7. Stroke PDUI 2015

M. KURNIAWAN, MD

DEPT. NEUROLOGI FKUI/RSCM

COMPREHENSIVE STROKE CARE

Practical Aspects for General Physician

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 : someone’s 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

TIME IS BRAIN!

Blockage of one blood vessel will cause ischemia within 5 minutes

Saver JL, Stroke 2006

STROKE

Time lost is Brain lost

TimeNeurons

LostSynapses

LostMyelinated fibers Lost

Premature Aging

1 second 32,000 230 million 200 m 8.7 hours

1 minute1.9

million14 billion 12 km 3.1 weeks

1 hour120

million830 billion 714 km 3.6 years

Complete 1.2 billion 8.3 trillion 7140 km 36 years

OUTLINES









WHAT IS STROKE ?WHO, 1970rapidly 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, 2013An 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

Embolic :

Blood clot forms

somewhere in the

body and travels to the brain

Thrombotic :

Clot forms on blood vessel

deposits

ISCHEMIC STROKE - 80%

HEMORRHAGIC STROKE (20%)

OUTLINES









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

• Sensory symptomsSudden 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









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









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 controlEven 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









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 SCALEA CHECKLIST FOR EMERGENCY MEDICAL DISPATCHERS

Govindarajan et al. BMC Neurology 2011;11:14.

Total score:

3 Clear evidence of stroke

2 Strong evidence of stroke

1 Partial evidence of stroke

0 No evidence of stroke

TIME IS BRAIN AND WE MUST

ACT FAST !

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)

OUTLINES









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

NINDS NIH website. Stroke proceedings. Latest update 2008.

DTN ≤60 min : the “golden hour” for evaluating & treating acute stroke

T=0

Suspected

stroke patient

arrives at

stroke unit

≤10 min

Initial MD evaluation

(including patient

history, lab work

initiation, & NIHSS)

≤ 15 min

Stroke team

notified

(including

neurologic

expertise)

≤ 25 min

CT scan

initiated

≤ 45 min

CT & labs

interpreted

≤ 60 min

rt-PA

given if patient

is eligible

THROMBOLYSIS PATHWAY

➊ Arrival to ED

➋ A&PE assessment

➌ Neurologist & Stroke team

notified

➍ Order priority CT Brain

➎ Lab & ECG exams

➏ CT scan performed

➐ CT report obtained

➑ Patient informed and

consent obtained

➒ Reconstitution and drawing

up of Alteplase

➓ Thrombolysis is initiated

INCLUSION CRITERIA1. Clinical signs and symptoms of definite acute stroke2. Clear time of onset3. Presentation within 3 hrs of acute onset4. Haemorrhage excluded by CT scan5. Age 18 - 80 years old 6. Consent to treat (every effort must be made to contact next of kin)

EXCLUSION CRITERIA1. Rapidly improving or minor stroke symptoms (NIHSS 1-4)2. NIHSS < 5 or >253. Stroke or serious head injury within 3 months4. Major surgery, obstetrical delivery, external heart massage in last 14 days 5. Seizure at onset of stroke6. Prior stroke and concomitant diabetes7. Severe haemorrhage in last 21 days8. Increase bleeding risk9. History of central nervous damage (neoplasm, haemorrhage, aneurysm,

spinal or intracranial surgery or haemorrhagic retinopathy)10. Blood pressure above 185 mmHg systolic or 110 mmHg diastolic11. Symptoms suggestive of SAH (even if CT is normal) 12. Known clotting disorder13. APTT abnormal, INR>1.514. Suspected iron deficient anaemia 15. Thrombocytopenia <100,00016. Hypoglycaemia or hyper glycaemia <50 mg/dL >400 mg/dL17. Bacterial endocarditis, pericarditis18. Acute pancreatitis19. Ulcerative GI disease in last 3 months, oesophageal varices, arterial-

aneurysm, arterial/venous malformation.20. Severe liver disease including cirrhosis, acute hepatitis

DTN60

min

The Golden HourThe Golden Hour

Pasien dicurigai

Stroke

DOKTER EMERGENSICURIGA STROKE AKUT < 4.5 jam)

Gejala FAST : (Lihat Ceklis)

-Face (mulut mencong)-Arm (lemah separuh badan)-Speech (pelo/afasia)-Time last normal (< 6 jam)

Gejala FAST : (Lihat Ceklis)

-Face (mulut mencong)-Arm (lemah separuh badan)-Speech (pelo/afasia)-Time last normal (< 6 jam)

Dalam 10 menit :1.EKG2.GDS (stick)3.Lab (bila perlu) (Warfarin INR ; NOAC APTT)4. Order Urgent CT/MRI Brain 5. Nilai NIHSS6.Pasang iv-line7.Call Neurologist

Dalam 10 menit :1.EKG2.GDS (stick)3.Lab (bila perlu) (Warfarin INR ; NOAC APTT)4. Order Urgent CT/MRI Brain 5. Nilai NIHSS6.Pasang iv-line7.Call Neurologist

DPJP NEUROLOGI

Konsul / Refer cito ! Neurologi

Konsul / Refer cito ! Neurologi

IGD (Triage) Ruang Rawat IGD (Triage) Ruang Rawat

ACTIVATE CODE STROKE

DPJP Neurologi Konfirmasi Stroke Iskemik Klarifikasi onset gejala NIHSS Order Obat Alteplase (Actilyse®)

UrgentCT/MRI Brain

ELIGIBILITAS TROMBOLISIS

Lihat Ceklis

START TROMBOLISIS

TRANSFER KE RUANGAN(STROKE UNIT/Bangsal

Neuro/HCU/ICU)

Dosis Alteplase 0.6-0.9 mg/kgBB

Berikan bolus 10% dosis Sisanya di drip dalam 1 jam

Dosis Alteplase 0.6-0.9 mg/kgBB

Berikan bolus 10% dosis Sisanya di drip dalam 1 jam

CO

DE S

TR

OK

E

CO

DE S

TR

OK

E

RS

CM

/FK

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RS

CM

/FK

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• 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

ACUTE STROKE CARE

OUTLINES









AFTER HOSPITAL CARESECONDARY 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

7. Stroke PDUI 2015

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