Riki Sukiandra

Neurology Department
Faculty of Medicine
Riau University - Pekanbaru
Stroke is a leading of death and disability in
worldwide (including Indonesia)

The economic consequence of stroke are
substantial

The estimated direct & indirect cost of
stroke in 2009 is $68,9 billion

Circulation 2009: 119; e21-e183
Riki Sukiandra, 2013
Patients who have experienced a
cerebrovascular even are at high risk of
recurrences (25%), as well as an increased risk
of MI and sudden death

JAMA 2000:284;2901-2980
Lancet 2005:365;2098-2103











Riki Sukiandra, 2013
Given the higher risk of stroke in older
people, the need for secondary prevention is
even greater to decrease the burden of
cerebrovascular disease

Antiplatelet therapy remains a cornerstone to
preventing recurrent vascular event in
symptomatic cerebrovascular disease
Riki Sukiandra, 2013
Stroke adalah gangguan fungsional otak
fokal maupun global yang terjadi secara
akut, berasal dari gangguan aliran darah
otak . Termasuk di sini perdarahan
subarachnoid, perdarahan intraserebral dan
iskemik atau infark serebri. Tidak termasuk
disini gangguan peredaran darah otak
sepintas, tumor otak, infeksi atau stroke
sekunder karena trauma (WHO, 1986)
Riki Sukiandra, 2013
Riki Sukiandra, 2013
Ischemic
Stroke







Clot occluding
artery
Intracerebral
Hemorrhage







Bleeding
into brain
Subarachnoid
Hemorrhage







Bleeding
around brain
Focal Brain Dysfunction
Diffuse Brain Dysfunction
Weakness - upper and lower extremity (C)
Weakness - face - lower half (C)
Hemisensory loss - upper and lower extremity (C)
Sensory loss - face - all modalities (C)
Aphasia receptive (D)
Aphasia expressive (D)
Hemineglect (ND)
Lateral gaze weakness (C)
Gaze preference (C)
Visual loss - homonymous hemianopia (C)



(AHA Stroke Center, 2004)
Riki Sukiandra, 2013
Weakness - upper and lower extremity (C)
Weakness - face - lower half (C)
Hemisensory loss - upper and lower extremity (C)
Sensory loss - face - all modalities (C)
Hemineglect (ND)
Aphasia expressive (D)

(AHA Stroke Center, 2004)
Riki Sukiandra, 2013
Visual loss - homonymous hemianopia (C)
Visual loss - upper quadrant anopsia (C)
Constructional apraxia (ND)
Aphasia receptive (D)

( AHA Stroke center, 2004)
Riki Sukiandra, 2013
Brain Stem / Cerebellum / Posterior
Hemisphere Stroke:
Motor or sensory loss in all four limbs
Limb or gait ataxia
Dysarthria
Dysconjugate gaze
Nystagmus
Amnesia
Bilateral visual field defects
Riki Sukiandra, 2013
Small Subcortical Hemisphere or Brain Stem (Pure
Motor) Stroke: Common Pattern
Weakness of face and limbs on one side of the body
without abnormalities of higher brain function,
sensation, or vision

Small Subcortical Hemisphere or Brain Stem (Pure
Sensory) Stroke: Common Pattern
Decreased sensation of face and limbs on one side of
the body without abnormalities of higher brain
function, motor function, or vision
Riki Sukiandra, 2013
Non-Modifiable
Risk Factors for Stroke
Age
Sex
Race/ethnicity
Family history

Modifiable Risk Factors
for Stroke
6
Hypertension
Diabetes
Smoking
Hyperlipidemia
Carotid stenosis
Atrial fibrillation
Riki Sukiandra, 2013
Demensia
Depresi
Kecacatan
Epilepsi
Kontraktur
Peptic ulcer

Bronchopneumonia
Deckubitus
Septikemia
Trombosis vena
profunda
Emboli pulmo
Ggn keseimbangan
cairan

Riki Sukiandra, 2013
Demensia
Depresi
Kecacatan
Epilepsi
Kontraktur
Peptic ulcer

Bronchopneumonia
Deckubitus
Septikemia
Trombosis vena
profunda
Emboli pulmo
Ggn keseimbangan
cairan

Riki Sukiandra, 2013
Riki Sukiandra, 2013
Pengendalian faktor risiko yang tidak dapat
dimodifikasi :
Tidak dapat diubah
Dapat diubah sebagai petanda (marker) stroke
pada seseorang.
Pengendalian faktor risiko yang dapat
dimodifikasi
Riki Sukiandra, 2013
Nonmodifiable
risk factors


Potentially modifiable or
preventable risk factors
Age
Gender
Race and
ethnicity
Genetic factors


Excessive alcohol
consumption
Drug abuse
Carotid artery
stenosis
History of transient
ischaemic attack
Migraine
Hypertension
Cardiac risk
factors
Diabetes mellitus
Cigarette smoking
Hyperlipidaemia
Obesity
Physical inactivity
Riki Sukiandra, 2013
HIPERTENSI
KELAINAN JANTUNG
DIABETES MELLITUS
RIWAYAT TIA DAN STROKE
DISLIPIDEMIA
FAKTOR RISIKO LAINNYA
Riki Sukiandra, 2013
Rekomendasi :
Upayakan TD sistolik < 140 mmHg; diastolik <
90 mmHg
Jika menderita DM atau peny. ginjal kronik TD
sistolik < 130 mmHg dan diastolik < 80 mmHg.
Modifikasi gaya hidup :






