; p=0.008) were significantly associated with pre-hospital delay.
Conclusion: Pre-hospital delay of AIS was very common and represented a challenging problem to improve stroke care in Indonesia. Wake-up stroke along with lack of patient understanding in recognizing stroke symptoms and ineffective referral system were the most prominent risk factors for pre-hospital delay in Indonesian AIS patients.

Author Biographies

Abdulloh Machin

Department of Neurology, Dr. Soetomo General Hospital, Surabaya, Indonesia

Department of Neurology, Universitas Airlangga Hospital, Surabaya, Indonesia

Wida Mardiana

Department of Neurology, Hajj General Hospital, Surabaya, Indonesia

Thanarat Suansanae

Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand

Suvatna Chulavatnatol

Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand


Abd-Allah, F., & Moustafa, R. R. (2014). Burden of stroke in Egypt: current status and opportunities. Int J Stroke, 9(8), 1105-1108.
Aguiar de Sousa, D., von Martial, R., Abilleira, S., Gattringer, T., Kobayashi, A., Gallofre, M., Fazekas, F., Szikora, I., Feigin, V., Caso, V., & Fischer, U. (2019). Access to and delivery of acute ischaemic stroke treatments: a survey of national scientific societies and stroke experts in 44 European countries. Eur Stroke J, 4(1), 13-28.
Chen, C.-H., Huang, P., Yang, Y.-H., Liu, C.-K., Lin, T.-J., & Lin, R.-T. (2007). Pre-hospital and in-hospital delays after onset of acute ischemic stroke—A hospital-based study in southern Taiwan. Kaohsiung Med Sci, 23(11), 552-559.
Emberson, J., Lees, K. R., Lyden, P., Blackwell, L., Albers, G., Bluhmki, E., Brott, T., Cohen, G., Davis, S., Donnan, G., Grotta, J., Howard, G., Kaste, M., Koga, M., von Kummer, R., Lansberg, M., Lindley, R. I., Murray, G., Olivot, J. M., Parsons, M., Tilley, B., Toni, D., Toyoda, K., Wahlgren, N., Wardlaw, J., Whiteley, W., del Zoppo, G. J., Baigent, C., Sandercock, P., & Hacke, W. (2014). Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet, 384(9958), 1929-1935.
Gani, A., & Budiharsana, M. P. (2018). The Consolidate Health Report on Indonesia Health Sector Review 2018 (P. B. Ali, R. G. M. Siahaan, & S. K. M. Ardhiantie, Eds.). Ministry of National Development Planning.
Ghandehari, K. (2013). Design of a standard Iranian protocol of intravenous thrombolysis with tissue plasminogen activator: A national project. Iran J Neurol, 12(2), 72-74.
Gu, H. Q., Rao, Z. Z., Yang, X., Wang, C. J., Zhao, X. Q., Wang, Y. L., Liu, L. P., Wang, C. Y., Liu, C., Li, H., Li, Z. X., Xiao, R. P., Wang, Y. J., & Chinese Stroke Center Alliance, I. (2019). Use of emergency medical services and timely treatment among ischemic stroke. Stroke, 50(4), 1013-1016.
Machin, A., & Hamdan, M. (2018). Factors associated with onset to hospital delay among stroke patients in the emergency department. Indian Journal of Public Health Research & Development, 9(11), 101-105.
Manners, J., Khandker, N., Barron, A., Aziz, Y., Desai, S. M., Morrow, B., Delfyett, W. T., Martin-Gill, C., Shutter, L., Jovin, T. G., & Jadhav, A. P. (2019). An interdisciplinary approach to inhospital stroke improves stroke detection and treatment time. J Neurointerv Surg, 11(11), 1080-1084.
Meretoja, A., Keshtkaran, M., Saver, J. L., Tatlisumak, T., Parsons, M. W., Kaste, M., Davis, S. M., Donnan, G. A., & Churilov, L. (2014). Stroke thrombolysis: save a minute, save a day. Stroke, 45(4), 1053-1058.
Minnerup, J., Wersching, H., Unrath, M., & Berger, K. (2014). Effects of emergency medical service transport on acute stroke care. Eur J Neurol, 21(10), 1344-1347.
Pandian, J. D., William, A. G., Kate, M. P., Norrving, B., Mensah, G. A., Davis, S., Roth, G. A., Thrift, A. G., Kengne, A. P., Kissela, B. M., Yu, C., Kim, D., Rojas-Rueda, D., Tirschwell, D. L., Abd-Allah, F., Gankpe, F., deVeber, G., Hankey, G. J., Jonas, J. B., Sheth, K. N., Dokova, K., Mehndiratta, M. M., Geleijnse, J. M., Giroud, M., Bejot, Y., Sacco, R., Sahathevan, R., Hamadeh, R. R., Gillum, R., Westerman, R., Akinyemi, R. O., Barker-Collo, S., Truelsen, T., Caso, V., Rajagopalan, V., Venketasubramanian, N., Vlassovi, V. V., & Feigin, V. L. (2017). Strategies to improve stroke care services in Low- and Middle-Income Countries: A systematic review. Neuroepidemiology, 49(1-2), 45-61.
Potter, C. A., Vagal, A. S., Goyal, M., Nunez, D. B., Leslie-Mazwi, T. M., & Lev, M. H. (2019). CT for treatment selection in acute ischemic stroke: A code stroke primer. Radiographics, 39(6), 1717-1738.
Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., Brown, M., Demaerschalk, B. M., Hoh, B., Jauch, E. C., Kidwell, C. S., Leslie-Mazwi, T. M., Ovbiagele, B., Scott, P. A., Sheth, K. N., Southerland, A. M., Summers, D. V., Tirschwell, D. L., & American Heart Association Stroke, C. (2018). 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49(3), e46-e110.
Sharma, V. K., Ng, K. W., Venketasubramanian, N., Teoh, H. L., & Chan, B. P. (2012). Intravenous thrombolysis for acute ischemic stroke in Asia. Expert Review of Neurother, 12(2), 209-217.
Suwanwela, N. C., Chutinet, A., & Kijpaisalratana, N. (2018). Thrombosis treatment in Thailand. Journal of Stroke Medicine, 1(1), 4.
Venketasubramanian, N., Yoon, B. W., Pandian, J., & Navarro, J. C. (2017). Stroke epidemiology in South, East, and South-East Asia: a review. J Stroke, 19(3), 286-294.
Wasay, M., Barohi, H., Malik, A., Yousuf, A., Awan, S., & Kamal, A. K. (2010). Utilization and outcome of thrombolytic therapy for acute stroke in Pakistan. Neurol Sci, 31(2), 223-225.
Yudiarto, F., Machfoed, M., Darwin, A., Ong, A., Karyana, M., & Siswanto, -. (2014). Indonesia Stroke Registry (S12.003). Neurology, 82(10 Supplement), 10-12.
How to Cite
Minalloh, R. H., Machin, A., Mardiana, W., Suansanae, T., Chulavatnatol, S., & Nathisuwan, S. (2022). Pre-Hospital and In-Hospital Delay in Acute Ischemic Stroke Patients in Indonesia: A Multi-center Study . Indonesian Journal of Pharmacy, 33(2), 299-306.
Research Article