STROKE

DETEKSI DINI STROKE

MELALUI PENGEMBANGAN
MODEL PREDIKTOR STROKE
BERBASIS FAKTOR RISIKO
WHAT IS STROKE ?
 CEREBROVASCULAR DISEASE:
PATHOGENESIS
Hemorrhagic Stroke (17%) Ischemic Stroke (83%)
Atherothrombotic
Cerebrovascular
Intracerebral Disease (20%)
Hemorrhage (59%) Cryptogenic (30%)

Subarachnoid Hemorrhage (41%)

Lacunar (25%) Embolism (20%)
Small vessel disease

Albers GW, et al. Chest. 1998;114:683S-698S.

Rosamond WD, et al. Stroke. 1999;30:736-743.
World Stroke Day, October 29, 2016
Blockage of one blood vessel will
cause ischemia within 5 minutes STROKE
Neurons Synapses Myelinated Premature
Time
Lost Lost fibers Lost Aging
1 second 32,000 230 million 200 m 8.7 hours
1.9
1 minute 14 billion 12 km 3.1 weeks
million
120
1 hour 830 billion 714 km 3.6 years
million

Complete 1.2 billion 8.3 trillion 7140 km 36 years

TIME IS BRAIN! Time lost is Brain lost

Saver JL, Stroke 2006

…AFTER 100%
REPERFUSION…
NEURONS CONTINUE TO DIE…

MINUTES

HOURS

DAYS to
WEEKS
 Brain Ischemia is a process,
NOT an event.

Minutes Hours Days

 Faktor Resiko
HEMORAGIS NON HEMORAGIS

MEROKOK
AVM DIABETES MELITUS
ANEURISMA HIPERTENSI LIPID DISORDER
DRUG ABUSE PENYAKIT JANTUNG
TIA
TIDAK DAPAT DIUBAH

Increasing Age
Sex (gender)
Heredity (family history) and
Race
Prior Stroke or Heart Attack
 DAPAT DIUBAH, DIOBATI ATAU
DIKONTROL
High blood pressure
Diabetes Mellitus
Carotid or other artery disease
Atrial fibrillation
Other heart disease
Transient ischemic
Sickle cell anemia
High blood cholesterol
MEMERLUKAN PERUBAHAN GAYA
HIDUP

Tobacco Use
Physical Inactivity and
Obesity
Excessive Alcohol
Ilegal Drug Abuse
 PRESENTASI KLINIS
STROKE AKUT
Hemiparesis  mendadak
Gangguan sensibilitas
Perubahan mendadak status mental (konfusi,
delirium, letargi, stupor atau koma)

Afasia
Disartria
Gangguan penglihatan
Ataksia
Vertigo, mual dan muntah, atau nyeri kepala
 PROGRAM PELAYANAN STROKE NASIONAL
TC
TEMPAT
KEGIATAN PROGRAM SDM PELAPORAN PROBLEM
KEGIATAN

P -REGISTER
DOKTER ?
FORM (-)
STROKE YASTROKEI
R RISK
-PREVENSI UMUM
PUSKESMAS, FACTOR
E PRIMER YANBINKES
KLINIK MASY. PRONE
PERSON JIWA

CLINICAL
RAWAT INAP PATHWAY
RS : P CLINICAL
NEUROLOG (K)
F1 BELUM LENGKAP
NEUROLOG
-UNIT A HIPERAKUT PATHWAY
STROKE T AKUT SDM KONSULTAN
-POJOK O SUB AKUT NEUROREHAB (-)
STROKE (REHAB MEDIK)
RAWAT INAP REHAB MEDIK ?
REHAB MEDIK NEUROLOG (K) F2 YASTROKI
KRONIK -KOGNITIF NEUROLOG YANMEDIK DASAR
RS
PEMULIHAN P -FISIK REHAB MEDIK
A PROGRAM
S DOKTER UMUM
F3 ? REHAB MEDIK (RBM)
C TERLATIH
YASTROKEI
RUJUKAN PREVENSI
PUSKESMAS A DARI RS ?
(PENGAWASAN
YANBINKES JIWA
SEKUNDER NEUROLOG)
 BAGAN KONSEP PELAYANAN STROKE DI MASYARAKAT
STROKE 1. MANAGEMENT STROKE PREVENTION
STROKE DI PUSKESMAS
AKUT
PRONE
TIA/RIND/SIE/
PERSON Prevention Primer:
CS
Low risk, high risk - perubahan pola hidup
-latihan vitalisasi otak
Ambulance service Gakin, Non Gakin -perawatan penyakit dasar
-pengobatan faktor resiko
KLINIK
Prevention Sekunder:
NEUROLOGI
-menilai keadaan klinik STROKE
DI PUSKESMAS
-melakukan Neuro Restorasi
IGD 24 JAM DI 5
-mendeteksi:
WILAYAH DKI
-ggg kognitif
-ggg emosi
-ggg psikomotorik

