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ANALYSIS OF THE TIME TO ADMISSION TO

HOSPITAL FOR STROKE PATIENT IN DR


SARDJITO HOSPITAL FROM 2009-2013
THESIS PROPOSAL
This thesis is presented as partial
requirements for the attainment of Bachelor of
Medicine Degree in
Gadjah Mada University, Yogyakarta, Indonesia

MUHAMMAD NURAZAM BIN AZMAN


10/304645/KU/14064

FACULTY OF MEDICINE
GADJAH MADA UNIVERSITY
YOGYAKARTA
2013

RESEARCH PROPOSAL
ANALYSIS OF THE TIME BETWEEN ONSET OF
STROKE AND ADMITTANCE TO HOSPITAL FOR
STROKE PATIENT IN DR SARDJITO HOSPITAL
FROM 2009-2013
Submitted by

MUHAMMAD NURAZAM BIN AZMAN


10/304645/KU/14064
Approved by

Material advisor

Date:

Dr. Ismail Setyopranoto, Sp.S(K)


NIP: 196305061989031 002
Methodology advisor

dr. H. Abdul Gofir, Sp.S(K)


NIP: 196505061996031 002

Date:

Chapter I. INTRODUCTION
a. Background:
Stroke occurs when the blood supply to the
brain is blocked or when a blood vessel in the
brain ruptures, causing brain tissue to die. It is
defined

as

neurological

sudden,

non

function

due

convulsive
to

an

loss

of

ischemic

or

hemorrhagic intracranial vascular event(Adams et


al.,

2003).

It

can

be

classifie

into

major

groups that are ishcemic and hemorrhagic stroke.


Hemorrhagic stroke refers to the condition where
a weakened blood vessel ruptures. It is mostly in
the

form

of

aneurysms and arteriovenous

malformations. However, the most common cause of


hemorrhagic stroke is uncontrolled hypertension.
Ischemic
result

stroke on
of

supplying

an

the

other

obstruction

blood

to

the

hand

of
brain

occurs

as

blood

vessel

causing

tissue

hypoxia and later ischemic. It is a biggest type


of stroke as it accounts for 87 percent of all
stroke cases. Meanwhile, there is also a condition
called

Transient

Ischemic

Attack(TIA)

which

sometimes called mini-stroke that occur when the

blood flow to the brain is blocked for a short


time usually under 5 minutes. However, it is still
an emergency condition that require emergency care
and may be a warning sign for future stroke.

Stroke had became one of the major cause of


death in recent years as about 6.2 millions or
around

10.6%

of

deaths

worldwide

in

2011

are

caused by this disease and this trend continue to


increase as compared to the previous decade. In
Indonesia

alone,

cause

death

of

stroke
among

has

adult

become

the

contributing

leading
up

to

15.4% of all deaths among Indonesians over five,


followed by Tuberculosis at 7.5% (IRIN, 2009)

Symptoms

of

strokes

arise

due

to

the

obstruction or rupture of blood supply to the


brain. It include sudden numbness or weakness
of the arms, face or legs, sudden confusion or
trouble

speaking

or

understanding

others,

sudden trouble for seeing in one or both eyes,


impairment of motoric and sensoric fuction and
also severe headache with no known cause (CDC-

DHDSP,
strokes

2008).
are

Some

of

lasting

the

brain

complication
damage,

of

long-term

disabilities or even death and this is worsen


by delayed hospital admission from the time of
stroke

onset.

Early

time

of

admission

after

stroke event can greatly effect the mortality


or morbidity of stroke patient. A study by the
American Heart

Association suggest that stroke

patient who are sent to the hospitals within 90


minutes

after

the

onset

and

receive

thrombolytic medication stand a greater chance


of

surviving

with

little

or

no

disabilities

within three months as compared to the patient


with
study

longer
by

time

European

to

admission.
Stroke

Meanwhile,

Organization

also

recommend that patient who arrive at hospital


within the golden hour of 3-4.5 hours of onset
could be given recombinant tissue plasminogen
activator alteplase which are shown to reduce
the incidence of stroke-related disability.

