stroke amnagement

1. Stroke Early Management
in Daily Emergency Unit
M. Kurniawan, MD, M.Sc(stroke.med)
Dept. Neurology Faculty of Medicine Universitas Indonesia
Cipto Mangunkusumo National Hospital Jakarta

2. Outlines
• Consequencies & Impacts of Stroke
• Stroke : Definition and Type
• Recognizing Signs and Symptoms
• Defining Risk Factors for Stroke
• Rapid recognition
• Emergency Management in the First 24 Hour

3. Outlines
• Consequencies & Impacts of Stroke
• Stroke : Definition and Type
• Recognizing Signs and Symptoms
• Defining Risk Factors for Stroke
• Rapid recognition
• Emergency Management in the First 24 Hour

4. 1 in 4
of us will have
stroke
Every 2 seconds, there will be 1 people
suffered from stroke
• 17 million new strokes every year
• 7 million stroke deaths/year
• No. 1 cause of death in adults in LMIC
(China, Russia, Indonesia, Brazil)

5. Stroke burden
in Indonesia
Riskesdas & Stroke Registry
• Stroke prevalence increase 56% within 5 years
• From 0.7% to 1.09% (2013 to 2018)
• 70% cases are ischemic
• Only 39.4% stroke patient did routine control to
doctor
• 63.7% elderly (>60 y.o) cannot live independently
after stroke
BPJS
• Steady increase of stroke cases and its treatment
cost every year
• 54% and 37% average increase, respectively
• Stroke remains in the top 4 catastrophic disease
after 5 years UHC
1.09% adult
population
(RISKESDAS)
2018
prevalence
21,1
12,9
6,7
5,3
0
5
10
15
20
25
Highest Cause of Death
(2014)

7. Time is Brain !
Blockage of one blood vessel
will cause ischemia within 5 minutes
Saver JL, Stroke 2006
STROKE
Time lost is Brain lost
Time
Neurons
Lost
Synapses
Lost
Myelinated
Fibers Lost
Premature
Aging
1 second 32,000 230 million 200 m 8.7 hours
1 minute 1.9 million 14 billion 12 km 3.1 weeks
1 hour
120
million
830 billion 714 km 3.6 years
Complete 1.2 billion 8.3 trillion 7140 km 36 years

8. Stroke is Emergency
Time is Brain Tissue
Saver. Stroke 2006;37:263-266.
González. Am J Neuroradiol 2006;27:728-735.
Donnan. Lancet Neurol 2002;1:417-425.
An untreated patient
loses approximately 1.9
million neurons every
minute in the ischaemic
area
Revascularization /
reperfusion offers the
potential to reduce the
extent of ischaemic injury
Ischaemic core
(brain tissue
destined to die)
Penumbra
(salvageable
brain area)
FAILED TO
UNDERSTAND…

10. Outlines
• Consequencies & Impacts of Stroke
• Stroke : Definition and Type
• Recognizing Signs and Symptoms
• Defining Risk Factors for Stroke
• Rapid recognition
• Emergency Management in the First 24 Hour

11. Stroke
An episode of neurological dysfunction
caused by focal cerebral, spinal, or retinal
infarction/ischemia, based on pathological,
imaging, or other objective evidence in a
defined vascular distribution; and/or clinical
evidence of cerebral, spinal cord, or retinal
focal ischemic injury based on symptoms
persisting ≥24 hours or until death, and
other etiologies excluded
(AHA/ASA Expert Consensus 2013)

12. Types of Stroke
Embolic (25%):
Blood clot forms somewhere in the
body (usually from heart) and
travels to the brain
Sudden and maximal deficit at
onset
Thrombotic (65%):
Clot forms on blood vessel deposits
Atherosclerosis
Ischemic Stroke - 70%

13. Hemorrhagic Stroke (30%)

14. Outlines
• Consequencies & Impacts of Stroke
• Stroke : Definition and Type
• Recognizing Signs and Symptoms
• Defining Risk Factors for Stroke
• Rapid recognition
• Emergency Management in the First 24 Hour

15. Cerebral Circulation
• Anterior Circulation
• Carotid arteries
• Anterior cerebral arteries
• Middle cerebral arteries
• Posterior Circulation
• Vertebral arteries
• Basilar artery
• Posterior cerebral
arteries

17. Signs & Symptoms
• Motoric symptoms
Sudden weakness of the face, arm or leg, especially on one side of the body
• Sensory symptoms
Sudden numbness/tingling of the face, arm or leg, especially on one side of the body
• Slurred speech or difficulty in speaking / understanding
• Sudden change in vision in one or both eyes
• Sudden Vertigo or Dizziness, loss of balance or coordination
• Acute onset of severe headache
• Sudden unconsciousness, confusion or disorientation
• Sudden difficulties in swallowing
• Sudden convulsion

18. Outlines
• Consequencies & Impacts of Stroke
• Stroke : Definition and Type
• Recognizing Signs and Symptoms
• Defining Risk Factors for Stroke
• Rapid recognition
• Emergency Management in the First 24 Hour