2. SDM PEL. STROKE DI PUSKESMAS

1). KONSULTAN
NEURO EMERGENCY RAWAT STROKE - Neurolog (Neurologi Komunitas)
UNIT BANGSAL RS BANGSAL RS 2). PELAKSANA
- Asisten Neurologi
- Dokter Keluarga
(Binaan PERDOSSI)
- Fisioterapis (Fisioterapi Komunitas
POST RAWAT KEMBALI KE HOME CARE UNIT PUSKESMAS: DKI)
DOKTER KELUARGA, PERAWAT MAHIR, FISIOTERAPIS
 STROKE
MANAGEMENT
TATALAKSANA STROKE DI
FKTP
TIME IS BRAIN AND WE MUST
ACT FAST !
TIME IS BRAIN
A pea sized piece of
brain dies for every
12 minutes that
treatment is delayed
Each minute you
wait, you lose close
to 2 million brain
cells

22
Blockage of one blood vessel will
cause ischemia within 5 minutes STROKE
Neurons Synapses Myelinated Premature
Time
Lost Lost fibers Lost Aging
1 second 32,000 230 million 200 m 8.7 hours
1.9
1 minute 14 billion 12 km 3.1 weeks
million
120
1 hour 830 billion 714 km 3.6 years
million

Complete 1.2 billion 8.3 trillion 7140 km 36 years

TIME IS BRAIN! Time lost is Brain lost

Saver JL, Stroke 2006

TIME LOST IS BRAIN
LOST
We don’t want them
here
We want them at home
Remember – Time
Lost is Brain Lost
Get them help
immediately
BAHAYA BILA STROKE
TERLAMBAT DITANGANI

CACAT

MENINGGA
L
KEUNTUNGAN PENANGANAN DINI

Sembuh
sempurna
Mengurangi
/ mencegah
kecacatan
Menghindar
i kematian
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
 PATOGENESIS / TATA LAKSANA
STROKE
Pra Patogenesa Patogenesa Pasca Patogenesa
Hiperakut Akut Sub Akut
Lesi RS RS
Pra RS Eng Unit Stroke P3SN Rumah/RBM/
Kom Homecare

Penyandang Pemulihan Adaptasi

risiko Hiperakut Akut Sub Akut
Lesi
Prevensi Restorasi Rehabilitasi
STROKE ACUTE CARE PATHWAY

CHANGING TRENDS….
Stroke is a preventable and treatable disease

More effective evidence based primary and secondary prevention

strategies

Evidence of interventions that are effective soon after the onset of

symptoms

Understanding of the care processes that contribute to a better

outcome has improved
HASANUDDIN STROKE SCORE ASSESMENT OF FIVE
VARIABLES
No Variable Clinical Findings Score Note
1. Blood S  200 and/or D 110 7.5
Pressure S < 200/ and/or D <110 1
(mmHg)
2. Active / Actively 6.5
Inactive Inactively 1
3. Headache Very severe 10
Severe 7.5
Mild 1
No headache 0
4 Vomiting Directly or several minutes until < 1 hour after the onset 10
1 hour until < 24 hours after the onset 7.5
 24 hours after the onset 1
Absent 0
5 Unconscious Directly or several minute until < 1 hour 10
1 hour until < 24 hours after the onset 7.5
 24 hours after the onset or transient 1
Absent 0
NIH-RECOMMENDED ED RESPONSE
TIME
DTN ≤60 min : the “golden hour” for evaluating & treating acute stroke

T=0 ≤10 min ≤ 15 min ≤ 25 min ≤ 45 min ≤ 60 min

Suspected Initial MD evaluation Stroke team CT scan CT & labs rt-PA
stroke patient (including patient notified initiated interpreted given if
arrives at history, lab work (including patient
stroke unit initiation, & NIHSS) neurologic is eligible
expertise)

NINDS NIH website. Stroke proceedings. Latest update 2008.

 INCLUSION CRITERIA
The Golden Hour 1.
2.
Clinical signs and symptoms of definite acute stroke
Clear time of onset
3. Presentation within 3 hrs of acute onset
THROMBOLYSIS PATHWAY 4. Haemorrhage excluded by CT scan
5. Age 18 - 80 years old

➊ Arrival to ED 6. Consent to treat (every effort must be made to contact next of kin)