b. Formulation of the Problems:


The problems that can arise are:
1. What is the time to admission for stroke patient
in Dr. Sardjito Hospital?
2. What is the appropriate time of admission that
should be used as the Golden Standard for stroke
patient?
3. Is there any changes in the time of admission of
stroke patient in Dr. Sardjto Hospotals during the
year 2009-2013?

c. Research authenticity:

There

are

several

studies

that

already

conducted in variuos countries to analyzed the


time to admisson of stroke patients in their
respective community.
For example, there is a study in Australia
that involve 284 patients who are admitted to
Royal

Adelaide

Australia

Hospital

between

the

Stroke
year

(Broadley SA, Thompson PD, 2003)

Unit,

2000

and

South
2002

There is also a study about the time to


hospital admission and start of treatment in
patients with ischemic stroke in northern Italy
which also study about the prediction of delay(
Vidale. S et al, 2013)
In this study, I hope to analyze the time
to admission of stroke patient in Dr. Sardjito
Hosptal

between

the

year

2009-2013

to

see

whether there are any improvement in the time


to admission over the years.

d. Objective of the Study:


The main objective of this study is to evaluate
the time to admission of stroke patient in Dr.
Sardjito

Hospital

improvement

in

the

and

to

yearly

see

is

trend

admission from year 2009 to 2013

e. Research benefits:

there
of

time

any
to

This research can help us to know about the yearly


trend of time to admission and see wheather there
is any improvement of time of admission for stroke
patient in Dr. Sardjito. This information could
help the Healthcare Office, Dr. Sardjito Hospital
management

and

the

doctors

to

formulate

the

appropriate guideline and procedure in managing


stroke patient. This research is also important
for the Healthcare Office in educating the public
on the importance of getting the stroke patient to
the hospital as soon as possible.

f. Ethical clearance:
This

study

will

be

conducted

with

the

ethical

clearance letter approved by Komisi Etik Penelitian


Kedokteran

dan

Kesehatan

Fakultas

Universitas Gadjah Mada.

Chapter II.LITERATURE REVIEW

Kedokteran,

a. Literature review:
a.i.Definition of stroke
Stroke is a sudden focal neurologic syndrome,
specifically

the

type

caused

by

cerebrovascular

disease (Ropper et. al, 2009).


Brain

disease

pathological
arteries)

that

disorder
or

occurs

of

blood

secondary

blood

vessels

supply

is

to

(usually

defined

as

cerebrovascular disease. It is due to occlusion by


rupture

or

embolus,
blood.

and

There

disease

of

vessel

disturbance
are

two

of

types

wall,

normal
of

thrombus

or

properties

of

stroke

which

are

hemorrhagic stroke and ischemic stroke. (Linslay et.


al, 2002).

a.ii. Types of stroke


a) Ischemic stroke (infarction)
Artherosclerotic

obstructions

of

big

cervical

and cerebral arteries, with ischemia in all parts or


part of the territory of the occluded artery lead to
thrombotic cerebral infarction. This is due to the
main artherosclerotic lesion or embolism at the more
distal cerebral arteries. Embolism of a clot in the
cerebral arteries coming from the other parts of the

arterial system can cause embolic cerebral infection.


Small deep infarcts in the small penetrating artery
explained the lacunar cerebral infarction. Usually it
is

caused

by

local

disease

such

as

chronic

hypertension (Thomas Truelsen et. al, 2006).

b) Hemorrhagic stroke
Hemorraghic

stroke

occur

due

to

spontaneous

intracerebral hemorrhage which lead to increase of


intracranial pressure and diminished supply of blood
to the brain. There are several factors that can lead
to hemorrhagic stroke such as arteriolar hypertensive
disease, coagulation disorder, vascular malformation
within the brain and malnutrition (Thomas Truelsen
et. al, 2006).

c) Subarachnoid hemorrhage
Subarachnoid

hemorrhage

occur

when

there

are

rupture of aneurysms at the bifurcations of large


arteries

at

the

inferior

surface

of

brain.