Bila dg modifikasi gaya hidup TD masih tetap >
140/90 mmHg, tambahkan obat anti
hipertensi.
kontrol berat badan, aktivitas fisik,
hindari minum alkohol dan diet
mengandung natrium sedang ( < 2,3
gram/hari)
Riki Sukiandra, 2013
HIPERTENSI
KELAINAN JANTUNG
DIABETES MELLITUS
RIWAYAT TIA DAN STROKE
DISLIPIDEMIA
FAKTOR RISIKO LAINNYA

Riki Sukiandra, 2013
Atrial fibrilasi
AMI dan LV trombus
Kardiomiopati
Rhematic mitral valve disease
Mitral valve prolapse (MVP)
Mitral annular Calcification (MAC)
Aortic valve disease
Prostetic heart valves
Riki Sukiandra, 2013
HIPERTENSI
KELAINAN JANTUNG
DIABETES MELLITUS
RIWAYAT TIA DAN STROKE
DISLIPIDEMIA
FAKTOR RISIKO LAINNYA

Riki Sukiandra, 2013
Rekomendasi :
Mengontrol dan mengendalikan kadar gula darah
:




target kadar HbA1C < 7 %
Mengobati hipertensi dan dislipidemia bila ada.
diet & olahraga
obat antidiabetika oral
insulin
Riki Sukiandra, 2013
HIPERTENSI
KELAINAN JANTUNG
DIABETES MELLITUS
RIWAYAT TIA DAN STROKE
DISLIPIDEMIA
FAKTOR RISIKO LAINNYA

Riki Sukiandra, 2013
Ps dg stroke iskemik/TIA atau dg riw. stroke
aterotrombotik/TIA sebelumnya:




Ps dg stroke iskemik/TIA yg tidak mendapat
antikoagulan :





antiplatelet lbh dianjurkan dp
antikoagulan utk mengurangi risiko
berulangnya stroke dan kejadian
kardiovaskuler lain.
antiplatelet ( aspirin 80-325 mg, atau
clopidogrel 75 mg
cilostazol
Riki Sukiandra, 2013
HIPERTENSI
KELAINAN JANTUNG
DIABETES MELLITUS
RIWAYAT TIA DAN STROKE
DISLIPIDEMIA
FAKTOR RISIKO LAINNYA

Riki Sukiandra, 2013
EVALUASI AWAL ( PJK - ):
CT <200mg% & HDL 35 : Ulangi 6- 1th
CT <200mg% & HDL<35 : analisa lipoprotein
CT 200-239 & HDL 35 &
< 2 fak.resiko PJK : Modif diit, ulangi 6-1th
CT 200-239 & HDL <35 &
< 2 fak.resiko PJK : analisa lipoprotein
CT 240 mg% : analisa lipoprotein

Riki Sukiandra, 2013
EVALUASI LDL :
Tanpa PJK & < 2 fak.resiko PJK :
Turunkan LDL < 160 mg%
Modifikasi diit selama 6 bl
Obat bila LDL 190 mg%
Tanpa PJK tetapi memp 2 fak.resiko PJK :
Turunkan LDL < 130 mg%
Modif diit selama 6 bl
Obat bila LDL 160 mg%
Dengan PJK atau peny.aterosklerotik lain:
Turunkan LDL < 100 mg%
Diit selama 6-12 mgg,
Obat bila LDL 130 mg%


Riki Sukiandra, 2013
HIPERTENSI
KELAINAN JANTUNG
DIABETES MELLITUS
RIWAYAT TIA DAN STROKE
DISLIPIDEMIA
FAKTOR RISIKO LAINNYA
Riki Sukiandra, 2013
Lifestyle
Alcohol: men < 2 oz / d, women < 1 oz / d
Diet: Low saturated fat, low Na+, high K+,
fruits > vegetables, Mediterranean diet
Exercise: > 20 min aerobic exercise, > 3 x / wk
Weight: maintain BMI 18.5-24.9 kg/m
2


Drugs to Avoid
Estrogen (oral contraceptives, HRT)
Sympathomimetic agents (incl. decongestants, diet
pills)
NSAIDs (if taking aspirin)
PPIs (if taking clopidogrel)
Riki Sukiandra, 2013
Diseksi arteri
Paten Foramen Ovale
Hiperhomosistein
Hiperkoaglasi inherited
trombophilia
Antipospolipid-antibodi sindrom
Penyakit Sickle sel
Cerebral venous sinus trombosis
Kehamilan
Stenosis karotis
Riki Sukiandra, 2013
TO PREVENT THE OCCURENCE OF STROKE IN
PATIENTS WITH RISK FACTORS
IN ADDITION PREVENTION OF FIRST-EVER STROKE
MAY ALSO PREVENT OTHER TARGET ORGAN
DAMAGE
GOAL OF SECONDARY STROKE
PREVENTION
PREVENT RECURRENT STROKE
CONTROL OF RISK-FACTORS TO PREVENT
OTHER TARGET-ORGAN FAILURE
PREVENTION OF VASCULAR DEMENTIA
Riki Sukiandra, 2013