Syahrul
Department of Neurology
Faculty of Medicine, Syiah Kuala University
Banda Aceh, March 29, 2011
ACUTE STROKE
1
STROKE


The third leading cause of death
The leading cause of serious, long-term disability

Indonesia : Riskesdas Depkes RI, 2007
 Prevalence of stroke 8,3 per 1.000 people
 Mortality : stroke 15,4%, hypertensive 6,8% &
ischemic heart disease 5,1%

Stroke Statistics,U.S. Statistics, 2010
 143,579 people die each year from stroke
 Each year, about 795,000 people suffer a stroke
 About 600,000 of these are first attacks, and
 185,000 are recurrent attacks

2
STROKE
A major economic burden on healthcare system
 Incidence is expected to increase 25% by 2050
 Ischemic stroke, when arteries are blocked by
blood clots (emboli) or by the gradual build-up of
plaque other fatty deposits.
(Approximately 80% of stroke are ischemic)
 Hemorrhagic stroke, occur when a blood brain
breaks leaking blood into the bain.
(20% of all stroke)

3
KLASIFIKASI

Patologi Anatomi

Stroke Iskemik



Stroke Hemoragik



Perdarahan Intra Serebral
Perdarahan Sub-Arakhnoid
Perjalanan Klinis





Trombosis Serebri
Emboli Serebri
Transient Ischemic Attack
Reversible Ischemic Neurological Defisit
Stroke In-evolution
Komplit Stroke
Sirkulasi Serebral


Stroke Sirkulasi Serebral Anterior
Stroke Sirkulasi Serebral Posterior
4
STROKE
5
Hemorragic Stroke
Ischemic Stroke
6
Ischemic Stroke
7
Ischemic Stroke
8
ISCHEMIC STROKE
9
RECENT MANGEMENT
OF ACUTE ISCHEMIC STROKE
 Approach
:
Pathophysiology
Clinical Signs & Symptoms
Diagnostic Supports
Neuro-Pharmacology Intervention
10
Pathophysiology
11
PATHOPHYSIOLOGY : THE ISCHEMIC PENUMBRA
CBF
CBF
50.9 cc/
100 gr otak/menit
Daya cadang
serebrovaskuler
35 – 40 cc
Kehilangan fungsi
20 – 35 cc
Aktifitas listrik
otak terhenti
< 10 – 20 cc
Kematian sel saraf
12
Ischemic core and penumbra in human stroke
(Stroke. 1999;30:93-99)
13
Ischemic core and penumbra in human stroke
(Stroke. 1999;30:93-99)
14
PATHOPHYSIOLOGY : THE ISCHEMIC PENUMBRA
(caspase apoptosis: programmed cell death)
(necrosis)
(necrotic
cell death)
(apoptosis :programmed
cell death)
Caspase
ISCHEMIC CORE AND ISCHEMIC PENUMBRA
(Friedlander 2003)
15
Cellular Injury During Ischemia
Consequences of Calcium Overload
16
Cellular Injury During Ischemia
Cellular Changes During Ischemia
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Thrombus Formation Role of Platelets
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3/4/2011
EDEMA FORMATION
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Clinical Signs & Symptoms
Anatomy of Stroke
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CLINICAL SIGNS & SYMPTOMS
Clinical Signs & Symptoms
Trombosis Serebri
Emboli Serebri
Onset
Akut, saat istirahat, pagi hari
Akut, saat aktifitas
Nyeri Kepala
Tidak ada
Nyeri kepala hebat, akut
Kesadaran Menurun
Tidak ada
1-2 jam
Defisit fokal neurologi
Ringan
Berat
Tekanan darah
Normal, sedikit meningkat
Sering normal, meningkat
Reflek patologi (babinsky)
Tidak dijumpai
Sering positif
Sumber trombus/emboli
Trombus : arteriosklerosis,
platelet, hiperkoagulasi,
hiperviskositas
Emboli : penyakit jantung,
pembuluh darah besar
CT Scan/MRI otak
Lakunar, small vessel oclusive
Teritorial, large vessel oclusive
Pemeriksaan Penunjang
Darah rutin, agregasi trombosit,
INR, fibrinogen, GD, Lipid
profile, fs ginjal, as urat, EKG,
Foto torak, TCD
Echokardiografi, TCD,
Angiografie;
Darah rutin, agregasi trombosit,
INR, fibrinogen, GD, Lipid profile,
fs ginjal, as urat, EKG, Foto torak
21
Clinical Signs & Symptoms
22
Diagnostic Supports
23
MRI : Brain Gold Standard
Coronal orientation: in a slice dividing the head into front and back halves.
Sagittal orientation: in a slice dividing the head into left and right halves.
Axial orientation: in a slice dividing the head into upper and lower halves.
24
MRI in Acute Ischemic Stroke
Left: diffusion-weighted MRI in acute ischemic stroke performed 35 minutes after
symptom onset.
Right: apparent diffusion coefficient (adc) map obtained from the same patient at the
same time.
25
MRI in Acute Ischemic Stroke
Diffusion-perfusion mismatch in acute ischemic stroke.
The perfusion abnormality (right) is larger than the diffusion
abnormality (left), indicating the ischemic penumbra, which is at
risk of infarction.
26
MRI in Acute Ischemic Stroke
Left: Perfusion-weighted MRI of a patient who presented 1 hour
after onset of stroke symptoms.
Right: Mean transfer time (MTT) map of the same patient.
27
CT SCAN : BRAIN
CT scan
Gold Standard
Ischemia, Infarction
(Size, Location)
Edematous (Midline Shift)
28
CAROTID ULTRASOUND
(CAROTID DOPPLER, CAROTID DUPLEX)
29
CEREBRAL ANGIOGRAPHY
(Cerebral Angiogram, Cerebral Arteriogram, Digital Subtraction Angiography
[DSA])
30
ECHOCARDIOGRAM
Examines the heart through the chest (called transthoracic echocardiogram,
or TTE), and one that examines the heart through the throat (called
transesophageal echocardiogram, or TEE)
31
ELECTROCARDIOGRAM
(EKG, ECG)
Atrial fibrilation
 CAD, Ischemic heart disease
 Infarct myocard (acute, acute)
 RBB, LBB
 LVH, RVH
T inversion; Q pathology;

