Rational Management of Stroke

Trunojoyo S
RiNDU, November’18
 Introduction
• Stroke → no.1 cause of disability

• Stroke in Indonesia → no.1 cause of mortality

– Indonesia : 193.3 /100,000
– Malaysia : 84.3 /100,000
– Japan : 43.4 /100,000

• Stroke is treatable…
– Current stroke treatment is time-limited.
Stroke Overview
Clinical Presentation
Stroke Awareness Campaign
Risk Factors
 Types of Stroke

20% 80%
 Diagnostic Modalities
• CT scan
– in hyperacute stroke: to rule out bleeding
• MRI
– most sensitive for ischemic
– time consuming
• DSA
– gold standard for vascular evaluation
– invasive procedure.
DSA
(Digital Subtraction Angiography)

→ Endovascular procedure…
• To evaluate brain vessels
• To analyse intracranial circulation.
DSA
(Digital Subtraction Angiography)
DSA: Carotid and VertebroBasilar
Acute Stroke Management
Plaque Thrombosis
Patophysiology of Brain Ischemia
Treatment for Hyperacute Ischemic Stroke

Modality options :

A. Intravenous Thrombolysis (IVT)

B. Thrombectomy
Treatment for Hyperacute Ischemic Stroke

Modality options :

A. Intravenous Thrombolysis (IVT)

B. Thrombectomy
 Trombolisis
Pengobatan Trombolisis :
• Obat pengencer darah
• Berbentuk cairan infus
• Butuh persiapan khusus, ± 1 jam.

Syarat Trombolisis :
• Harus diberikan dalam waktu < 4,5 jam
– Terhitung sejak mulai terjadi gejala stroke
• Pasien tiba di RS dalam waktu < 3 jam.
Alteplase (rt-PA)
Clinical Trials of IVT
Recommendation for IVT
Recom for Extended-time IVT
Candidate patient for IVT :
• Onset within 3-4.5 hour
• NIHSS score 4-25
 Alteplase (rt-PA)
• Standard dose: Alteplase 0.9 mg/kg
– 10% bolus, 90% infuse 60min
• For Asian population → 0.6 mg/kg
– Non-inferior efficacy
– Lower bleeding risk
Contraindication to Thrombolysis
Treatment for Hyperacute Ischemic Stroke

Modality options :

A. Intravenous Thrombolysis (IVT)

B. Thrombectomy
Thrombectomy Devices

2008

2004

2012
 Trombektomi
Prosedur Trombektomi :
• Dilakukan di ruang CathLab
• Menggunakan stent-retriever
• Butuh persiapan khusus, ± 2 jam.

Syarat Trombektomi :
• Dilakukan dalam waktu < 8 jam
– Terhitung sejak mulai terjadi gejala stroke
• Pasien tiba di RS dalam waktu < 6 jam.
Clinical Trials of Thrombectomy
Trials of Extended-time Thrombectomy
Recommendation for Thrombectomy
Advantage of Thrombectomy:
→ Lower bleeding risk.
Case: Pre- dan Post Thrombectomy
Post Stroke
Post Stroke:
Vascular Cognitive Impairment (1)
Typical VCI syndromes include:
• Slow thinking
• Difficulty switching attention
• Judgement decline
• Continuously low mood and mood swings
• Gait apraxia:
– Slow, short and uneven steps
– Difficulty in the start of movements
– Instability during turns and
– Increased breadth of stance.
Post Stroke:
Vascular Cognitive Impairment (2)
Treatment of VCI:
• General:
– Regular physical exercises
– Normalization of BP
– Statins (if atherosclerotic lesion is assumed)
– Blood thinner
• Antiplatelet (ASA, clopidogrel)
• Warfarin or NOAC (apixaban, dabigatran, rivaroxaban)
• PDE3 inhibitors
– Pentoxifylline, cilostazol, triflusal.
Post Stroke:
Vascular Cognitive Impairment (3)
Pentoxifylline (Trental)
• Therapeutic doses: 400 mg, three times daily
– Increase cAMP
• Improves the rheological properties of the blood
– reduces viscosity (due to decreased fibrinogen)
– increases the elasticity of erythrocytes
– reduces platelets aggregation
• Protective effect on endothelium and blood-brain
barrier
– inhibit the synthesis of pro-inflammatory cytokines
– inhibit the atherosclerotic process.
 Conclusion
• Time is Brain
– Time Lost is Brain Lost

• Current stroke treatment modalities:

– Intravenous Thrombolysis
– Thrombectomy.