Aldy S Rambe

Departemen Neurologi FK-USU/

RSUP H Adam Malik Medan

STROKE ISKEMIK FK-USU 2016 1

 Stroke epidemic between 1990 and 2010 :
stroke-related deaths increased by 26%
disability-adjusted life-years by 19%
 Survivors of a TIA or stroke represent a
population at increased risk of subsequent
stroke
 3rd leading causes of death, major cause of
disability
 158,000 deaths due to stroke per year
 Stroke-related death every 3.3 minutes

Goldstein et al. Stroke Dec. 2, 2010

Hankey, Lancet Neurol 2014; 13: 178–94
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The Lancet Neurology 2009; 8:345-354 (DOI:10.1016/S1474-4422(09)70023-7)

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STROKE PREVALENCE IN INDONESIA :
12.1 ‰

RISKESDAS 2013

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 RISKESDAS 2013

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STROKE ISKEMIK FK-USU 2016 6
 THE CUMULATIVE RISK OF
EARLY RECURRENT STROKE
RECURRENT STROKE
Hankey, Lancet Neurol 2014; 13: 178–94

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DEFINISI STROKE
Stroke adalah tanda- Stroke: an episode of
tanda klinis yang acute neurological
berkembang cepat akibat dysfunction presumed
gangguan fungsi otak to be caused by
fokal (atau global), ischemia or
dengan gejala-gejala yang hemorrhage, persisting
berlangsung ≥ 24 jam ≥24 hours or until
atau menyebabkan death, but without
kematian, tanpa adanya sufficient evidence to
penyebab lain yang jelas be classified (Sacco, et
selain vaskuler. al, 2013)
(WHO, 1986)
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Klasifikasi
Klinis:
1. T I A = Transient ischemic attacks.
2. Stroke iskemik :
* Thrombosis serebri.
* Emboli serebri.
3. Stroke hemoragik :
* Perdarahan intra-serebral (PIS).
* Perdarahan sub-arakhnoidal (PSA).

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 MEMBEDAKAN SI DAN SH SECARA KLINIS

SI SH
• Onset saat istirahat • Saat aktif
• Usia lebih tua • Lebih muda
• Kesadaran umumnya baik • Lebih sering menurun
• TIK umumnya tdk meninggi • Lebih sering meninggi
• Kaku kuduk tdk dijumpai • Bisa dijumpai

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Stadium
• T I A.
• Reversible Ischemic Neurologic Deficit (RIND)
= T I A , tapi > 24 jam.
• Stroke in evolution (progressing-stroke).
• Completed stroke : - Iskemik
- Hemoragik

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TRANSIENT ISCHEMIC ATTACK

Serangan iskemik serebral fokal  oklusi

sementara arteri yang mengalami
penyempitan lumen

Etiologi : vasospasme, emboli kecil,

trombus

Defisit neurologis  reversibel

Perbaikan < 24 jam 12

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 STROKE ISKEMIK
• Disfungsi otak fokal /global mendadak bersifat
menetap dalam 24 jam akibat sumbatan
pembuluh darah otak (trombus atau emboli)
dengan faktor risiko hipertensi, DM, PJK, AF,
dislipidemia, hiperuresemia, hiperkoagulasi,
merokok dan obesitas

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Pathogenesis of brain damage
in acute ischemic stroke

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 KASKADE ISKEMIK
r CBF
(ml/100g / menit) JARINGAN OTAK

50-60 Normal
Gangguan Biokimiawi
(sintesa protein)
35
Gangguan metab. Glukosa Laktoasidosis
(Glikolisis anaerobik)

20 “Ion Pump Failure”

Glutamate Release ,
Gangguan metab. Enersi  Ca influx,
Free radicals, dst
15
Gangguan fungsional “Electrical Failure”
(depolarisasi membran)
10 Kerusakan Histologis
(Pannekrosis) “Energy Failure”
Neuron, glia, Endotel
0-4
Reperfusi STRATEGI TERAPI Neuroproteksi 15
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 GEJALA DAN TANDA KLINIS BERDASARKAN
TERITORI ARTERI YANG TERLIBAT
• A. serebri media :
gangguan motorik dan sensorik kontralateral
(wajah, lengan, dan lebih ringan pada tungkai)
afasia (bila lesi di hemisfer dominan)
neglect (bila lesi di hemisfer non dominan)

• A. serebri anterior :
gangguan motorik dan sensorik kontralateral
(tungkai dan lebih ringan pada lengan)

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 GEJALA DAN TANDA KLINIS BERDASARKAN
TERITORI ARTERI YANG TERLIBAT (lanjutan)
• A. serebri posterior :
defisit lapangan pandang kontralateral
afasia dan confusion (bila pada hemisfer dominan)

• Penetrating arteries (lacunar) :

gangguan motorik atau sensorik kontralateral
(wajah, lengan, dan tungkai)
Bisa dijumpai ataksia atau disartria

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 GEJALA DAN TANDA KLINIS BERDASARKAN
TERITORI ARTERI YANG TERLIBAT (lanjutan)
• A. vertebralis (atau a. serebelli posterior inferior) :
truncal ataxia, disartria, disfagia, gangguan sensorik
ipsilateral wajah dan gangguan sensorik kontralateral
dari leher ke bawah

