UPDATE STROKE DIAGNOSIS

TERAPI DAN SISTIM RUJUK

BALIK

DR. dr. Retnaningsih, Sp.S (K) KIC

RS dr Kariadi/ Fakultas Kedokteran Universitas
Diponegoro
Semarang
WSD 2017
Stroke - a major public health problem
STROKE CAN AFFECT ANYONE AT ANY TIME

1 in
6 MILLION 1 IN 6 EVERY 6
WORLDWIDE, NEARLY
6 MILLION PEOPLE DIE
WORLDWIDE, 1 IN 6
PEOPLE ON AVERAGE WILL
SECONDS
EVERY 6 SECONDS,
EACH YEAR FROM A SUFFER A STROKE IN
SOMEONE DIES FROM
STROKE1,2 THEIR LIFETIME1
A STROKE1,2

1. World Stroke Organization Campaign. http://www.world-

stroke.org/advocacy/world-stroke-campaign
2. MacKay J, Mensah G. WHO, 2004.
http://www.who.int/cardiovascular_diseases/resources/atlas
Time is brain tissue

PENUMBRA
(SALVAGEABLE
BRAIN AREA)2

ISCHAEMIC CORE
(BRAIN TISSUE
DESTINED TO DIE)2

AN UNTREATED PATIENT LOSES APPROXIMATELY REPERFUSION OFFERS THE

1.9 MILLION NEURONS EVERY MINUTE IN THE POTENTIAL TO REDUCE THE EXTENT OF
ISCHAEMIC AREA1 ISCHAEMIC INJURY3

1. Saver J. Stroke 2006;37:263-266.

2. González R. Am J Neuroradiol 2006;27:728-735.
3. Kidwell C. Stroke 2004;35(suppl):2662-2665.
Phases of acute stroke treatment
TREATMENT OF ACUTE STROKE PATIENTS CAN BE DIVIDED INTO FOUR PHASES
EACH WITH ITS OWN PRIMARY OBJECTIVES AND THERAPEUTIC FOCUS

Reduces risk of death and disability through accurate

PRE-HOSPITAL PHASE
diagnosis, hospital choice and impact on
From symptom onset to hospital door time-to-treatment

Reduces risk of death and disability by absolute focus

HYPER ACUTE PHASE on recanalisation of artery or reduction of swelling
Door – hour 1 due to bleeding.

Reduces risk of death by neurological

ACUTE PHASE screening and close monitoring of
1 – 24 hours after admission cardiac and respiratory systems

Reduces risk of death by

close monitoring of cardiac
POST-ACUTE PHASE and respiratory systems
24 – 72 hours after admission and prevention of
recurrent stroke
Emergency stroke care depends on a 4-step
chain

EMERGENCY EMERGENCY
GENERAL PUBLIC STROKE UNIT
CALL CENTRE MEDICAL SERVICES

RECOGNISE STROKE SYMPTOMS IDENTIFY STROKE SYMPTOMS PROMPT EVALUATION &
STABILISATION
REACT APPROPRIATELY PRIORITY DISPATCH OF EMS
PRIORITY TRANSFER TO STROKE
FACILITIES
PRE-NOTIFICATION OF
HOSPITAL
IMMEDIATE TRIAGE,
ASSESSMENT AND IMAGING
MULTIDISCIPLINARY STROKE
TEAM
ACCURATE DIAGNOSIS
TREAT APPROPRIATELY

PRIORITY TRANSPORT & TREATMENT

1. Kothari R, et al. Stroke 1995;26:937-941.

2. Kothari R, et al. Stroke 1995;26:2238-2241.
3. Kaste M, et al. Cerebrovasc Dis 2000;10(Suppl 3):S1-S11.
 The thrombolysis challenge
TIMELY ADMINISTRATION OF rt-PA IMPROVES OUTCOMES FOR ELIGIBLE PATIENTS WITH AIS
THROMBOLYSIS* IS UNDERUSED