ST depretson; ST elevation
32
LABORATORY TEST
Blood routine, Glucose, Lipid Profile, Uric Acid
 Fibrinogen, Agregation of Trombocyte,INR
 Protein C, S; Anticardiolipin Antibody (ACA)

33
Neuro-Pharmacology
Intervention
34
Neurocritical Care Intervention
Optimization of medical treatment is key in
the care of the stroke patient and we
should be cautious when prognosticating
early in the setting of acute stroke and be
aware of the potential effect ‘do not
resuscitate’ status may have on patient
outcome
J NeuroIntervent Surg 2011;3:34-37
35
“TIME IS BRAIN”
Prehospital Management
Hospital Management
Emergency Medical Service
Facilities for Emergency Stroke Care
36
“TIME IS BRAIN”
Medical emergency, early hospital management
 Time depedent therapy

Rapid confirmation (CT scan or MRI)
 Urgent investigation (cause of stroke)

Acute therapy
 Comprehensive risk factor management
(antihypertensive therapy, early rehabilitation,
discharge planning)

37
TROMBOLYSIS
rt-PA
Intravenous
Recombinant Tissue Plasminogen Activator
The ‘’engine for emergency stroke”
Beneficial within 3 hours of stroke onset
(NINDS 1995, PROACT II study 1999,
National Stroke Foundation 2007, AHA/ASA 2007)
World Stroke Congress, Seoul Korea, 20104 hours
38
Antithrombotic & Anticoagulant
Antithrombotic Therapy
After the onset of stroke (>3 hours)
aspirin 325 mg
Anticoagulant Therapy
After the onset of stroke (emboli )(3 – 8 hours)
39
Aspirin and Clopidogrel in the
Acute Treatment of Ischemic Stroke
The acute treatment window for ischemic stroke is
the loading of aspirin and clopidogrel within 36
hours of symptom onset of stroke
 Treated with 325 mg of aspirin and 375 mg of
clopidogrel within 36 hours of symptom onset
 Loading with 375 mg of clopidogrel and 325 mg of
aspirin appears to be safe when administered up
to 36 hours after stroke and transient ischemic
attack onset in this pilot study. Neurologic
deterioration may be decreased and warrants
further study .

