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Syahrul Department of Neurology Faculty of Medicine, Syiah Kuala University Banda Aceh, March 29, 2011 1.

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Presentation on theme: "Syahrul Department of Neurology Faculty of Medicine, Syiah Kuala University Banda Aceh, March 29, 2011 1."— Presentation transcript:

1 Syahrul Department of Neurology Faculty of Medicine, Syiah Kuala University Banda Aceh, March 29,

2  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 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

3  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

4  Patologi Anatomi  Stroke Iskemik  Trombosis Serebri  Emboli Serebri  Stroke Hemoragik  Perdarahan Intra Serebral  Perdarahan Sub-Arakhnoid  Perjalanan Klinis  Transient Ischemic Attack  Reversible Ischemic Neurological Defisit  Stroke In-evolution  Komplit Stroke  Sirkulasi Serebral  Stroke Sirkulasi Serebral Anterior  Stroke Sirkulasi Serebral Posterior 4

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6 Hemorragic StrokeIschemic Stroke 6

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10  Approach :  Pathophysiology  Clinical Signs & Symptoms  Diagnostic Supports  Neuro-Pharmacology Intervention 10

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20 Anatomy of Stroke 20

21 Clinical Signs & SymptomsTrombosis SerebriEmboli Serebri OnsetAkut, saat istirahat, pagi hariAkut, saat aktifitas Nyeri KepalaTidak adaNyeri kepala hebat, akut Kesadaran MenurunTidak ada1-2 jam Defisit fokal neurologiRinganBerat Tekanan darahNormal, sedikit meningkatSering normal, meningkat Reflek patologi (babinsky)Tidak dijumpaiSering positif Sumber trombus/emboli Trombus : arteriosklerosis, platelet, hiperkoagulasi, hiperviskositas Emboli : penyakit jantung, pembuluh darah besar CT Scan/MRI otakLakunar, small vessel oclusiveTeritorial, large vessel oclusive Pemeriksaan PenunjangDarah 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

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23 Diagnostic Supports 23

24 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

25 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

26 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

27 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

28 CT scanGold Standard Ischemia, Infarction (Size, Location) Edematous (Midline Shift) 28

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31 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

32  Atrial fibrilation  CAD, Ischemic heart disease  Infarct myocard (acute, acute)  RBB, LBB  LVH, RVH  T inversion; Q pathology; ST depretson; ST elevation 32

33  Blood routine, Glucose, Lipid Profile, Uric Acid  Fibrinogen, Agregation of Trombocyte,INR  Protein C, S; Anticardiolipin Antibody (ACA) 33

34 Neuro-Pharmacology Intervention 34

35 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:

36 Prehospital Management Hospital Management Emergency Medical Service Facilities for Emergency Stroke Care 36

37  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

38 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

39 Antithrombotic Therapy After the onset of stroke (>3 hours)  aspirin 325 mg Anticoagulant Therapy After the onset of stroke (emboli )  (3 – 8 hours) 39

40  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

41 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: ) 41

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43 43 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 transformation. CMAJ, March 1, 2005; 172 (5)

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45  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

46 Recent Advances in the Treatment of Hypertensive Emergencies Crit Care Nurse 2010;30:

47 1. Rapid onset of action 2. Predictable dose response 3. Titratable to desired BP 4. Minimal dosage adjustment 5. Minimal adverse effects 6. Easy conversion to oral agents 7. Acceptable cost-to-benefit ratio 8. Does not impair blood flow to vital organs (No sudden dips in BP; Does not decrease cardiac output) 9. Does not increase ICP 10. Normalizes CBF autoregulatory curve 47

48  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

49 Hemorragic Stroke 49

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51 Clinical Signs & SymptomsPerdarahan IntraserebralPerdarahan Sub-arakhnoid OnsetAkut, saat aktifitasAkut, aktifitas Nyeri Kepala Kesadaran Menurun+++++ Defisit fokal neurologihebatKK + Tekanan darahTinggi sekaliN (sedikit meningkat) Reflek patologi (babinsky)+KK + Sumber perdarahanRuptur mikroaneurisma berry, sakular Ruptur AV-M CT Scan/MRI otakPerdarahan intraserebralPerdarahan sub arakhnoid Pemeriksaan PenunjangCT scan, MRI, Angiografie; EKG, hematologi CT scan, MRI, Angiografie; EKG, hematologi 51

52 ManagementPerdarahan IntraserebralPerdarahan Sub-arakhnoid Kesadaran MenurunPerawatan Intensive Tekanan DarahRegulasi cepat 1-2 jamPemberian antiserebral vasospasme Pemeriksaan Neuro- Diagnostik CT scan, MRI kepala, Angiografi; Hematologi Medikamentosa/OperatifKomprehensif 52

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