COMPREHENSIVE

STROKE CARE
Practical Aspects for General Physician

M. KURNIAWAN, MD
DEPT. NEUROLOGI FKUI/RSCM

OUTLINES

Consequencies & Impacts of Stroke

Stroke : Definition and Type
Recognizing Signs and Symptoms
Scope of Stroke Care & The Role of GP
Defining Risk Factors & Primary Prevention
Early Detection & Pre Hospital Management
First Response in Emergency Setting
After Hospital Stroke Care

OUTLINES

Consequencies & Impacts of Stroke

Stroke : Definition and Type
Recognizing Signs and Symptoms
Scope of Stroke Care & The Role of GP
Defining Risk Factors & Primary Prevention
Early Detection & Pre Hospital Management
First Response in Emergency Setting
After Hospital Stroke Care

WORLDWIDE IMPACT
Annually 15 million people, 5 million death, 5 million
permanently disable because of stroke
Every 2 seconds : someone in the world suffers a stroke
Every 6 seconds : someone dies of a stroke
Every 6 seconds : someones QOL will forever be changed
permanently disabled
The lifetime risk of stroke :
1 in 5 for women
1 in 6 for men
Economic burden of stroke : US$ 53,6 billion
Direct cost : US$ 33 billion
Indirect cost : US$ 20,6 billion per-year

Prevalence : 12.1 per-1000 (Jakarta : 14,6 per-1000)

Main cause of death and disability
Estimation of 2020 : 7.6 million death of stroke

Blockage of one blood vessel will

cause ischemia within 5 minutes
Neurons
Lost

Synapses
Lost

Myelinated
fibers Lost

Premature
Aging

1 second

32,000

230 million

200 m

8.7 hours

1 minute

1.9
million

14 billion

12 km

3.1 weeks

1 hour

120
million

830 billion

714 km

3.6 years

1.2 billion

8.3 trillion

7140 km

36 years

Time

Complete

TIME IS
BRAIN!

STROK
E

Time lost is
Brain lost

Saver JL, Stroke 2006

OUTLINES

Consequencies & Impacts of Stroke

Stroke : Definition and Type
Recognizing Signs and Symptoms
Scope of Stroke Care & The Role of GP
Defining Risk Factors & Primary Prevention
Early Detection & Pre Hospital Management
First Response in Emergency Setting
After Hospital Stroke Care

WHAT IS STROKE ?
WHO, 1970
rapidly developing clinical signs of
focal (or global) disturbance of
cerebral function, lasting more than
24 hours or leading to death, with
no apparent cause other than that
of vascular origin

AHA/ASA Expert Consensus,

2013
An episode of neurological dysfunction
caused by focal cerebral, spinal, or
retinal infarction/ischemia, based on
pathological, imaging, or other
objective evidence in a defined
vascular distribution; and/or clinical
evidence of cerebral, spinal cord, or
retinal focal ischemic injury based on
symptoms persisting 24 hours or until
death, and other etiologies excluded

TYPES OF STROKE
ISCHEMIC STROKE - 80%
Embolic :
Blood clot forms
somewhere in the
body and travels to the brain
Thrombotic :
Clot forms on blood vessel
deposits

HEMORRHAGIC STROKE
(20%)

OUTLINES

Consequencies & Impacts of Stroke

Stroke : Definition and Type
Recognizing Signs and Symptoms
Scope of Stroke Care & The Role of GP
Defining Risk Factors & Primary Prevention
Early Detection & Pre Hospital Management
First Response in Emergency Setting
After Hospital Stroke Care

SIGNS & SYMPTOMS

Motoric symptoms
Sudden weakness of face, arm or leg, esp. on one side of the body

Sensory symptoms
Sudden numbness/tingling of face, arm or leg, esp. on one side of body

Slurred speech or difficulty in speaking / understanding

Sudden change in vision in one or both eyes
Sudden Vertigo or Dizziness, loss of balance or coordination
Acute onset of severe headache
Sudden unconsciousness, confusion or disorientation
Sudden difficulties in swallowing
Sudden convulsion
Increased intracranial pressure
Cushing, decreased concsiousness, pupil anisochoria

OUTLINES

Consequencies & Impacts of Stroke

Stroke : Definition and Type
Recognizing Signs and Symptoms
Scope of Stroke Care & The Role of GP
Defining Risk Factors & Primary Prevention
Early Detection & Pre Hospital Management
First Response in Emergency Setting
After Hospital Stroke Care

SCOPE OF STROKE
CARE
1. Primary Prevention
2. Early Detection
Screen for signs and symptoms Using screening tools