ONLY 2-10% OF AIS PATIENTS RECEIVE IV THROMBOLYSIS* WITH rt-PA1

REASONS FOR PRE-HOSPITAL DELAYS INCLUDE

POOR RECOGNITION OF SIGNS AND SYMPTOMS2

INAPPROPRIATE OR DELAYED MEDICAL ASSISTANCE2

AVOIDANCE OR DELAYED DISPATCH OF EMS2

POOR TRIAGE AND INACCURATE EARLY ASSESSMENT3,4

LACK OF COMMUNICATION WITH THE RECEIVING HOSPITAL5

DELAYED ARRIVAL (OUTSIDE THE TIME WINDOW) AT A STROKE CENTRE1

Recombinant tissue plasminogen activator (rTPA) is the only FDA-approved for ischemic
stroke drug. However, rTPA’s narrow therapeutic window, its application to less than 5% of
stroke patients.
developing a safe and effective anti-stroke therapeutic agent will fulfill an unmet need and
have the potential significant.
POOR RECOGNITION OF SIGNS AND SYMPTOMS
INAPPROPRIATE OR DELAYED MEDICAL ASSISTANCE2
Barriers to Providing Prehospital Care
to Ischemic Stroke Patients
Kota semarang merintis Ambulance Hebat !!!
AVOIDANCE OR DELAYED DISPATCH OF EMS2

Emergency
Diagnose stroke Choose hospital Pre-notify team
transport
1. POOR TRIAGE AND INACCURATE EARLY ASSESSMENT3,4

2. LACK OF COMMUNICATION WITH THE RECEIVING

HOSPITAL5 -------- PRE NOTIFICATION

3. DELAYED ARRIVAL (OUTSIDE THE TIME WINDOW) AT A

STROKE CENTRE1
1. Diagnose stroke

1. Diagnosing stroke
Choose hospital
• Choose most appropriate hospital that can provide the patients with
recanalization therapy, and stroke unit care
 Do as much as possible before hospital arrival
Oxygen saturation Blood pressure IV access Glucose test Pre-admit patient

Leaving as little as
possible to be done
after hospital arrival

Deliver directly to CT scanner

The Third “S”
STROKE

https://www.laerdal.com/us/item/15-1043
4 key actions to reduce DTN Time

1. AMBULANCE
PRE- 2. DIRECT TO CT 3. POC TESTING 4. TREAT AT CT
NOTIFICATION
1. Pre-notification
BENEFITS HOW?

ALERT STROKE TEAM STROKE PHONE IN HOSPITAL

REDUCES IN-HOSPITAL DELAY HOSPITAL BUSINESS CARD IN AMBULANCES

STROKE TEAM PRESENT ON PATIENT
ARRIVAL AT THE DOOR
COLLECT RELEVANT INFO
(EMERGENCY RESPONSE TEAM FORM)
NOTIFY HOSPITAL OF PENDING STROKE
PATIENT ARRIVAL
2. Direct to CT
BENEFITS HOW?

REDUCES IN-HOSPITAL DELAY PREHOSPITAL STROKE PROTOCOL BYPASSES THE ED:

PATIENT SHOULD BE MOVED FROM THE AMBULANCE
NO TIME LOST WITH TRANSFER FROM ER TO CT ROOM STRETCHERS STRAIGHT ONTO CT TABLE, INSTEAD
OF AN ER BED
DECREASE DOOR-TO-CT AND DOOR-TO-NEEDLE TIMES
CT ROOM SHOULD BE EMPTIED PRIOR TO PATIENT ARRIVAL

STROKE TEAM AND NEUROLOGIST MEET AT THE CT ROOM

RAPID NEUROLOGIC EVALUATION: PATIENT IS EXAMINED
UPON ARRIVAL, ON CT TABLE
NO DELAY CT INTERPRETATION:
STROKE PHYSICIAN INTERPRETS THE CT, NOT WAITING FOR
FORMAL RADIOLOGY REPORT
REDUCED IMAGING: CT ADVANCED IMAGING RESERVED FOR
UNCLEAR CASES ONLY
 Phases of acute stroke treatment
TREATMENT OF ACUTE STROKE PATIENTS CAN BE DIVIDED INTO THREE PHASES

HYPER ACUTE TREATMENT

AIMED AT STABILIZING THE PATIENT AND/OR REMOVING
THE BLOOD CLOT TO PREVENT DEATH AND DISABILITY
CAUSED BY THE ACUTE STROKE

ACUTE TREATMENT
AIMED AT PREVENTING OTHER CAUSES OF DEATH IN THE
FIRST 24 HOURS

POST-ACUTE TREATMENT
AIMED AT PREVENTING RECURRENT STROKE AS WELL
AS OTHER CAUSES OF DEATH AND DISABILITY FROM
24 HOURS ONWARDS
Priority bloods in the hyper acute phase
LABORATORY TESTS TO CONSIDER IN ALL PATIENTS INCLUDE:

