STROKE

Epidemiologi penyakit
Di AS, stroke mrp penyebab kematian ke-3 setelah jantung
dan kanker, diderita oleh 500.000 orang per tahunnya
Di Indonesia, menurut SKRT th 1995, stroke termasuk
penyebab kematian utama, dengan 3 per 1000 penduduk
menderita penyakit stroke dan jantung iskemik.
Di dunia, menurut SEAMIC Health Statistic 2000, penyakit
serebrovaskuler seperti jantung koroner dan stroke berada di
urutan kedua penyebab kematian tertinggi di dunia.
Secara umum, 85% kejadian stroke adalah stroke oklusif, 15
% adalah stroke hemoragik
 Stroke accounts for 10% of all-cause
mortality
Tuberculosis Malaria
Diarrhoea
Perinatal causes
2% Other causes
3% 3%
Chronic obstructive pulmonary 4%
disease 27%
5%
HIV/AIDS 5%

Respiratory infections 7%
Coronary heart
disease
9%
13%
Accidents Stroke Cancer

10% 12%

Since 80s, a significant increase (> 2-fold ) has been noticed in incidence of stoke : 1–
2 /1.000 people in USA, 2–2.5/1.000 in Western και 3–3.5/1.000 in Eastern Europe

American Stroke Association. Heart Disease and Stroke Statistics 2004

STROKE: A Major Problem for Public Health
increased ~65% until 2025

Estimated number of strokes in USA during 2002-2025

Broderick JP et al. Stroke 2004;35:205-211

 Defenisi
penyakit yang terjadi akibat
terganggunya aliran darah ke otak secara tiba-tiba
sehingga menyebabkan kerusakan neurologis

Tipe oklusif/ Tipe hemoragi/

penyumbatan perdarahan
stroke yang stroke yang
disebabkan disebabkan
karena adanya karena
penyumbatan perdarahan
pembuluh intrakranial
darah
TYPES & RISK FACTORS
RISK FACTORS
 Fixed
 Age
 Gender( male> female)
 Race(Asian>european)
 Heredity
 Previous Vascular
event.eg: MI, peripheral
embolism
 High fibrinogen
o Modifiable
 High blood pressure
 Heart disease(atrial
fibrillation, heart failure,
endocarditis)
 Diabetes mellitus
 Hyperlipidaemia
 Smoking
 Excess alcohol
consumption
 Oral contraceptives
 Social deprivation
 Obesity, sedentary
lifestyle
 Faktor risiko
usia  insidensi stroke sebanding dgn meningkatnya
usia  di atas umur 55 th, insidensinya meningkat 2 kali
lipat
hipertensi  ada hubungan langsung antara tingginya
tekanan darah dengan risiko terjadinya stroke
jenis kelamin  insidensi pada pria 19% lebih tinggi
drpd wanita
TIA (transient ischemic attack)  60% kasus stroke
iskemi didahului dengan TIA  makin sering terjadi,
makin besar risiko terjadinya stroke
 TYPES OF STROKE

STROKE

Ischemic Haemorrhagic(1
stroke(85%) 5%)

Intracerebral Subarachnoid
Thrombotic Embolic(MC) haemorrhage
haemorrhage
TYPES OF STROKE
 CT Read – within 45 min

Hemorrhagic

Ischemic
Risk Factor High Risk Caution Low Risk
Blood Pressure > 140/90 120-139/80-89 <120/80
or
I don’t know
Cholesterol > 240 200-239 <200
or
I don’t know
Diabetes Yes Borderline No
Smoking I still smoke
Atrial Fibrillation I have an irregular I don’t know My heartbeat is
heartbeat regular
Diet I am overweight I am slightly My weight is
overweight healthy
Exercise I am a couch potato I exercise sometimes I exercise
regularly

I have stroke in Yes not sure no

My family
 Non-modifiable risks
AGE Doubling of stroke rate
each 10 years after age 55
White
Black
Men Women
Men Women
45–54 1.4 0.8
2.1 2.5
55–64 2.6 1.6 4.9 4.6
65–74 6.7 4.2 10.4 9.8
75–84 11.8 11.3 23.3 13.5
85 16.8 16.5 24.7 21.8
Prevalence (per 100,000)
 Non-modifiable risks
Prevalence
(Per 100,000) FAMILY Hx (Relative Risk)
RACE
Blacks 233
Paternal 2.4
Hispanics 196
Maternal
Whites 93
1.4