Some

studies just exclude this type of stroke because it


is not often to cause direct damage to the brain.
However, symptoms in accordance to stroke definition
maybe developed in person with this type of stroke

and make it should be counted as stroke too (Thomas


Truelsen et. al, 2006).

a.iv. Pathophysiology of stroke


In ischemic stroke, the blood supply to the brain
is disturbed causing the decreasing supply of oxygen
and

glucose

artery

supply

(45%)

unknown

to

embolic

causes

are

the
in

the

brain.

origin
causes

Small

(20%)
of

or

large

and

others

ischemic

stroke

(Janice L. Hinkle et. al, 2007).

When intima is roughened and plague forms along


the

injury

vessel,

thrombosis

in

extracranial

and

intracranial can be formed. Platelet will adhere and


aggregate at the injured endothelial, activates the
coagulation

at

the

site

of

plague,

thrombus

is

developed. This will lead to decrease in blood flow


in the extracranial and intracranial system and the
function

of

collateral

circulation

is

maintained.

Decrease perfusion and cell death will occurred when


compensatory mechanism of collateral circulation is
failed and compromised the perfusion(Janice L. Hinkle
et. al, 2007).

A clot travels from a distant source and embedded


in cerebral vessel may cause embolic stroke (Janice
L. Hinkle et. al, 2007).

a.iv. Golden Hour of stroke treatment


Stroke patients who arrive at the hospitals within
a short period of time after the onset of stroke and
receive IV thrombolytic therapy show better prognosis
as compare to those who have longer time to admission
to hospital. However, there is a certain time window
where administration of IV thrombolytic therapy could
provide affective result to the patient. A study by the
NINCDS has provide the evidence of IV rtPA benefits
when given within 3 hours of the symptoms onset of
which the result shows an increase of 30% in the number
of patients who show little or no neurologic deficit
when re-examined after 3 months.
This 3 hours time window or also called the Golden
Hours for stroke treatment is also used by the United
States,

Canada

and

Europe

as

benchmark

for

the

administration of IV rtPA for stroke patients where the


onset of stroke is defined as the time when the stroke

began

of

the

last

time

where

the

patient

was

seen

normal.

b.theoritical framework

ischemic

subarachnoid
hemorrhagic

hemorrhagic

stroke

roughened of
endothelial

Increase
intracranial
pressure damages
the brain tissue

forming of
plague
Formation of blood
clot in the brain
forming of
thrombosis
intracerebral
hemorrhage

adherence of
platelet

activated of
coagulation

developing of
thrombus

bursting of brain
blood vessels

hypertension,
coagulation
disorder, vascular
malformation

C.Conceptual framework:

Time to admission for stroke patient in Dr. Sardjito


Hospital in 2009-2013

< 90 minutes

< 3 hours

> 3 hours

Analysis on the time to


admission

Chapter III. Methodology


a.Research design:
This

research

will

use

the

observational

descriptive study design. The data is collected from


the secondary data which is the medical record of the

patient who have ischemic or hemorrhagic stroke for


the first time in 2009-2013 in Dr Sardjito Hospital
in Yogyakarta. The data will be used to analyze the
trend of time to admission for stroke patient in Dr.
Sardjito Hospital.

b.Sample size:
The

sample

size

include

all

patients

who

experienced the first event of stroke from January 2009


until December 2013 in Dr. Sardjito Hospital.

c.Subject:
The

data

collection

will

take

place

in

Dr.

Sardjito Hospitals in Yogyakarta from January 2009 to


December 2013. The subject will be the medical record
of patient who suffered stroke from January 2009 to
December 2013.
The inclusion criteria of this research are (1)
medical record which shows the first event of stroke
(2) patients with transient ischemic attack (TIA) (3)
patients

with

intracerebral

thrombotic
hemorrhage

and
of

embolic

any

cause

(4)

primary

(5)

medical

record date from January 2009 until December 2013.

The exclusion criteria of this research are (1)


children patients which is 16 years old and under (2)
patients with subarachnoid hemorrhage.

d.Tool and material:


The data for this study will be taken from the
medical record from neurology department in a

Dr.