POINT OF CARE: LAB TESTS:

• Point of care: Blood glucose and international • Complete Blood Count (with Platelet count)
normalized ratio (INR)
• Electrolytes panel (Renal function studies)
• Hypoglycemia may cause focal signs and
symptoms that mimic stroke, and hyperglycemia • Cardiac markers: TP
is associated with unfavorable outcomes. • Coagulation tests: prothrombin time (PT),
activated partial thromboplastin time (aPTT), TT
or ECT
BECAUSE TIME IS CRITICAL, FIBRINOLYTIC THERAPY SHOULD NOT BE DELAYED WHILE AWAITING THE RESULTS OF THE PT,
APTT, OR PLATELET COUNT UNLESS:

THERE IS CLINICAL SUSPICION OF A BLEEDING ABNORMALITY OR THROMBOCYTOPENIA,

THE PATIENT HAS RECEIVED HEPARIN OR WARFARIN,

THE PATIENT HAS RECEIVED OTHER ANTICOAGULANTS (DIRECT THROMBIN INHIBITORS OR DIRECT FACTOR XA INHIBITORS).

THE ONLY LABORATORY RESULTS REQUIRED IN ALL PATIENTS BEFORE FIBRINOLYTIC THERAPY IS INITIATED IS A GLUCOSE DETERMINATION AND INR;
USE OF FINGER-STICK MEASUREMENT DEVICES IS ACCEPTABLE.

Jauch EC, Saver JL, Adams HP, Jr., et al. Guidelines for the early management of patients with acute ischemic
stroke: a guideline for healthcare professionals from the American Heart Association/ American Stroke
Association. Stroke. 2013;44:870-947.
3. Treat at CT
BENEFITS HOW?

DECREASE DOOR-TO-NEEDLE TIME DELIVERY OF RTPA ON CT TABLE: STROKE BAG

REDUCES IN-HOSPITAL DELAY RTPA BOLUS ADMINISTERED ON CT TABLE FOLLOWED

BY INFUSION IN AN ADJACENT ROOM
NO TIME LOST WITH TRANSFER FROM CT ROOM TO ER
THE STROKE BAG CONTAINS ALL THE MATERIALS
AND DRUGS NEEDED TO START TREATMENT
THE STROKE BAG ALSO CONTAINS ALL CHECKLISTS
AND PROTOCOLS
 ACUTE PHASE
1 – 24 hours after admission

During the acute phase the patient is still at risk from the cerebral
infarction as a result the neurological status needs to be
monitored closely for deterioration of symptoms.
The focus now starts shifting to reducing the risk of death as a
result of cardiac or respiratory causes.
Thrombolysis of acute ischaemic stroke ESO recommendations

2008 guidelines
▪ In patients admitted within 3 hours of stroke onset brain CT should be obtained to guide routine
thrombolysis treatment with rt-PA (Class I, Level A)

2009 guidelines update

▪ I.V. rt-PA (0.9 mg/kg body weight, max. 90 mg), with 10% of the dose given as a bolus followed by
a 60-minute infusion, is recommended within 4.5 hours of onset of ischaemic stroke (Class I, Level
A)
▪ The use of multimodal imaging may be useful for patient selection for thrombolysis but is not
recommended for routine clinical practice (Class III, Level C)
Actilyse:
ACTILYSE IS SUPPLIED IN VIALS AS A DRY POWDER AND SOLVENT FOR INJECTION AND INFUSION.

THE RECONSTITUTED SOLUTION CONTAINS

1 MG ALTEPLASE/1 ML.
1 VIAL WITH 467 MG POWDER CONTAINS:
10 MG ALTEPLASE, OR
1 VIAL WITH 933 MG POWDER CONTAINS:
20 MG ALTEPLASE, OR
1 VIAL WITH 2333 MG POWDER CONTAINS:
50 MG ALTEPLASE.
Eso guidelines 2008: IV and IA thrombolysis
RECOMMENDATIONS

• Intravenous rtPA (0.9 mg/kg BW, maximum 90 mg), with 10% of the dose given as a
bolus followed by a 60-minute infusion, is recommended within 3 hours of onset of
ischaemic stroke (Class I, Level A)
• Intravenous rtPA may be of benefit also for acute ischaemic stroke beyond 3 hours
after onset (Class I, Level B) but is not recommended for routine clinical practice.
• The use of multimodal imaging criteria may be useful for patient selection (Class III,
Level C)

