Dr. Ida Ratna Nurhidayati, Sp.S Bagian Ilmu Penyakit Saraf Fakultas Kedokteran Universitas YARSI
Stroke A syndrome characterized characteri zed by rapidly developing clinical symptoms and/or signs of focal focal,, and at times global global (applied (applied to patients in deep coma and those with subarachnoid haemorrhage), loss of cerebral functions, functions, with symptoms lasting more than 24 h or leading to death, death, with no apparent cause other than of vascular origin (Bull World Health Organ 1976;54(5):541-53)
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)
Executive Summary: Heart Disease and Stroke Statistics 2012 Update –
A Report From the American Heart Association ( Circulation 2012;125:188-197)
First attacks 610.000
795.000/year Recurrent attacks 185.000
3rd leading cause of death
134.000/year 1 every 18 deaths
Guidelines for the Primary Prevention of Stroke A Guideline for Healthcare Professionals From the AHA/ASA ( Stroke 2011;42:517-584)
Leading cause of functional impairment
h s t e a t e a D R I n c i d e n c e
20% of survivors requiring institutional care after 3 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
Level of Competence
Decide
Treat
Therapeutic Window ISCHEMIC rtPA 3 h onset
Refer
HEMORRHAGIC RAF VII 4 h onset
How to Diagnose?
Diagnosis
Treatment Option
Prognosis
The diagnosis of a cerebrovascular event is usually made at the bedside, not in the laboratory or in the radiology department
It depends on the history of the sudden onset of focal neurological symptoms in the appropriate clinical setting and the exclusion of other conditions that can present in a similar way
STROKE
Iskemik
Trombus
Embolus
Hemoragik
PIS
SAH
Two systematic review of stroke incidence studies Sudlow et al., 1997 (Stroke 1997;28:491-9) Feigin et al., 2003 (Lancet Neurol 2003;2:43-53)
Cerebral infarction Intracerebral hemorrhage Subarachnoid hemorrhage Uncertain
How to differentiate?
STROKE
Iskemik
Hemoragik
Lateralisasi
TIK
TIK
Lateralisasi
STROKE
Iskemik
Trombus
Embolus
Aktivitas (-) Progresivitas
Aktivitas (+) Menetap
STROKE
Hemoragik
PIS
SAH
TRM (-)
TRM (+)
Topis Korteks Kekuatan otot ekstremitas atas & bawah berbeda
VS
Subkorteks Kekuatan otot ekstremitas atas & bawah sama
Pem. Penunjang Diagnosis (gold standard ) Faktor Risiko
CT-scan Kepala non kontras
Laboratorium - Profil lipid (kol. total, HDL, LDL, TG) - Profil gula darah (GDP, GD2PP, HbA1C) - Asam urat - Hemostasis lengkap (PT, APTT, D-dimer, INR, Fibrinogen) - Kadar hemoglobin Elektrokardiografi (EKG) Rontgen Toraks PA/AP
Prognostik
Laboratorium : GDS, kadar leukosit + hitung jenis
Tata Laksana Iskemik Antiagregasi Trombosit (asam asetil salisilat) Neuroprotektor (citicholine) Stabilisator Plak + Mencegah Vaskulitis (simvastatin) Antihiperhomosisteinemia (vitamin B6,B12, asam folat) HT Emergensi (TDD > 120)
VS
Hemoragik Neuroprotektor (citicholine) Antihiperhomosisteinemia (vitamin B6,B12, asam folat)
Manajemen TD Fase Akut Iskemik MAP > 140
VS
Hemoragik MAP > 130
Blood Pressure Management
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