Sardjito Hospitals in Yogyakarta.

e.Data Collection Method:


The data will be obtained from medical record of
patients with first event of stroke. The information
on the onset and time to admission of stroke patient
will be recorded.

f.Research framework:
Identify medical record of patients with first event of
stroke from January 2009 to December 2013

Data collection

Fits research criteria

Data input

Data analyse

g.Variable:
Independent variable:

time to admission for stroke


patient from 2009-2013.

Dependent variable

patient

with

first

event

of

stroke

h.Operational definition:

Age : the age of the patient is ranging from

16 until 90
Type of stroke: type of stroke that will be
analyzed are ischemic stroke and hemorrhagic

stroke.
Subarachnoid is not included because it falls
under the population that is not covered in
the guideline by National Institute of Health
and Care Excellent (NICE) (National Institute
of Health and Care Excellent,2013).

i.Result analysis:
The collected data will be put in the table by
using the Microsoft excel. The transferred data is
then will be analyzed.

Table 1 : Data of the time to admission of stroke


patient in

Dr. Sardjito Hospital

Time to admission

Percentage

Mean

varia
bles
2009

< 3 hours

> 3 hours

2010

2011

2012

2013

Chapter IV. Reference


1. Allan
H.
Ropper,
Martin
A.
Samuels,
2009,
Cerebrovascular
Disease,
Adams
and
Victors
Principle of Neurology, ninth edition, Mc Graw Hill,
page 746, 781-782
2. Stephen L. Hauser, Scott A. Josephson, 2010,
Cerebrovascular Disease, Harrisons Neurology In

Clinical Medicine, second edition, McGraw Hill, page


249
3. Emily McFadden, Robert Luben, Nicholas Wareham,
Sheila Bingham and Kay-Tee Khaw, Social Class, Risk
Factors, and Stroke Incidence in Men and Women: A
Prospective
Study
in
the
European
Prospective
Investigation
Into
Cancer
in
Norfolk
Cohort,
2009;40:1070-107
4. Broadley SA and Thompson PD., Time To Hospital
Admission For Acute Stroke: An Observational Study,
2003; 178 (7): 329-331

5. Jeffrey L. Saver, Eric E. Smith, Gregg C. Fonarow,


Mathew J. Reeves, Xin Zhao, DaiWai M. Olson and Lee
H. Schwamm, The ''Golden Hour'' and Acute Brain
Ischemia: Presenting Features and Lytic Therapy
in>30 000 Patients Arriving Within 60 Minutes of
Stroke Onset,2010;41:1431-1439
6. Vidale S. Beghi E. Gerardi F. DePiazza C. Proserpio
S. Arnaboldi M. Bezzi G. Bono G. Grampa G. Guidotti
M. Perrone P. Porazzi D. Zarcone D. Zoli A.
Agostoni E, Time to Hospital Admission and Start of
Treatment in Patients with Ischemic Stroke in
Northern
Italy
and
Predictors
of
Delay,
2013;70:349-355
7. Sapna
E.
Sridharan,
J.P.
Unnikrishnan,
Sajith
Sukumaran, P.N. Sylaja, S. Dinesh Nayak, P. Sankara
Sarma and Kurupath Radhakrishnan, Incidence, Types,
Risk Factors, and Outcome of Stroke in a Developing
Country:
The
Trivandrum
Stroke
Registry,
2009;40:1212-1218
8. Janice L. Hinkle, PhD RN CNRN, Mary McKenna
Guanci, MS RN CNRN,Acute Ischemic Stroke Review,
2007;39(5):285-293, 310.
http://www.medscape.com/viewarticle/567653_2
9. National Institute of Health and Care Excellent
(NICE), Stroke: Diagnosis and initial management of
acute stroke and transient ischemic attack (TIA),
July 2008,

http://publications.nice.org.uk/strokecg68/guidance
10. World Health Organization(WHO), Fact Sheets: Top
10 Leading Cause Of Death In The World 200-2011,
July 2013,
http://who.int/mediacentre/factsheets/fs310/en/ind
ex.html

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