19. Modifiable risk factors
 Hypertension
 Previous stroke
 Heart Disease
• Coronary Artery Disease
• Valve disease/replacement
• Atrial Fibrillation (3-4x risk)
 Smoking (2x risk ischemic; 4x risk hemorrhagic)
 Elevated cholesterol level
 Obesity
 Alcohol intake
 Oral contraceptives/HRT

20. Non-modifiable Risks
• Age : Risk doubles per-decade over 55
• Gender : Men have greater risk
• Race : African-American, Asian and Hispanic
have greater risk
• Diabetes Mellitus :
Exacerbated by hypertension or poor glucose control
Even diabetics with good control are at increased risk
• Family history of stroke or TIA

21. Outlines
• Consequencies & Impacts of Stroke
• Stroke : Definition and Type
• Recognizing Signs and Symptoms
• Defining Risk Factors for Stroke
• Rapid recognition
• Emergency Management in the First 24 Hour

22. WHY RAPID RECOGNITION ?
• Rapid recognition increases early detection & diagnosis
• Increase % of patients age ≥18 y.o presenting within 3 hours of stroke
onset who are evaluated within 10 minutes of arriving in the emergency
department
• Increase % of patients receiving appropriate thrombolytic and
antithrombotic therapy
• Increase % of patients at high risk for stroke presenting with TIA
symptoms within 24 hours who are admitted to hospital
• Increase % of stroke patients who receive appropriate medical
management within the initial 24-48 hours of diagnosis for prevention of
complications
• Improve patient outcome and family education

23. Strategy
• Knowing signs and symptoms
• Screen for signs and symptoms →
especially in people with >1 risk factor
• Using screening tools

24. Time is Brain and we must
Act FAST !

29. Outlines
• Consequencies & Impacts of Stroke
• Stroke : Definition and Type
• Recognizing Signs and Symptoms
• Defining Risk Factors for Stroke
• Rapid recognition
• Emergency Management in the First 24 Hour

30. ED Evaluation and Management

31. 1. Use of a stroke severity scale (preferably NIHSS)
2. Brain imaging : non-contrast head CT or MRI within 20 minutes of ED arrival
3. Vascular & perfusion imaging using multimodal CT and MRI (with) should
not delay thrombolysis
4. For patients meet criteria for neuroendovascular therapy, noninvasive
extracranial and intracranial vascular imaging (using CTA or MRA) is
recommended during initial imaging, but this should not delay tPA.
5. Additional imaging other than CT and CTA or MRI with MRA such as
perfusion studies to select patients for mechanical thrombectomy in < 6
hours is not recommended.
6. In patients with stroke symptoms within 6-24 hours after last normal with
LVO in the anterior circulation, CT perfusion, MRI perfusion, DW-MRI is
recommended to assist in selecting patients for mechanical thrombectomy

33. Other tests
1.The only serum test required before thrombolysis is
blood glucose assessment
2.Baseline ECG or troponin is recommended in
patients with acute stroke, but these should not
delay administration of tPA
3.Chest X-ray in patients presenting with stroke and no
history of pulmonary or cardiac disease is unclear. If
one is obtained, it should not delay tPA

34. Evidence - Based Guidelines of Stroke Thrombolysis
I.V. rt-PA (0.9 mg/kg body weight, max. 90 mg), with 10% of the dose given as a bolus
followed by a 60-minute infusion, is recommended within 4.5 hours of onset of
ischaemic stroke (Class I, Level A)
ESO Guidelines 2009 Update. www.eso-stroke.org
Intravenous rt-PA is recommended for selected patients who may be treated
within 3 hours of onset of ischemic stroke (Class I Level A)
rt-PA should be administered to eligible patients who can be treated in the
time period of 3 to 4.5 hours after stroke (Class I Level B)
AHA/ASA Guideline 2018
Alteplase is recommended within its marketing authorisation for treating AIS in adults if
treatment is started as early as possible within 4.5 hours of onset of stroke symptoms,
and intracranial haemorrhage has been excluded by appropriate imaging techniques
NICE Guidline 2012

35. NIH-Recommended ED Response Time
NINDS NIH website. Stroke proceedings. Latest update 2008
DTN ≤60 min : the “golden hour” for evaluating & treating acute stroke
T=0
Suspected
stroke patient
arrives at
stroke unit
≤10 min
Initial MD evaluation
(including patient
history, lab work
initiation, & NIHSS)
≤ 15 min
Stroke team
notified
(including
neurologic
expertise)
≤ 25 min
CT scan
initiated
≤ 45 min
CT & labs
interpreted
≤ 60 min
rt-PA
given if
patient
is eligible

