1. STROKE
Afifah Machlaurin

2. ISI MATERI Patofisiologi Stroke Jenis-jenis Stroke Pengobatan Stroke
Pencegahan Stroke

3. Apa Itu Stroke?? When the blood supply to
part of the brain is suddenly
interrupted or when a blood
vessel in the brain bursts
(NINDS 2005)

4. Tipe-tipe Stroke?

6. Can STROKES be prevented?
Modifiable risk factors
High BP
Cigarette smoking
Alcohol intake
Uncontrolled Heart disease
Atrial fibrillation
(creates mini clots)
Uncontrolled Diabetes
Carotid congestion

7. High blood cholesterol
Sedentary lifestyle
Obesity
Seasons– spring and fall
Stress

8. Tanda dan Gejala Stroke??

9. 180 minute Time is tissue The longer the brain is without oxygen and glucose the more brain cells die

10. NINDS** Recommended Goals
Door to doctor minutes
Door to CT completion 25 minutes
Door to CT read minutes
Door to treatment minutes
Access to neurological expertise* 15 minutes
Access to neuro-surgical expertise* 120 minutes
Admit to monitored bed minutes
* by phone or in person
** National Institute of Neurological Diseases and Stroke
Are these reasonable times? Can we meet these goals? What happens at night and on weekends?

11. Algoritme Stroke

12. Manajemen Terapi :
Goal is to
restore blood
flow as soon as
possible

13. Mechanical Thrombolysis
Often used in adjunct with tPa
MERCI (Mechanical Embolus Removal in Cerebral Ischemia) Retrieval System is a corkscrew-like apparatus designed to remove clots from vessels
PENUMBRA system aspirates the clot
MERCI
Symptomatic ICH occurred in 9.8% of patients overall, and a favorable outcome, (a modified Rankin score of 2 or less), was seen in 36% of patients at 90 days.
PENUMBRA- recanalization rate for patients treated with the Penumbra system, measured for the target vessel, was 81.6%. Symptomatic intracranial hemorrhages occurred in 11.2% of patients. A modified Rankin score of 2 or less at 90 days was seen in 25% of patients.

14. Video Terapi dengan tPA

15. tPa Fast Facts Contraindications Tissue plasminogen activator
“clot buster”
IV tpa window 3 hours
IA tpa window 4.5 hours
Disability risk  30% despite ~5% symptomatic ICH risk
Hemorrhage
SBP > 185 or DBP > 110
Recent surgery, trauma or stroke
Coagulopathy
Seizure at onset of symptoms
NIHSS >21
Age?
Glucose < 50

17. LEVELS OF EVIDENCE- PRIMARY RISK
FACTORS

18. LEVELS OF
EVIDENCE-
PHARMACOTHERAPY

19. LEVELS OF EVIDENCE NEUROSURGERY AND NEUROCARDIOLOGY

20. Blood Pressure Management
BP Management
The goal is to maintain cerebral perfusion!!
Higher BP goals with Ischemic stroke  Elevated blood pressure should remain untreated in the acute period (first7 days)
BP> 220/120 mm Hg  short-acting parenteral agents (e.g., labetalol, nicardipine, nitroprusside) are preferred
Lower BP goals with Hemorrhagic stroke (avoid hemorrhagic expansion, especially in AVMs and aneurysms)
For the most part, ICH stroke guidelines recommend using IV medications to lower SBP < 160 while still maintaining adequate MAP and CPP
Ischemic strokes are a bit trickier to manage. One must keep in mind that the patient’s blood pressure will lower on its own by approximately 25 – 30 % within the first 24 hours.
Furthermore aggressive treatment of hypertension in ischemic strokes has been shown to worsen neurological function by reducing perfusion pressure
Castillo and collegues performed a study in that showed that a drop in either SBP or DBP > 20 points were associated with higher rates of mortality and larger volumes of infarctions. They also noted that early administration of antihypertensinve medications to patients with SBP > 180 was associated with an increased risk of death.
**** CHHIPS trial ***
According to the guidelines, sbp should be reduced by 15 – 25% within the first day as excessively high blood pressures are associated with an increased risk of hemorrhagic conversion.

21. In AIS, high BP is a response,
BP-AIS Relationship
Penumbra
Core
Clot in Artery
BP increase is due to art erial occlusion (i.e., an ef fort to perfuse penumbr a)
Failure to recanalize (w/ or w/o thrombolytic therapy) results in high BP and poor neuro outcomes
Lowering BP starves penumbra, worsens outcomes
In AIS, high BP is a response,
not a cause—don’t lower it!

22. Save the Penumbra!! PENUMBRA CORE TIME (hours) CEREBRAL BLOOD FLOW CBF
(ml/100g/min)
CBF
< 8
8-18
TIME (hours) 1 2 3 20 15 10 5
PENUMBRA
CORE
Neuronal dysfunction
Neuronal death
Normal function

23. Aspirin
50 to 325 mg/day started between 24 and 48 hours after completion of alteplase has also been shown to reduce long-term death and disability
Warfarin
the antithrombotic agent of first choice for secondary prevention in patients with atrial fibrillation

24. Supportive Therapy Glucose Management
Infarction size and edema increase with acute and chronic hyperglycemia
Hyperglycemia is an independent risk factor for hemorrhage when stroke is treated with t-PA
Antiepileptic Drugs
Seizures are common after hemorrhagic CVAs
ICH related seizures are generally non-convulsive and are associated to with higher NIHSS scores, a midline shift, and tend to predict poorer outcomes
Elevated glucose levels at the time of admission predicts an increased 28 day mortality rate in both diabetic and non-diabetic patients.
Study done by Vespa and collegues done in 2003 showed that 18 / 63 patients ( 28% ) of patients in a neuro ICU seized on EEG within 72 hours of admission
ICH stroke guidelines recommend IV medications to quickly stop seizures. Benzos tend to be first line choice, followed by IV phenytoin or fos-phenytoin, Brief period of prophylactic AED therapy has been shown to redice the risk of early seizures esp in patient with lobar hemorrhage.

25. Hyperthermia Treat fevers!
Evidence shows that fevers > 37.5 C that persists for > 24 hrs correlates with ventricular extension and is found in 83% of patients with poor outcomes
Fevers tend to be more common in basal ganglia and lobar ICHs and patients with IVH. Scwartz and collegues published a study in 200 that stated patients who survived the first 72 hours after hospital admission, the duration of fever is realted to outcome and is a an independent prognostic factor in stroke patients.
However, although there have been several studies done, to date there is no recommended drug or dose of medication that is recommended in the treatment of fevers in stroke patients.
Guidelines currently recommend that clinicians seek out a souce (don’t just assume that the fever is neurogenic in nature) and treat accordingly.

26. Video Atrial Fibrilation Vs Stroke

27. Video Clotting Farctor Vs Stroke