General Management of

Acute Stroke

Moch Syahrial P, dr, Sp.S

Dept of Neurology, Gambiran General Hosptal
 Stroke

A syndrome characterized by rapidly

developing clinical signs of focal (or global)
disturbance lasting 24 hours or longer, or
leading to death/disability with no apparent
cause other than of vascular origin

National Institute of Neurological Disorders and Stroke, 2002.

 Six mainstays
to the management of acute stroke

• Diagnosis procedures to confirm diagnosis and provide the

opportunity to make therapeutic decision
• Treatment of general conditions that influence long-term
functional outcome (BP, body temp, glucose level)
• Specific therapy directed against particular aspects of stroke
pathogenesis, either recanalisation of a vessel occlusion or
prevention of mechanisms leading to neuronal death
(neuroprotection)
• Prevention and treatment of complication, either medical or
neurological
• Early secondary prevention, to reduce the incidence of early
stroke recurrence
• Early rehabilitation

EUSI 2003
Emergent Dx and Assessment
Emergent Care: Evaluation, Diagnosis, and Triage
(Hour 0)

In addition to stabilizing the patient (supporting the ABCs -- airway,

breathing, circulation), the aims of emergent care are 4-fold:

• To confirm the presence of acute stroke vs other systemic or

neurologic disorder(s)

• To identify patients eligible (or ineligible) for acute IVT;

• To screen for medical or neurologic complications; and

• To provide baseline historical data to help determine the

vascular distribution, pathophysiology, and etiology of stroke

Emergent evaluation includes the medical history and physical (H&P)

examination, neurologic examination, and brain imaging studies.
Immediate General Assessment: <10 Minutes
From Arrival

• Assess ABCs, vital signs

• Provide oxygen by nasal cannula
• Obtain IV access; obtain blood samples
(CBC, electrolytes, coagulation studies)
• Check blood sugar; treat if indicated
• Perform general neurological screening
assessment
 Immediate Neurological Assessment:
<25 Minutes From Arrival

• Review patient history

• Establish onset (<3 hours required for thrombolytics)
• Perform physical examination
• Perform neurological examination:
Determine level of consciousness (Glasgow Coma Scale)
Determine level of stroke severity (NIH Stroke Scale or Hunt
and Hess Scale)
• Order urgent noncontrast CT scan
(door-to–CT scan performed: goal <25 min from arrival)
• Perform lateral cervical spine x-ray (if patient comatose/history
of trauma)
Immediate Diagnostic Studies: Evaluation of a
Patient With Suspected Acute Stroke
All patients:
• Brain CT (brain MRI could be considered at qualified
centers)
• Electrocardiogram
• Blood glucose
• Serum electrolytes
• Renal function tests
• Complete blood count, including platelet count
• Prothrombin time/international normalized ratio [INR]
• Activated partial thromboplastin time [aPTT]
Selected patients:

• Hepatic function tests

• Toxicology screen

• Blood alcohol determination

• Pregnancy test

• Oxygen saturation or arterial blood gas tests (if hypoxia is

suspected)

• Chest radiography (if lung disease is suspected)

• Lumbar puncture (if subarachnoid hemorrhage is suspected

and CT is negative for blood)

• Electroencephalogram (if seizures are suspected)

 TERAPI UMUM: 6B
• BREATH • BOWEL
Pernafasan Konstipasi
Oksigenasi Nutrisi
• BLOOD Perdarahan GIT

Tekanan darah • BLADDER

Gula darah Retensi/inkontinensia urine
• BRAIN Keseimbangan cairan &
elektrolit
Penurunan kesadaran
Kejang • BONE & BODY SKIN
Peningkatan TIK • Imobilitas → dekubitus
PENYULIT NEUROLOGIK

EDEMA SEREBRAL &

PENINGKATAN TIK

KEJANG

TRANSFORMASI PERDARAHAN
 TANDA PENINGKATAN TIK
• Nyeri kepala • Penurunan kesadaran
• Muntah proyektil • Cushing reflex
• Hiccup • Kejang
• Penglihatan kabur • Pupil unisocor
• Dilated pupil, nonreactive
pupil
• Papil edema
• Cranial nerve VI palsy
uni/bilateral
• Decerebrate/decorticate
posture
 TERAPI PENINGKATAN TIK
• Tinggikan posisi kepala 300
• Posisi kepala hendaklah menghindari penekanan vena
jugular
• Hindari pemberian cairan glukosa atau cairan hipotonik
• Hindari hipertermia, hipoglikemia, hiperglikemia
• Jaga normovolemia
• Osmoterapi atas indikasi
• Intubasi untuk menjaga normoventilasi (pCO2 35-40
mmHg)
 KEJANG
• STATUS EPILEPTIKUS

Bangkitan kejang yg berlangsung lebih dari 30 mnt, atau

adanya dua bangkitan kejang atau lebih dimana diantara
bangkitan kejang tadi tdk terdapat pemulihan kesadaran

• KLASIFIKASI
SE Konvulsi
SE non-konvulsif
 PENANGANAN SE
• Stad I (0-10 mnt) • Memperbaiki fungsi
kardiorespirasi
• Memperbaiki jalan nafas,
pemberian oksigen, resusitasi
• Px status neurologis

• Stad II (1-60 mnt) • Pengukuran TD, N, t

• EKG
• IV Line, sample darah
• Diazepam 10-20 mg i.v
 PENANGANAN SE
• Stad III (0-60 mnt) • Menentukan etiologi
• Bila kejang berlangsung terus
selama 30 mnt setelah
pemberian diazepam pertama,
beri Phenytoin
• Terapi vasopresor bila diperlukan
• Koreksi komplikasi

• Stad IV (30-900 mnt)

• Bila kejang tdk teratasi, trasfer ke
ICU, berikan propofol, midazolam
atau thiopentone