Penyakit Neurovaskular

Bagian Ilmu Penyakit Saraf

Fakultas Kedokteran Universitas YARSI
 Executive Summary: Heart Disease
and Stroke Statistics–2012 Update
Epidemiology A Report From the American Heart Association
(Circulation 2012;125:188-197)

First attacks
610.000

Incidence 795.000/year
Recurrent attacks
185.000

3rd leading cause

of death

Death 134.000/year
1 every 18
deaths
Definition Stroke
Stroke
A syndrome characterized by rapidly developing clinical symptoms and/or
signs of focal, and at times global (applied to patients in deep coma and
those with subarachnoid haemorrhage), loss of cerebral functions, with
symptoms lasting more than 24 h or leading to death, with no apparent
cause other than of vascular origin (Bull World Health Organ 1976;54(5):541-53)

TIA
TIA
Clinical syndrome characterized by an acute loss of focal cerebral or
monocular function with symptoms lasting less than 24 h and which is
thought to be due to inadequate cerebral or ocular blood supply as a
result of low blood flow, thrombosis or embolism associated with disease
of the arteries, heart, or blood (J Neurol Neurosurg Psychiatry 1991;54(9):793-802)
 Guidelines for the Primary
Prevention of Stroke
Epidemiology A Guideline for Healthcare Professionals From the AHA/ASA
(Stroke 2011;42:517-584)

Leading cause of
functional
Death
Rates
Death
Rates

impairment

20% of survivors requiring

Incidence

institutional care after 3

Incidence

months

15-30% being permanently

disabled
Relationship between the duration of focal neurological symptoms due
to TIA and ischemic stroke and the percentage of patients with an
appropriately sited abnormality on brain imaging with CT
(J Neurol Neurosurg Psychiatry 1992;55(2):95-7)
Clinical Symptoms
and/or Signs
 LevelofofCompetence
Level Competence
Decide

Therapeutic
Treat Window

ISCHEMIC
rtPA  3 h onset

Refer HEMORRHAGIC
RAF VII  4 h onset
 How to Diagnose?
Clinical
Diagnosis
History Taking
Topical
Physical Diagnosis Diagnosis
Examination
Etiological
Pathologic Diagnosis
Diagnosis

Treatment Option Prognosis

History
HistoryTaking
Taking

The
The nature
nature of
of the
the symptoms
symptoms and
and signs
signs

The
The speed
speed of
of onset
onset and
and temporal
temporal course
course of
of the
the
neurological
neurological symptoms
symptoms

Were
Were there
there any
any possible
possible precipitants?
precipitants?

Were
Were there
there any
any accompanying
accompanying symptoms?
symptoms?

Is
Is there
there any
any relevant
relevant past
past or
or family
family history?
history?

Are
Are there
there any
any relevant
relevant lifestyle
lifestyle habits/behaviors?
habits/behaviors?
 Physical
PhysicalExamination
Examination

Confirm
Confirm the
the presence
presence of
of focal
focal neurological
neurological signs,
signs, ifif any,
any,
anticipated
anticipated from
from the
the history
history

Discover
Discover possible
possible etiological
etiological explanations
explanations for
for the
the event
event

Identify
Identify contraindications
contraindications to
to investigation
investigation

Anticipate
Anticipate nursing
nursing and
and rehabilitation
rehabilitation needs
needs
Differential
Diagnosis
 Final diagnosis in two recent studies of patients
Final diagnosis in two recent studies of patients
presenting with suspected TIA and stroke
presenting with suspected TIA and stroke

Hand et al., 2006 (Stroke 2006;37(3):769-75)

Nor AM et al., 2005 (Lancet Neurol 2005;4(11):727-34)
 The
Thediagnosis
diagnosisofofaacerebrovascular
cerebrovascularevent
eventisis
usually
usuallymade
madeatatthethebedside,
bedside,not
notininthe
the
laboratory
laboratoryororininthe
theradiology
radiologydepartment
department