36. THROMBOLYSIS PATHWAY
➊Arrival to ED
➋A&PE assessment
➌Stroke team notified
➍Order priority CT Brain
➎Lab & ECG exams
➏CT scan performed
➐CT report obtained
➑Patient informed and consent obtained
➒Reconstitution and drawing up of
Alteplase
➓Thrombolysis is initiated
INCLUSION CRITERIA
1. Clinical signs and symptoms of definite acute stroke
2. Clear time of onset
3. Presentation within 3 hrs of acute onset
4. Haemorrhage excluded by CT scan
5. Age 18 - 80 years old
6. Consent to treat (every effort must be made to contact next of kin)
EXCLUSION CRITERIA
1. Rapidly improving or minor stroke symptoms (NIHSS 1-4)
2. NIHSS < 5 or >25
3. Stroke or serious head injury within 3 months
4. Major surgery, obstetrical delivery, external heart massage in last 14 days
5. Seizure at onset of stroke
6. Prior stroke and concomitant diabetes
7. Severe haemorrhage in last 21 days
8. Increase bleeding risk
9. History of central nervous damage (neoplasm, haemorrhage, aneurysm, spinal or intracranial surgery
or haemorrhagic retinopathy)
10. Blood pressure above 185 mmHg systolic or 110 mmHg diastolic
11. Symptoms suggestive of SAH (even if CT is normal)
12. Known clotting disorder
13. APTT abnormal, INR>1.5
14. Suspected iron deficient anaemia
15. Thrombocytopenia <100,000
16. Hypoglycaemia or hyper glycaemia <50 mg/dL >400 mg/dL
17. Bacterial endocarditis, pericarditis
18. Acute pancreatitis
19. Ulcerative GI disease in last 3 months, oesophageal varices, arterial-aneurysm, arterial/venous
malformation.
20. Severe liver disease including cirrhosis, acute hepatitis
DTN
The Golden Hour

37. Pasien dicurigai
Stroke
DOKTER EMERGENSI
CURIGA STROKE AKUT < 4.5 jam)
Gejala FAST : (Lihat Ceklis)
-Face (mulut mencong)
-Arm (lemah separuh badan)
-Speech (pelo/afasia)
-Time last normal (< 4.5 jam)
Dalam 10 menit :
1. EKG
2. GDS (stick)
3. Lab (bila perlu)
(Warfarin → INR ; NOAC → APTT)
4. Order Urgent CT/MRI Brain
5. Nilai NIHSS
6. Pasang iv-line
7. Call Neurologist
DPJP NEUROLOGI
Konsul / Refer cito !
Neurologi
• IGD (Triage)
• Ruang Rawat
ACTIVATE CODE STROKE
DPJP Neurologi
• Konfirmasi Stroke Iskemik
• Klarifikasi onset gejala
• NIHSS
• Order Obat Alteplase
Urgent
CT/MRI Brain
ELIGIBILITAS TROMBOLISIS
Lihat Ceklis
START TROMBOLISIS
TRANSFER KE RUANGAN
(STROKE UNIT/HCU/ICU)
•Dosis Alteplase 0.6-0.9 mg/kgBB
• Berikan bolus 10% dosis
• Sisanya di drip dalam 1 jam
CODE
STROKE
RSCM/FKUI
DNT:
60
Minutes

39. General Management
1. Supplemental oxygen to maintain oxygen saturation >94%
2. Hypotension and hypovolemia should be treated to ensure systemic perfusion
3. Blood pressure goal of <185/110 mm Hg is recommended in eligible tPA patients
4. In patients for which endovascular therapy is planned, a BP goal <185/110 is
reasonable before the procedure
5. Hypothermia for treatment in acute stroke is not well established
6. If hyperthermia (>38°C) is present, a careful evaluation for the source is
recommended. The source should be treated, and antipyretics recommended
7. Hyperglycemia is associated with worse outcomes, maintain serum glucose 140-
180 mg/dL
8. Hypoglycemia (< 60 mg/dL) should be treated

40. Antiplatelet medications
1. Aspirin is recommended in patients with stroke within 24-48
hours after onset. If treated with tPA, aspirin is generally
delayed for 24 hours
2. Aspirin is not a substitute for tPA if patients eligible for tPA
3. Dual platelet therapy with aspirin and clopidogrel for 21
days may be beneficial for secondary stroke prevention in
patients with minor stroke
4. Ticagrelor is not recommended for acute treatment, it may
be reasonable in patients with contraindications to aspirin

41. Anticoagulants
1. Anticoagulant for cardioembolic stroke secondary
prevention (especially in Atrial Fibrillation)
2. Anticoagulation for patients with severe internal carotid
artery stenosis or non-occlusive, extracranial intraluminal
thrombus is not well established
3. Argatroban, dabigatran, and other thrombin inhibitors are
not well established for acute stroke care
4. Factor Xa inhibitors are not well established for acute
stroke care

42. Cerebral/cerebellar edema
1. Surgical decompression with ventriculostomy or craniectomy may be
needed for clinical deterioration from infarction resulting in edema
2. Osmotic therapy in patients with clinical deterioration is reasonable
3. Brief moderate hyperventilation (PCO2 30-34 mm Hg) is reasonable
with severe neurological decline from cerebral edema
4. Hypothermia or barbiturates for edema are not recommended
5. Corticosteroids are not recommended for treatment of cerebral edema

43. Miscellaneous
1. Routine use of prophylactic antibiotics is not
recommended
2. Routine bladder catheter placement is not
recommended due to increased risk of
catheter-associated UTI

47. Subarachnoid Hemorrhage Management