Guidelines Ischaemic Stroke 2008

Mechanical thrombectomy
IT IS THE MECHANICAL REMOVAL OF A CLOT BY MEANS OF MEDICAL DEVICES.
Coil-retriever: Merci
IN 2004 MERCI WAS THE FIRST DEVICE FOR
REMOVAL OF THROMBUS FROM INTRACRANIAL
ARTERIES APPROVED BY THE FDA
THE DEVICE DEPLOYS A SCREW-LIKE WIRE, WHICH
ENGAGES THE THROMBUS AND TRACKS IT
TOWARD PROXIMAL VESSELS WITH LARGER
DIAMETER, AND FINALLY ASPIRATES THE
RETRIEVED PARTS OF A THROMBUS.
IT WAS EMPLOYED FOR THE FIRST TIME IN THE
MERCI TRIAL
Updated guidelines
IF ENDOVASCULAR THERAPY IS CONTEMPLATED, A NON-INVASIVE INTRACRANIAL VASCULAR STUDY IS STRONGLY RECOMMENDED DURING THE
INITIAL IMAGING EVALUATION OF THE ACUTE STROKE PATIENT BUT SHOULD NOT DELAY INTRAVENOUS rt-PA IF INDICATED.
THE BENEFITS OF ADDITIONAL IMAGING BEYOND CT AND CTA OR MR AND MRA, SUCH AS CT PERFUSION OR DIFFUSION- AND PERFUSION-
WEIGHTED IMAGING, FOR SELECTING PATIENTS FOR ENDOVASCULAR THERAPY ARE UNKNOWN (CLASS IIB; LEVEL OF EVIDENCE C).

STEP 1: STEP 2: STEP 3: STEP 4:

Plain CT rt-PA CT Angio Endovascular

CT ANGIO & ENDOVASCULAR

SHOULD NOT BE DONE BEFORE
RT-PA IN ELIGIBLE PATIENTS
 POST-ACUTE PHASE
24 – 72 hours after admission

The major focus in this phase is on reducing the risk of mortality by focussing on
respiratory and cardiac complications as well as preventing recurring stroke.
This can be achieved through:
• Continuous cardiac monitoring
• A simplified stroke unit protocol that intensively monitors Fever, Sugar and
Swallowing to identify and treat respiratory disease and sepsis
• Intensive screening for causes of the stroke and treatment to prevent
recurrent stroke.
 INTERVENTION: FESS PROTOCOLS

FEVER SUGAR SWALLOWING

(N=2 ELEMENTS) (N=5 ELEMENTS) (N=2 ELEMENTS)

FORMAL VENOUS GLUCOSE

ON ADMISSION EDUCATION PROGRAM AND
COMPETENCY ASSESSMENT FOR
NURSES RUN BY SPEECH
4 - 6 HOURLY TEMPERATURE PATHOLOGISTS
1- 6 HOURLY FINGER-PRICK
READINGS FOR 72 HOURS
GLUCOSE FOR 72 HOURS

ON ADMISSION: 8-16 MMOL/L (ND)

SCREEN WITHIN 24 HOURS OF
OR 8-11 MMOL/L (D): SALINE
STROKE UNIT ADMISSION
INFUSION FOR THE FIRST SIX HOURS

GLUCOSE ≥16 MMOL/L (ND):

TEMPERATURE ≥37.5°C TREATED
IV INSULIN
WITH PARACETAMOL REFERRAL TO SPEECH PATHOLOGIST
FOR FULL ASSESSMENT FOR THOSE
GLUCOSE ≥11 MMOL/L (D): WHO FAILED THE SCREEN
IV INSULIN

Middleton S, McElduff P, Ward J, Grimshaw JM, et al. Lancet 2011;378(9804):1699-1706.

Neurocritical Care Management of AIS: Temperature
• Fever accelerates the secondary injury cascade, causing neuronal
death, increased infarct volume, cerebral edema, midline shift,
morbidity, and mortality after ischemic stroke
Hyperglycemia and Brain injury
DYSPHAGIA
Care continuum
Conclusions: These findings suggest that acute ischemic
stroke patients with baseline undernutrition are being
undernourished during hospitalization. Strategic nutritional
support, particularly in patients with baseline
undernutrition, may improve clinical outcomes.
Arch Neurol. 2008;65(1):39-43
Epilepsi post stroke
Post stroke Parkinsonsm
Virtual Reality for Stroke Patients
TERIMA KASIH
•TERIMAKASIH