3. Fast Definitive Diagnosis

- Knowing neurologic symptoms & examination
- Brain CT-Scan

4. Reperfusion/Recanalization & Acute Stroke Care

5. Secondary Prevention
6. Neurorestoration/Rehabilitation

OUTLINES

Consequencies & Impacts of Stroke

Stroke : Definition and Type
Recognizing Signs and Symptoms
Scope of Stroke Care & The Role of GP
Defining Risk Factors & Primary Prevention
Early Detection & Pre Hospital Management
First Response in Emergency Setting
After Hospital Stroke Care

MODIFIABLE RISK
FACTORS

Hypertension (RR : 4-6x)

Elevated cholesterol level (statin decreased risk by 25%)
Heart Disease
Coronary Artery Disease
Valve disease/replacement
Atrial Fibrillation (3-4x risk)
Previous stroke
Obesity
Alcohol intake
Smoking (2x risk ischemic; 4x risk hemorrhagic)
Oral contraceptives/HRT

NON - MODIFIABLE RISK

FACTORS

Age : Risk doubles per-decade over 55

Gender : Men have greater risk
Race : African-American, Asian and Hispanic have
greater risk
Diabetes Mellitus (RR 2-4x)
Exacerbated by hypertension or poor glucose control
Even diabetics with good control are at increased risk

Family history of stroke or TIA

PRIMARY STROKE
PREVENTION
Knowing and manage risk factors
Risk stratification for more advance screening
examination by specialist (e.g : Echocardiography,
Carotid Doppler, Transcranial Doppler/TCD)

Possible to implement in Primary Health Care

Services (Puskesmas)

OUTLINES

Consequencies & Impacts of Stroke

Stroke : Definition and Type
Recognizing Signs and Symptoms
Scope of Stroke Care & The Role of GP
Defining Risk Factors & Primary Prevention
Early Detection & Pre Hospital Management
First Response in Emergency Setting
After Hospital Stroke Care

WHY EARLY DETECTION ?

ISCI Guideline 2010

Increase % of patients age 18 y.o presenting within 3

hours of stroke onset, who are evaluated within 10
minutes of arriving in the emergency department

Increase % of patients receiving appropriate

thrombolytic and antithrombotic therapy

Increase % of stroke patients who receive appropriate

medical management within the initial 24-48 hours of
diagnosis for prevention of complications

Improve patient outcome and family education

CINCINNATI STROKE SCALE

A CHECKLIST FOR EMERGENCY MEDICAL
DISPATCHERS

Total score:
3 Clear evidence of stroke
2 Strong evidence of stroke
1 Partial evidence of stroke
0 No evidence of stroke
Govindarajan et al. BMC Neurology
2011;11:14.

TIME IS BRAIN AND WE

MUST
ACT FAST !

PREHOSPITAL STROKE
Recommended
CARE
Manage
ABCs

Cardiac monitoring (ECG)

Intravenous access (Ringer Lactate or Ringer Acetate)
Oxygen (as required if O2 saturation <94%)
Assess for hypoglycemia
NPO (Nothing per oral)
Alert receiving ED of nearest stroke center
Rapid transport to closest appropriate facility capable of
treating acute stroke
Not Recommended
Dextrose-containing fluids in non-hypoglycemic patients
Excessive blood pressure reduction (hypotension decrease
cerebral perfusion and worsen stroke)
Excessive intravenous fluids (increased ICP)

OUTLINES

Consequencies & Impacts of Stroke

Stroke : Definition and Type
Recognizing Signs and Symptoms
Scope of Stroke Care & The Role of GP
Defining Risk Factors & Primary Prevention
Early Detection & Pre Hospital Management
First Response in Emergency Setting
After Hospital Stroke Care

STROKE IS TIME CRITICAL

ABC & FAST DIAGNOSIS

Maintain ABC
Knowing neurologic signs & symptoms
Perform focused neurologic exams
Clinical exams in 10 minutes time !!!
If suspected stroke perform urgent Brain CT-Scan
This part must be done in Health Facility which has CT-Scan
Consult to neurologist for Reperfusion/Recanalization Therapy
and Acute Stroke Care
Intravenous thrombolysis
Intraarterial thrombolysis
Mechanical thrombectomy

NIH-RECOMMENDED ED
RESPONSE TIME
DTN 60 min : the golden hour for evaluating & treating acute stroke

10 min
15 min
T=0
Suspected Initial MD evaluation Stroke team
stroke patient (including patient
notified
arrives at
history, lab work
(including
stroke unit
initiation, & NIHSS) neurologic
expertise)

25 min
CT scan
initiated

45 min
CT & labs
interpreted

60 min
rt-PA
given if
patient
is eligible

NINDS NIH website. Stroke proceedings. Latest

update 2008.