SEX
Men 174
Women 122
TO REDUCE YOUR RISK FOR STROKE: If your RED score is 3 or more,
1. Know your blood pressure. If high, work with your doctor to lower it. please ask your doctor about
2. Find out from your doctor if you have atrial fibrillation. stroke prevention right away
3. If you smoke, stop.
4. If you drink alcohol, do so in moderation. If your yellow score is 4-6,
5. Find out if you have high cholesterol. you’re off to a good start. Keep
If so, work with your doctor to control it. working on it!
6. If you are diabetic, follow your doctor's recommendations
carefully to control your diabetes. If your green score is 6-8,
7. Include exercise in the activities you enjoy in your daily routine. congratulations! You’re doing
8. Enjoy a lower sodium (salt), lower fat diet. very well at controlling your
9. “Ask your doctor” how you can lower your risk of stroke. risk for stroke!
10. KNOW THE SYMPTOMS OF STROKE.
If you have any stroke symptoms, seek immediate medical attention.
Symptoms include:
• Sudden numbness or weakness of face, arm or leg - especially on one side of
the body.
• Sudden confusion, trouble speaking or understanding.
• Sudden trouble seeing in one or both eyes.
• Sudden trouble walking, dizziness, loss of balance or coordination.
• Sudden severe headache with no known cause.
If you have experienced any of these symptoms, you may have had a TIA or a stroke – call
911 immediately!
1-800-STROKES 1-800-787-6537www.stroke.org
 Etiologi
Stroke hemoragik  disebabkan
oleh kenaikan tekanan darah
yang akut atau penyakit lain
yang menyebabkan
melemahnya pembuluh darah
Stroke oklusif atau stroke
iskemik  disebabkan oleh
penyumbatan pembuluh darah
akibat adanya emboli,
ateroskelosis, atau oklusi
trombotik pada pembuluh
darah otak
 Thromboembolic

ISCHEMIC
Brain
infarct

HEMORRHAGIC

Brain vessel
thrombosis

Willis Emboli from

cycle
extracranial
thrombosis
Arterio-venous
Dysplasia TIA

Intracerebral
hemorrhage
 Diagnosis
Untuk akurasi diperlukan instrumen
seperti : computed tomography (CT) scan
dan magnetic resonance imaging (MRI)
CT atau MRI dapat menunjukkan adanya
infark (> 2mm) atau perdarahan  untuk
membedakan jenis stroke
 Prognosis (1)
• Indikator prognosis adalah : tipe dan luasnya serangan, age of onset,
dan tingkat kesadaran
• Hanya 1/3 pasien bisa kembali pulih setelah serangan stroke iskemik
• Umumnya, 1/3-nya lagi adalah fatal, dan 1/3- nya mengalami
kecacatan jangka panjang
• Jika pasien mendapat terapi dengan tepat dalam waktu 3 jam setelah
serangan, 33% diantaranya mungkin akan pulih dalam waktu 3 bulan
 Prognosis (2)
• Prognosis pasien dgn stroke hemoragik (perdarahan
intrakranial) tergantung pada ukuran hematoma 
hematoma > 3 cm umumnya mortalitasnya besar,
hematoma yang massive biasanya bersifat lethal
• Jika infark terjadi pada spinal cord  prognosis
bervariasi tergantung keparahan gangguan
neurologis  jika kontrol motorik dan sensasi nyeri
terganggu, prognosis jelek
Stroke iskemik Patogenesis (1)
adanya aterotrombosis atau emboli  memutuskan aliran darah
otak (cerebral blood flow/CBF)
Nilai normal CBF = 53 ml/100 mg jaringan otak/menit
Jika CBF < 30 ml/100 mg/menit  iskemik
Jika CBF < 10 ml/100 mg/menit  kekurangan oksigen  proses
fosforilasi oksidatif terhambat  produksi ATP (energi)
berkurang  pompa Na-K-ATPase tidak berfungsi 
depolarisasi membran sel saraf  pembukaan kanal ion Ca 
kenaikan influks Ca secara cepat  gangguan Ca homeostasis 
Ca merupakan signalling molekul yang mengaktivasi berbagai
enzim  memicu proses biokimia yang bersifat eksitotoksik 
kematian sel saraf (nekrosis maupun apotosis)  gejala yang
timbul tergantung pada saraf mana yang mengalami
kerusakan/kematian
Penyebab:
• emboli
• atherosklerosis pada
arteri otak (pembentukan
plak/deposisi lemak
pada pembuluh darah)
• hiperkoagulabilitas
darah, peningkatan kadar
platelet, trombosis
Stroke hemoragik Patogenesis (2)
Hemoragi merupakan penyebab ketiga tersering serangan
stroke
Penyebab utamanya: hipertensi  terjadi jika tekanan darah
meningkat dengan signifikan  pembuluh arteri robek 
perdarahan pada jaringan otak  membentuk suatu massa 
jaringan otak terdesak, bergeser, atau tertekan (displacement of
brain tissue)  fungsi otak terganggu
Semakin besar hemoragi yg terjadi  semakin besar
displacement jaringan otak yang terjadi
Pasien dengan stroke hemoragik sebagian besar mengalami
ketidaksadaran  meninggal
 Atherosclerosis
From risk factors to endothelial injury & CVD