J Stroke Cerebrovasc Dis. 2008; 17(1): 26–29.
40
When & How To Treat Hypertension ?
When and how to treat hypertension in
acute ischemic stroke?
The effect of BP modification during the acute
phase of ischemic stroke on functional outcome
is strongly dependent on age.
(Hypertension 2009; 54:769-774)
41
Loss of CBF Regulation During Acute Ischemic Stroke
Hypertension 2009;54;702-703
42
Autoregulation of cerebral blood flow in a normal brain and in the ischemic
penumbra (the tissues surrounding the ischemic core after a stroke)
In the normal brain, cerebral blood flow is kept at 50 mL/100 g per minute, despite continuous
fluctuations of mean blood pressure between 70 and 120 mm Hg (continuous line). Any increase in
pressure leads to vasoconstriction and any decrease to vasodilation, which prevents the risk of
cerebral hyper- and hypoperfusion, respectively. Above and below the limits of cerebral blood flow
autoregulation, cerebral perfusion passively follows the perfusion pressure. In the ischemic
penumbra, tissue perfusion follows perfusion pressure (dashed line): any fall in blood pressure may
precipitate ischemia, while an increase in blood pressure may cause edema and hemorrhagic
43
transformation. CMAJ, March 1, 2005; 172 (5)
44
Anti-hypertensive Medications
in the Acute Ischemic Stroke
Mostly as mono-therapy was common among a
history of hypertension
 Angiotensin-converting enzyme inhibitors (ACEI)
65 (45.6%)
 Diuretics 41 (34.5%)
 ACEI were used in combination with diuretics in
29 (23.4%)
 In Cochrane review found no evidence that giving
calcium antagonists after an ischemic stroke
saves lives or prevents disabilities.

45
Recent Advances in the Treatment of Hypertensive Emergencies
Crit Care Nurse 2010;30: 24-30
46
The Ideal Acute Antihypertensive Agent
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Rapid onset of action
Predictable dose response
Titratable to desired BP
Minimal dosage adjustment
Minimal adverse effects
Easy conversion to oral agents
Acceptable cost-to-benefit ratio
Does not impair blood flow to vital organs (No sudden
dips in BP; Does not decrease cardiac output)
Does not increase ICP
Normalizes CBF autoregulatory curve
47
Neuroprotective Agents in Stroke

Prevention of Early Ischemic Injury
N-Methyl-D-Aspartate Receptor Antagonists
 Modulation of Non-NMDA Receptors

 Nalmefene
 Lubeluzole
 Clomethiazole
Free Radical Scavengers and Trapping Agents
NXY-059

Prevention of Reperfusion Injury
Antiadhesion Antibodies
 Membrane Stabilization
 Neuronal Healing

48
Hemorragic Stroke
49
HEMORRAGIC STROKE
50
CLINICAL SIGNS & SYMPTOMS
Clinical Signs & Symptoms
Perdarahan Intraserebral
Perdarahan Sub-arakhnoid
Onset
Akut, saat aktifitas
Akut, aktifitas
Nyeri Kepala
++++
+++
Kesadaran Menurun
++++
+
Defisit fokal neurologi
hebat
KK +
Tekanan darah
Tinggi sekali
Reflek patologi (babinsky)
+
KK +
Sumber perdarahan
Ruptur mikroaneurisma
berry, sakular
Ruptur AV-M
CT Scan/MRI otak
Perdarahan intraserebral
Perdarahan sub arakhnoid
Pemeriksaan Penunjang
CT scan, MRI, Angiografie;
EKG, hematologi
N (sedikit meningkat)
CT scan, MRI, Angiografie;
EKG, hematologi
51
MANAGEMENT
Management
Perdarahan Intraserebral
Perdarahan Sub-arakhnoid
Kesadaran Menurun
Perawatan Intensive
Perawatan Intensive
Tekanan Darah
Regulasi cepat 1-2 jam
Pemberian antiserebral
vasospasme
Pemeriksaan NeuroDiagnostik
CT scan, MRI kepala,
Angiografi; Hematologi
CT scan, MRI kepala,
Angiografi; Hematologi
Medikamentosa/Operatif
Komprehensif
Komprehensif
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BRAIN CT SCAN
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BRAIN CT SCAN
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Terimong geunaseh...
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