• A. basilaris :
limb ataxia, diartria, disfagia, gangguan motoik dan
sensorik (bisa bilateral), pupil asimetris, disconjugate
gaze, gangguan lapangan pandang, respon melambat

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 FAKTOR RISIKO
Penyakit pembuluh darah : Penyakit jantung :
• Hipertensi • AF
• Diabetes mellitus • Recent myocardial infarction
• Dislipidemia • CAD
• Hipotiroidi • CABG
• Hiperurisemia • LVH
• Hiperhomosisteinemia • Calcified aortic stenosis
• Obesitas • Mitral annular calcification
• Merokok • PFO
• Inaktifitas • Bacterial endocarditis
• Alkohol berlebihan • Nonbacterial
• Arterioskeloris, arteritis, thromboendocarditis
fibromuscular dysplasia

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 FAKTOR RISIKO (lanjutan)

Kandungan darah abnormal : Berkurangnya perfusi serebral :

• Hypercoagulability • Berkurangnya cardiac output
• Emboli : platelet, kolesterol, • Steal syndrome
thromboemboli • Kinking and compression of
intracranial vessels

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 DIAGNOSIS TIA DAN STROKE ISKEMIK
• Klinis
• Scoring/Algoritma :
SIRIRAJ STROKE SCORE
ALGORITMA GAJAH MADA dll
• Laboratorium : darah/urine rutin, ureum, creatinine, KGD
puasa/2 jam pp, profil lipid, asam urat, fungsi tiroid, profil
koagulasi, elektrolit.
• Evaluasi jantung : EKG, ekokardiografi
• Neurosonologi : Duplex ultrasound, TCD
• Foto thoraks
• CT scan, MRI, Arteriografi
• LP

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NEURORADIOLOGI

• Gold standard : CT scan kepala

• Kapan dilakukan ?????
• Tidak ada ketentuan yang pasti
• Infark secara radiologis visible > 48 jam
• Tidak perlu buru-buru CT-scan
kecuali ragu stroke hemoragik.

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 4 COMPONENTS OF ISCHEMIC STROKE CARE

1. Acute therapy and optimization of

neurological status
2. Etiological work-up for secondary prevention
3. Prevention of neurological deterioration or
medical complications
4. Recovery and rehabilitation

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ACUTE
ISCHEMIC
STROKE

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 TIME IS BRAIN, SAVE THE PENUMBRA

• The penumbra is the zone of reversible ischemia

around the core of irreversible infarction.

• The brain tissue in the penumbra is particularly

succeptible to hypoperfusion, hyperglycemia, fever
and seizures.

• It is salvageable in the first few hours after ischemic

stroke onset

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 SAVE THE PENUMBRA !!!!
penumbra
core

1 hour 2 hour 3-4 hour 4-6 hour

Core =~1:1 ~ 2-3 : 1 ~ 4-5 : 1 ? 10-20 : 1

penumbra

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26
 1. Acute therapy and optimization of
neurological status

Main goal  open the artery and re-established

blood flow

• IV TPA is the only FDA-approved treatment for

ischemic stroke in the USA
 Neuroprotective agents(hypothermia, other
drugs) are under investigation

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 1. Acute therapy and optimization of neurological
status (cont.d)

• Maintenance of cerebral perfusion  euvolemia,

support BP, bed flat
• Do not treat hypertension acutely, unless :
1. was treated by TPA
2. end organ damage ( CHF, MCI, HE,
dissecting aortic aneurysm etc)
3. SBP> 220 mmHg or DBP > 120 mmHg
• Use short-acting agent : labetalol, nicardipine
• Goal : BP reduction 10-15%

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 1. Acute therapy and optimization of neurological
status (cont.d)

• Antiplatelet : aspirin effective for acute treatment

• Anticoagulant : not effective for acute treatment,
only for secondary prevention in AF and
cardioembolic stroke
Never start anticoagulant without brain imaging
• Hyperglycemia : treat glucose aggressively
• Hyperthermia : treat aggressively with
acetaminophen and cooling blanket

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 2. Etiological work-up for secondary prevention

• Screening for arterial stenosis/obstruction  MRA,

carotid ultrasound, TCD, DSA, CTA
• Cardiac evaluation  EKG, echocardiogram
• Recurrent stroke risk factors screening :
* monitor BP
* obtain fasting lipid panel
* screen for diabetes
* screen for hyperhomocysteinemia
* smoking cessation

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 3. Prevention of neurological deterioration or
medical complications
• DVT prophylaxis
• Aspiration precautions
• Gastrointestinal ulcer prophylaxis
• Take out indwelling urinary catheter as soon
as possible
• Monitor platelet counts if on heparin

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 4. Prevention of neurological deterioration or medical
complications : Drug therapy in the first 72 hours :

1. Antiplatelet : * aspirin 81-325 mg OD

* clopidogrel 75mg OD
* aspirin 25 mg + dypiridamole 200 mg OD
2. DVT prophylaxis : heparin, LMWH, compression stocking
3. Anticoagulant for cardioembolic stroke : heparin, coumadin,
NOAC (dabigatran, rivaroxaban)
4. Insulin to treat hyperglycemia
5. Acetaminophen to treat hypertermia
6. Statins : target LDL < 100 mg%
7. Antihypertensive : ACEI, ARB, diuretics, beta blockers,
Ca-channnel blockers

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THANK YOU

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