LDL-C BP Risk factors Diabetes Smoking Cardiac failure

Oxidative stress

Endothelial dysfunction

NO Local mediators Tissue ACE-Ang II

Endothelium Collagen growth Proteinolysis

PAI-1 VCAM,ICAM,
factors
cytokines

Vascular injury &

Thrombosis Inflammation Vasocontraction Plaque rupture
remodeling

Adhesion molecules
CV Clinical events
VCAM: vascular cell adhesion molecule,
ICAM: intercellular adhesion molecule
PAI-1: plasminogen activator inhibitor 1
Gibbons GH. N Engl J Med 1994
HISTORY
 Ask for onset and progression of neurological
symptoms – completed stroke or stroke in evolution
History of previous TIAs
History of hypertension & diabetes mellitus
History of heart conditions like arrhythmias, RHD &
prosthetic valves
History of seizures & migraine
History of anticoagulant therapy
History of oral contraceptive use
History of any hypercoagulable disorders like sickle
cell anemia & polycythemia vera
Substance abuse: cocaine, amphetamines
 Gejala dan tanda (1)
Gejala yang muncul bervariasi tergantung di mana
terjadi serangan stroke iskemia, misalnya:
unilateral weaknesses  biasanya hemiparesis
(lumpuh separo)
unilateral sensory complaints  numbness,
paresthesia (mati rasa)
Aphasia  language comprehension
Monocular visual loss  gangguan penglihatan
sebelah
Vascular Clinical manifestations
Tabel manifestasi klinik stroke iskemik berdasar daerah yang terserang
territory
Internal Ipsilateral blindness (ophthalmic artery)
carotid artery Middle cerebral artery symptomatology
Middle Contralateral weakness and sensory loss involving arm and face more than leg
cerebral Aphasia
artery Hemineglect, anosognosia (denial of neurologic deficit), spatial disorientation in the right cerebral
hemisphere
Variable degrees of homonymous visual-field defects
Anterior Contralateral weakness and sensory loss predominantly involving the lower extremity
cerebral Urinary incontinence, especially with bilateral lesions
artery Arm dyspraxia
Abulia (lacks will; indecisive)
Transcortical motor aphasia in dominant side
Posterior Contralateral homonymous hemianopsia
cerebral Contralateral hemisensory loss without weakness
artery Variable visual association cortical deficits, such as alexia without agraphia and associative visual
agnosia
Basilar artery Paralysis of limbs (usually bilateral, but may be asymmetric)
Usually severe bulbar or pseudobulbar paralysis of the cranial musculature (dysphagia, dysarthria, facial
diplegia, and others)
Paucity of sensory or cerebellar abnormalities
Abnormalities of eye movement (internuclear ophthalmoplegia, "one-and-a-half syndrome," nystagmus,
skew deviation, ocular bobbing, miosis, and ptosis)
Coma
Vertebral Variable degrees of vertigo, dizziness, nausea, and vomiting
artery Ipsilateral facial with contralateral body and limb hypoesthesia to pin prick and temperature
Ipsilateral truncal or appendicular ataxia
 Gejala dan tanda (2)
Pada stroke hemoragik:
onset manifestasi kliniknya cepat  gejala fisik
neurologis yang muncul tergantung pada tempat
perdarahan dan besarnya perdarahan  mayoritas
pasien kehilangan kesadaran, dan banyak yang
akhirnya meninggal tanpa sempat sadar lagi 
sebelum pingsan, pasien umumnya akan
mengalami sakit kepala dan dizziness
EXAMINATION OF A STROKE PATIENT
The neurological examination is highly variable and
depends on the location of the vascular lesion.
Skin: look for xanthelasma,rashes,limb ischemia
Eyes:look for diabetic changes,retinal
emboli,hypertensive changes,arcus senilis
CVS: hyper/hypotension, abnormal
rhythm,murmursraised JVP, peripheral pulses and
bruits Respiratory system: pulmonary edema, infection
Abdomen: urinary retention
Locomotor system: injuries sustained during collapse
with stroke, comorbities which influence functional
abilities.
LEFT AND RIGHT HEMISPHERE STROKE:
COMMON PATTERNS
Left (Dominant) Hemisphere
Stroke: Common Pattern
 Aphasia
 Right hemiparesis
 Right-sided sensory loss
 Right visual field defect
 Poor right conjugate gaze
 Dysarthria
 Difficulty reading, writing,
or calculating
Right (Non-dominant)
Hemisphere Stroke:
Common Pattern
 Neglect of left visual field
 Extinction of left-sided
stimuli
 Left hemiparesis
 Left-sided sensory loss
 Left visual field defect
 Poor left conjugate gaze
 Dysarthria
 Spatial disorientation
CLINICAL LOCALIZATION OF STROKE
SYNDROMES

