Reasons withholding intravenous thrombolysis for acute ischemic stroke in an Indonesian Tertiary Center

Abstract

Background Intravenous thrombolysis is the current therapy of choice in patients with acute ischemic stroke (AIS). While highly effective, the rate at which the procedure is employed is low. Studies evaluating the causes withholding thrombolytic treatment in developing nations remain scarce. We aim to determine the factors withholding thrombolytic treatment in AIS patients. Methods This is a retrospective study of AIS patients at Siloam Hospitals Lippo Village, Indonesia, in a 10-month period between April 2019 to February 2020. Patient data were collected from the medical records. Results One hundred and forty-five cases of AIS were found within a 10-month period (April 2019 to February 2020). Thrombolysis was performed in 6.90% of all patients with AIS (21.28% when adjusted for eligible patients with onset ≤ 4.5 h). Prehospital delay exceeding 4.5 h was the most common cause of withholding thrombolytic treatment (68.28% of patients present above 4.5 h or with unknown onset). Among patients presenting ≤ 4.5 h, causes withholding thrombolysis include clinical improvement (35.14%), mild non-disabling symptoms (32.43%), patient/family refusal (18.92%), extensive infarction (5.41%), seizures at onset (2.7%), as well as history of acute bleeding diathesis (2.7%) and gastrointestinal bleeding (2.7%). Conclusions Prehospital delay constitutes the primary obstacle toward receiving thrombolytic therapy for AIS, especially in developing countries. Among patients with onset below 4.5 h, other notable causes include clinical improvement, mild non-disabling symptoms, and patient/family refusal. Of note, the rate of patient/family refusal in our study was much higher compared to previous findings, which may reflect possible socio-economic, communication, or educational issues.

Therapeutic journey of patients affected by stroke: cohort study

“…Corroborating a Brazilian study, carried out in the South of the country, which obtained a median time of 1.3h (0.76h to 2.26h). 16 Nonetheless, it was different in international studies, such as one held in Indonesia, where the median was 45 minutes, 29 and in another developed in Lebanon, where 32.9% underwent a CT scan in less than 20 minutes. 14…”

Characteristics and reasons for delayed presentation in acute ischemic stroke: single-centered study in Indonesia

“…It is widely recognized that the earlier the intravenous thrombolysis is administered, the better the outcome is [18]. While intravenous thrombolysis remains underutilized globally, the rate of intravenous thrombolysis in Indonesia is still very low, ranging between 0.5% and 6.9% compared to a study in Italy that showed a much higher intravenous thrombolysis rate of 24.4% [7,[19][20][21]. Other than the delayed presentation, several factors also contributed to the rate of intravenous thrombolysis, including spontaneous clinical improvement, minor stroke, patient/family refusal, extensive infarction, seizures at onset, and history of gastrointestinal bleeding and/or acute bleeding diathesis [20,22,23].…”