INCLUSION CRITERIA

The Golden Hour

1.
2.
3.
4.
5.
6.

THROMBOLYSIS PATHWAY
Arrival to ED
A&PE assessment

EXCLUSION CRITERIA
1.
2.
3.
4.

Neurologist & Stroke team

notified
Order priority CT Brain
Lab & ECG exams
CT scan performed
CT report obtained
Patient informed and
consent obtained
Reconstitution and drawing
up of Alteplase
Thrombolysis is initiated

Clinical signs and symptoms of definite acute stroke

Clear time of onset
Presentation within 3 hrs of acute onset
Haemorrhage excluded by CT scan
Age 18 - 80 years old
Consent to treat (every effort must be made to contact next of
kin)

DTN
60 min

5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

Rapidly improving or minor stroke symptoms (NIHSS 1-4)

NIHSS < 5 or >25
Stroke or serious head injury within 3 months
Major surgery, obstetrical delivery, external heart massage in
last 14 days
Seizure at onset of stroke
Prior stroke and concomitant diabetes
Severe haemorrhage in last 21 days
Increase bleeding risk
History of central nervous damage (neoplasm, haemorrhage,
aneurysm, spinal or intracranial surgery or haemorrhagic
retinopathy)
Blood pressure above 185 mmHg systolic or 110 mmHg diastolic
Symptoms suggestive of SAH (even if CT is normal)
Known clotting disorder
APTT abnormal, INR>1.5
Suspected iron deficient anaemia
Thrombocytopenia <100,000
Hypoglycaemia or hyper glycaemia <50 mg/dL >400 mg/dL
Bacterial endocarditis, pericarditis
Acute pancreatitis
Ulcerative GI disease in last 3 months, oesophageal varices,
arterial-aneurysm, arterial/venous malformation.
Severe liver disease including cirrhosis, acute hepatitis

 IGD
(Triage)
Ruang
Rawat

Pasien
dicurigai
Stroke

CODE STROKE
RSCM/FKUI

DOKTER EMERGENSI
CURIGA STROKE AKUT <
4.5 jam)

ACTIVATE CODE
STROKE
Urgent
CT/MRI
Brain

Konsul / Refer
cito !
Neurologi
DPJP
NEUROLOGI

ELIGIBILITAS
TROMBOLISIS
Lihat Ceklis

START
TROMBOLISIS
TRANSFER KE
RUANGAN
(STROKE

Gejala FAST : (Lihat

Ceklis)
-Face (mulut mencong)
-Arm (lemah separuh
badan)
-Speech (pelo/afasia)
10 menit
-Dalam
Time last
normal: (< 6
1.EKG
jam)

2.GDS (stick)
3.Lab (bila perlu)
(Warfarin INR ; NOAC
APTT)
4. Order Urgent CT/MRI Brain
5. Nilai NIHSS
6.Pasang iv-line
7.Call Neurologist

DPJP Neurologi

Konfirmasi Stroke Iskemik

Klarifikasi onset gejala
NIHSS
Order Obat Alteplase
(Actilyse)

Dosis Alteplase 0.60.9 mg/kgBB

Berikan bolus 10%
dosis
Sisanya di drip
dalam 1 jam

ACUTE STROKE CARE

Restoration of brain function and prevention of complications

Starting after thrombolysis or within 24-48 hours after diagnosis

Hospitalized for 5-7 days
Blood pressure management
Treat hyperthermia
Treat hypo- or hyperglycemia (BG target : 100 - 150 mg/dL)
Initiate deep vein thrombosis (DVT) prophylaxis
Initiate early neurorestoration/rehabilitation
Nutritional management
Starting secondary stroke prevention
Antithrombotic
Control risk factors

OUTLINES

Consequencies & Impacts of Stroke

Stroke : Definition and Type
Recognizing Signs and Symptoms
Scope of Stroke Care & The Role of GP
Defining Risk Factors & Primary Prevention
Early Detection & Pre Hospital Management
First Response in Emergency Setting
After Hospital Stroke Care

AFTER HOSPITAL CARE

SECONDARY PREVENTION

In order to prevent stroke after stroke

According to BPJS Policy :

After acute stroke care and 6 month neurorestoration by neurologist

Antiplatelet & Anticoagulation as prescribed by neurologist

Control all risk factors
Can be done in Primary Health Care
Consult to neurologist
Every 6 month for advance risk factor management, or
If there is suspicion of new stroke event

TIME IS BRAIN : DETECT EARLY & ACT

FAST

THANK YOU