Prerequisites

 Functional anatomy of brain.

 Blood supply to the different parts of brain.

BLOOD SUPPLY OF BRAIN
 Sasaran terapi
Terapi yang diberikan tergantung jenis
strokenya  iskemik atau hemoragik
Sasaran : aliran pembuluh darah otak
Berdasarkan waktu terapinya :
- Terapi pada fase akut
- Terapi pencegahan sekunder atau
rehabilitasi
 Strategi terapi
Pendekatan terapi pada fase akut stroke iskemik:
restorasi aliran darah otak dengan menghilangkan
sumbatan/clots, dan menghentikan kerusakan
seluler yang berkaitan dengan iskemik/hipoksia
Therapeutic window : 12 – 24 jam, golden period :
3 – 6 jam  kemungkinan daerah di sekitar otak
yang mengalami iskemik masih dapat diselamatkan
Pada stroke hemoragik  terapi tergantung pada
latar belakang setiap kasus hemoragiknya
Tatalaksana terapi (1)

Stroke iskemik akut

Menghilangkan Terapi
sumbatan aliran darah pembedahan
(surgical therapy)

Terapi trombolitik Carotid endarterectomy

Terapi antiplatelet (baik untuk pasien dgn
Terapi antikoagulan stenosis ≥ 70%)
Tatalaksana terapi (2)

Stroke hemoragik

Pembedahan Terapi suportif Mengatasi

perdarahan

Untuk lokasi perdarahan Infus manitol Vit K dan plasma beku

dekat permukaan otak Protamin
Asam traneksamat
 Obat-obat yang digunakan pada terapi serangan
akut
Terapi trombolitik : tissue plasminogen activator (t-PA), Alteplase
Mekanisme: mengaktifkan plasmin  melisiskan tromboemboli
Penggunaan t-PA sudah terbukti efektif jika digunakan dalam 3
jam setelah serangan akut
Catatan: tetapi harus digunakan hati-hati karena dapat
menimbulkan risiko perdarahan
Terapi antiplatelet : aspirin, clopidogrel, dipiridamol-aspirin ,
tiklopidin  masih merupakan mainstay dalam terapi stroke
Urutan pilihan : Aspirin atau dipiridamol-aspirin, jika alergi
atau gagal  clopidogrel,  jika gagal : tiklopidin
Terapi antikoagulan  masih kontroversial karena risiko perdarahan
intrakranial
Agen: heparin, unfractionated heparin, low-molecular-weight
heparins (LMWH), heparinoids warfarin
Terapi pemeliharaan (pencegahan) stroke