ItItdepends on the history of the sudden

depends on the history of the sudden
onset
onsetofoffocal
focalneurological
neurologicalsymptoms
symptomsininthe the
appropriate
appropriateclinical
clinicalsetting
settingand
andthe
theexclusion
exclusion
ofofother
otherconditions
conditionsthat
thatcan
canpresent
presentininaa
similar
similarway
way
Topical
Topical How to differentiate?
 Two systematic review of stroke incidence
Two systematic review of stroke incidence
studies Pathology
Pathology
studies
Sudlow et al., 1997 (Stroke 1997;28:491-9)
Sudlow
Feigin etetal.,
al.,2003
1997(Lancet
(StrokeNeurol
1997;28:491-9)
2003;2:43-53)
Feigin et al., 2003 (Lancet Neurol 2003;2:43-53)

Cerebral infarction
Intracerebral
hemorrhage
Subarachnoid
hemorrhage
Uncertain

How to differentiate?
 Gold Standar
Gold Standar Pathology
Pathology
CT/MR brain scanning or postmortem
CT/MR brain scanning or postmortem

Siriraj No clinical
Score scoring method
Clinical can
differentiate,
Scoring with absolute
Gajah reliability,
Method Mada ischemic stroke
Score from ICH
Etiology
Etiology

How to
differentiate?
Etiology
Etiology Clinical Syndrome
BAMFORD Classification

TACI
TACI
Total Anterior Circulation Infark Occlucion of the mainstem or a branch of the
Total Anterior Circulation Infark MCA/ACA/ICA by embolism from the heart,
embolism from proximal arterial sites of
atherothrombosis, and sometimes by
PACI
PACI
Partial Anterior Circulation Infark
thrombotic occlusion of sever ICA stenosis
Partial Anterior Circulation Infark

Small, deep, not a cortical, infarct by ‘complex’

LACI small vessel disease, atheroma of the parent
LACI
Lacunar Circulation Infark
Lacunar Circulation Infark artery. Seldom caused by embolism .

POCI Almost any cause

POCI
Posterior Circulation Infark
Posterior Circulation Infark
Diagnostic
Diagnostic
Radiology
Approach
Approach Non-contrast Brain CT Scan
Thorax Rö AP/PA
Laboratory
( Complete blood count,
blood glucose, lipid profile,
hemostasis, uric acid)

Electrocardiography
 AimsofofTreatment
Aims Treatment

Optimizing the patient’s change of surviving and minimizing

the impact of the stroke and any recurrent vascular events
on the patient and carers

Minimizing the impact

Short-term effects causing the patient’s neurological impairments

Patient’s function (i.e. disability)
Role in society (i.e. handicap)
 General
Management
Airway and breathing stabilization

Hemodynamic stabilization

Avoiding raised intracranial pressure

Controlled of seizure

Controlled body temperature

 Specific
Management
Fluid and electrolyte management

Raised ICP management

Blood pressure (BP) management

Blood glucose management

Seizure management

Thrombolytic therapy

Neurosurgical intervention
 Acute
Stroke

Antiagregasi trombosit
Statin Antihiperhomosisteinemia
Antihiperhomosisteinemia Neuroprotektor
Neuroprotektor
 BloodPressure
Blood PressureManagement
Management

Acute
AcuteIschemic
IschemicStroke
Stroke
Emergency hypertension  SBP > 220 mmHg and/or DBP > 120 mmHg
Emergency hypertension  SBP > 220 mmHg and/or DBP > 120 mmHg

Acute Hemorrhagic Stroke

Acute Hemorrhagic Stroke
Emergency hypertension  SBP > 200 mmHg or MAP > 150 mmHg
Emergency hypertension  SBP > 200 mmHg or MAP > 150 mmHg
SBP > 180 mmHg or MAP > 130 mmHg  lower to 160/90 mmHg or
SBP > 180 mmHg or MAP > 130 mmHg  lower to 160/90 mmHg or
MAP 110 mmHg
MAP 110 mmHg
 BloodPressure
Blood PressureManagement
Management
Conclusion

Acute stroke is a medical emergency

Make the right diagnosis, give the initial

treatment, refer soon

Different stroke, different treatment,

prognosis, and risk of recurrence