EXCLUSION CRITERIA
➋ A&PE assessment
1. Rapidly improving or minor stroke symptoms (NIHSS 1-4)
2. NIHSS < 5 or >25
➌ Neurologist & Stroke team 3. Stroke or serious head injury within 3 months
notified 4. Major surgery, obstetrical delivery, external heart massage in last 14 days
5. Seizure at onset of stroke
➍ Order priority CT Brain 6. Prior stroke and concomitant diabetes
7. Severe haemorrhage in last 21 days
8. Increase bleeding risk
➎ Lab & ECG exams
DTN 9. History of central nervous damage (neoplasm, haemorrhage, aneurysm,
spinal or intracranial surgery or haemorrhagic retinopathy)
➏ CT scan performed 60 min 10. Blood pressure above 185 mmHg systolic or 110 mmHg diastolic
11. Symptoms suggestive of SAH (even if CT is normal)
➐ CT report obtained 12. Known clotting disorder
13. APTT abnormal, INR>1.5
➑ Patient informed and 14. Suspected iron deficient anaemia
15. Thrombocytopenia <100,000
consent obtained
16. Hypoglycaemia or hyper glycaemia <50 mg/dL >400 mg/dL

➒ Reconstitution and drawing 17. Bacterial endocarditis, pericarditis

18. Acute pancreatitis
up of Alteplase 19. Ulcerative GI disease in last 3 months, oesophageal varices, arterial-
aneurysm, arterial/venous malformation.
➓ Thrombolysis is initiated 20. Severe liver disease including cirrhosis, acute hepatitis
 MODERN MANAGEMENT OF
ISCHEMIC STROKE

Step 1 Step 2 Step 3 Step 4 Step 5

Staff
secondary Patient
< 3 – 4.5 3 – 6/7 hours 6 - 8 hours acute/sub
In-Service
prevention Outcomes
hours acute

IV IA Mechanical Intracranial Carotid /Vertebral

Thrombolysis Thrombolysis Thrombectomy Stent Angioplasty & Stenting

Time is Brain
 PREHOSPITAL STROKE CARE
Recommended
• 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)
  IGD (Triage) Pasien dicurigai Gejala FAST : (Lihat Ceklis)
 Ruang Rawat Stroke
-Face (mulut mencong)
-Arm (lemah separuh badan)
-Speech (pelo/afasia)
DOKTER EMERGENSI
CURIGA STROKE AKUT < 4.5 jam) -Time last normal (< 6 jam)

Dalam 10 menit :
CODE STROKE
1. EKG
2. GDS (stick)
RSCM/FKUI
ACTIVATE CODE STROKE 3. Lab (bila perlu)
(Warfarin  INR ; NOAC  APTT)
4. Order Urgent CT/MRI Brain
5. Nilai NIHSS
Konsul / Refer cito ! 6. Pasang iv-line
Urgent Neurologi 7. Call Neurologist
CT/MRI Brain DPJP NEUROLOGI
DPJP Neurologi
 Konfirmasi Stroke Iskemik
 Klarifikasi onset gejala
 NIHSS
ELIGIBILITAS TROMBOLISIS  Order Obat Alteplase (Actilyse®)
Lihat Ceklis

 Dosis Alteplase 0.6-0.9

mg/kgBB
START TROMBOLISIS  Berikan bolus 10% dosis
 Sisanya di drip dalam 1 jam

TRANSFER KE RUANGAN
(STROKE UNIT/Bangsal
Neuro/HCU/ICU)
NEW STRATEGIES
Thrombolytic
• rtPA alternatives
• IIb/IIIa inhibitors
• TCD enhanced thrombolysis
Neuroprotective
• Mild Hypothermia
• Albumin
• Drug Therapy
Endovascular
• EKOS (ultrasound enhanced thrombolysis
• Neuroflo (perfusion augmentation)
• Stent Retriever
BIPLANE AND 3D
RECONSTRUCTION
ENDOVASCULAR
TREATMENT
Femoral or radial access
Series of catheters
• Sheath
• Guide Catheter
• Micro catheter
Wire navigation
INTRA-ARTERIAL
RTPA TREATMENT
rtPA into the thrombus
MECHANICAL
EMBOLECTOMY
MERCI DEVICE
MECHANICAL
EMBOLECTOMY
PENUMBRA
 EXTRACRANIAL
STENTING
Extracranial Carotid Artery
Stenosis
Distal Protection
 INTRACRANIAL
STENTING
ICAD accounts for 10-29%
of brain ischemic events
Symptomatic ICAD 25% of
patients with 70-99%
stenosis had a stroke
within 2 years
Balloon angioplasty alone
not effective
WWW.THEMEGALLERY.COM
Muhammad Akbar Neurology Department
Hasanuddin University
STROKE SYSTEMS OF CARE
THE ROLE OF THE ED
End of fragmented Care
Coordination and Cooperation
• Primary Prevention
• Community Education
• EMS
• ED/Hyperacute
• Secondary Prevention
• Rehabilitation
• Continuous Quality Improvement
Schwamm, L. H. (2012) Major advances
across the spectrum of stroke care
Nat. Rev. Neurol.
doi:10.1038/nrneurol.2011.225