Terapi Antiplatelet
• Aspirin  menghambat sintesis tromboksan
(senyawa yang berperan dlm proses pembekuan
darah)
• Dipiridamol, atau kombinasi Dipiridamol - Aspirin
• Tiklopidin dan klopidogrel  jika terapi aspirin
gagal
• Silostazol
Terapi Antikoagulan
Masih dalam penelitian, efektif untuk
pencegahan emboli jantung pada pasien
stroke
Terapi hormon estrogen
Pada wanita post-menopause terapi ini
terbukti mengurangi insiden terjadinya
stroke
Antihipertensi
dibutuhkan karena hipertensi merupakan faktor
risiko (50% pada stroke iskemik dan 60% pada
stroke hemoragik)
Penggunaan antihipertensi harus memperhatikan
aliran darah otak dan aliran darah perifer 
menjaga fungsi serebral
Obat pilihan :
• golongan AIIRA (angiotensin II receptor antagonis)
contoh : candesartan
• golongan ACE inhibitor
Terapi memulihkan metabolisme otak
Tujuan: - meningkatkan kemampuan kognitif
• Meningkatkan kewaspadaan dan mood
• Meningkatkan fungsi memori
• Menghilangkan kelesuan
• Menghilangkan dizzines
Contoh: citicholin, codergocrin mesilate, piracetam
Terapi rehabilitasi
misal : fisioterapi, terapi wicara dan bahasa
 Evaluasi outcome terapi
Faktor risiko yang dapat diatasi harus dipantau :
profil kolesterol, BB, rokok, hipertensi, dll
Pasien dgn terapi antikoagulan dipantau terhadap
paramater koagulasi/perdarahan
Pasien yang mendapat aspirin dipantau
kemungkinan gangguan/perdarahan GIT
Pasien yang dapat tiklopidin dipantau efek
samping dan interaksi obatnya: periksa darah rutin
untuk deteksi adanya neutropenia
 Title
NIH Stroke Scale
Responses and scores
1a Level of 0 = Alert
consciousne 1 = Drowsy
ss 2 = Obtunded
3 = Coma/unresponsive
6 Motor function leg 0 = No drift
1b Orientation 0 = Answers both correctly a.    left 1 = Drift before 5
questions 1 = Answers one correctly seconds
(two) 2 = Answers neither correctly b.    right 2 = Falls before 5
seconds
1c Response to 0 = Performs both tasks
3 = No effort against
commands correctly
gravity
(two) 1 = Performs one task
4 = No movement
correctly
2 = Performs neither task 7 Ataxia 0 = Absent
1 = Ataxia in one limb
2 Gaze 0 = Normal horizontal
2 = Ataxia in two limbs
movements
1 = Partial gaze palsy 8 Sensory 0 = Normal
2 = Complete gaze palsy 1 = Mild sensory loss
2 = Severe sensory loss
3 Visual fields 0 = No visual field defect
1 = Partial hemianopsia 9 Language 0 = Normal
2 = Complete hemianopsia 1 = Mild aphasia
3 = Bilateral hemianopsia 2 = Severe aphasia
3 = Mute or global
4 Facial movement 0 = Normal
aphasia
1 = Minor facial weakness
2 = Partial facial weakness 10 Articulation 0 = Normal
3 = Complete unilateral 1 = Mild dysarthria
paralysis 2 = Severe dysarthria
5 Motor function 0 = No drift 11 Extinction or 0 = Normal
arm 1 = Drift before 10 seconds inattention 1 = Mild (loss 1 sensory
a.    left 2 = Falls before 10 seconds modality)
3 = No effort against gravity 2 = Severe (loss 2
b.    right 4 = No movement modalities)
EDUCATION TOPICS FOR THE
STROKE PATIENT
Stop Smoking
Healthy Diet
Manage Cholesterol
Increase physical activity
Lower blood pressure
Limit alcohol, no illicit drugs
Maintain good blood sugar
Take antiplatelet agents as prescribed
selesai