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Dr. Ida Ratna Nurhidayati, Sp.

S
Bagian Ilmu Penyakit Saraf
Fakultas Kedokteran Universitas YARSI
Stroke
A syndrome characterized by rapidly developing clinical symptoms and/or
signs of focal, and at times global (applied to patients in deep coma and
those with subarachnoid haemorrhage), loss of cerebral functions, with
symptoms lasting more than 24 h or leading to 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
Death
Rates

impairment

20% of survivors requiring


Incidence

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

Therapeutic
Treat Window

ISCHEMIC
rtPA  3 h onset

Refer HEMORRHAGIC
RAF VII  4 h onset
How to Diagnose?

Diagnosis

Treatment Option Prognosis


History Taking

The nature of the symptoms and signs

The speed of onset and temporal course of the


neurological symptoms

Were there any possible precipitants?

Were there any accompanying symptoms?

Is there any relevant past or family history?

Are there any relevant lifestyle habits/behaviors?


Physical Examination

Confirm the presence of focal neurological signs, if any,


anticipated from the history

Discover possible etiological explanations for the event

Identify contraindications to investigation

Anticipate nursing and rehabilitation needs


Final diagnosis in two recent studies of patients
presenting with suspected TIA and stroke

Hand et al., 2006 (Stroke 2006;37(3):769-75)


Nor AM et al., 2005 (Lancet Neurol 2005;4(11):727-34)
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
How to differentiate?
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?
Gold Standar
CT/MR brain scanning or postmortem

No clinical
scoring method
can
differentiate,
with absolute
reliability,
ischemic stroke
from ICH
How to
differentiate?
Clinical Syndrome
BAMFORD Classification

TACI
Total Anterior Circulation Infark Occlucion of the mainstem or a branch of the
MCA/ACA/ICA by embolism from the heart,
embolism from proximal arterial sites of
atherothrombosis, and sometimes by
PACI thrombotic occlusion of sever ICA stenosis
Partial Anterior Circulation Infark

Small, deep, not a cortical, infarct by ‘complex’


LACI small vessel disease, atheroma of the parent
Lacunar Circulation Infark artery. Seldom caused by embolism .

POCI Almost any cause


Posterior Circulation Infark
Aims of Treatment

Optimizing the patient’s change of surviving and minimizing


the impact of the stroke and any recurrent vascular events
on the patient and carers

Minimizing the impact

Short-term effects causing the patient’s neurological impairments


Patient’s function (i.e. disability)
Role in society (i.e. handicap)
Airway and breathing stabilization

Hemodynamic stabilization

Avoiding raised intracranial pressure

Controlled of seizure

Controlled body temperature


Fluid and electrolyte management

Raised ICP management

Blood pressure (BP) management

Blood glucose management

Seizure management

Thrombolytic therapy

Neurosurgical intervention
Blood Pressure Management

Acute Ischemic Stroke


Emergency hypertension  SBP > 220 mmHg and/or DBP > 120 mmHg

Acute Hemorrhagic Stroke


Emergency hypertension  SBP > 200 mmHg or MAP > 150 mmHg
SBP > 180 mmHg or MAP > 130 mmHg  lower to 160/90 mmHg or MAP
110 mmHg
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

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