Acute Stroke Management:

Intravenous Thrombolysis (IVT)

Trunojoyo S
Webinar Nevi Medan, Sep20
 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 Awareness Campaign
 Types of Stroke

20% 80%
Plaque Thrombosis
Patophysiology of Brain Ischemia
Treatment for Hyperacute Ischemic Stroke

Modality options :

A. Intravenous Thrombolysis (IVT)

B. Thrombectomy
 Trombolisis
Pengobatan Trombolisis :
• Fibrinolytic agent, via infusion
• 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.
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
 Code Stroke
• FDA approved IVT in 1996. EBM: I-A
– masih sedikit RS dg protokol IVT
– lebih sedikit lagi RS yg konsisten mengerjakan IVT,
sehingga sejumlah “eligible patients” masih lolos.
• Stroke Unit atau Stroke Corner
– apa bedanya dg IMC/HCU...?
– angka IVT : parameter stroke center.
 Kenapa IVT “sulit” dikerjakan?
1) Therapeutic window sangat singkat
– 1996: < 3 jam … 2009: < 4,5 jam
2) Protokol “rumit”
– penentuan kandidat dengan NIHSS
– daftar kontraindikasi
– cara pemberian obat
– monitoring efek samping
3) Kekhawatiran risiko komplikasi
4) Harga obat Alteplase mahal
5) Kapasitas ICU terbatas
 Strategi agar IVT bisa konsisten…
• Awareness Triage/UGD
• Simplified protocol
– door-to-drug time = 45 menit
• Tidak menunggu DPJP datang
– koordinasi dg DPJP via WA
• Pemberian obat di UGD
– tim Stroke Unit bertugas memastikan protokol IVT berjalan
• Pakai dosis Asia (dosis lebih rendah)
– lebih ekonomis, efek samping lebih kecil
Alteplase (rt-PA)
 Code Stroke __ [Triage]
Kandidat pasien:
• Onset stroke < 3.5 jam SMRS
• Tingkat keparahan  NIHSS (4-25 poin)
– Motor power < 4
– GCS > 12
• Gula Darah > 70
 Code Stroke __ [UGD] 1
1) IV line + blood sample .…………(menit 5-10)
– Tunda NGT / Foley cath
– Tunda arterial puncture (AGD)
– Tunda Antiplatelet (ASA/CPG)

2) Head CT-scan …………………..…(menit 10-30)

– kontak radiologi ASAP
 Code Stroke __ [UGD] 2
3) Exclusion criteria …………….………(menit 30)
# History
– Any previous intracranial bleed
– Less than 3 months: Stroke Iskemik, STEMI
– Less than 3 weeks: Major surgery, GIT/UT bleed
# CT-scan  send via WA ke DPJP
– No bleeding
– No large hypodensity
* Lab: platelets >100, PT <15, APTT <45, INR <1.4
 Code Stroke __ [UGD] 3
4) Informed consent ………………(menit 30-45)
– Financial clearance
5) Maintain SBP <180
– k/p: nicardipine infusion
6) Alteplase, 1 vial (50mg) …............(menit 45)
• Dosis: 0.6 mg/kgBB
• 10% (bolus) + 90% (infus 60 menit)
Alteplase, 1 vial = 50 mg (1 mg/cc)
• Dosis: 0.6 mg/kgBB
• 10% (bolus) + 90% (infus 60 menit)
• Pembulatan:
< 40 kg = 25 mg (bolus 2.5 mg + drip 22.5 mg)
40-49 kg = 30 mg (3 + 27)
50-59 kg = 35 mg (3.5 + 31.5)
60-69 kg = 40 mg (4 + 36)
70-79 kg = 45 mg (4.5 + 40.5)
> 80 kg = 50 mg (5 + 45)
 Code Stroke __ [stroke unit]
Monitoring TD dan komplikasi:
• Maintain SBP <180
– k/p: nicardipine infusion
• Gejala TTIK
– k/p: CT-scan ulang.
 Conclusion
• Time is Brain
– Time Lost is Brain Lost

• Current stroke treatment modalities:

– Intravenous Thrombolysis
– Thrombectomy