COMPREHENSIVE STROKE CARE Practical Aspects for General Physician M. kURNIAWAN, MD Dept. Neurologi FKUI/RSCM

outlines Consequencies & Impacts of Stroke Stroke : Definition and Type Recognizing Signs and Symptoms Scope of Stroke Care & The Role of GP Defining Risk Factors & Primary Prevention Early Detection & Pre Hospital Management First Response in Emergency Setting After Hospital Stroke Care

outlines Consequencies & Impacts of Stroke Stroke : Definition and Type Recognizing Signs and Symptoms Scope of Stroke Care & The Role of GP Defining Risk Factors & Primary Prevention Early Detection & Pre Hospital Management First Response in Emergency Setting After Hospital Stroke Care

Worldwide Impact Annually 15 million people, 5 million death, 5 million permanently disable because of stroke Every 2 seconds : someone in the world suffers a stroke Every 6 seconds : someone dies of a stroke Every 6 seconds : someone’s QOL will forever be changed – permanently disabled The lifetime risk of stroke : 1 in 5 for women 1 in 6 for men Economic burden of stroke : US$ 53,6 billion Direct cost : US$ 33 billion Indirect cost : US$ 20,6 billion per-year

INDONESIA 3.049.200 people 237 millions (2010) 146.000 people National Stroke Prevalence Tahun 2010 3.049.200 people Stroke Prevalence DKI Jakarta 146.000 people Indonesia has population of stroke comparable to ~ 75% of total population of Singapore (± 4.3 millions in 2010) Prevalence : 12.1 per-1000 (Jakarta : 14,6 per-1000) Main cause of death and disability Estimation of 2020 : 7.6 million death of stroke

Myelinated fibers Lost Blockage of one blood vessel will cause ischemia within 5 minutes 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 Time is Brain! Saver JL, Stroke 2006

outlines Consequencies & Impacts of Stroke Stroke : Definition and Type Recognizing Signs and Symptoms Scope of Stroke Care & The Role of GP Defining Risk Factors & Primary Prevention Early Detection & Pre Hospital Management First Response in Emergency Setting After Hospital Stroke Care

What is STROKE ? WHO, 1970 AHA/ASA Expert Consensus, 2013 rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin AHA/ASA Expert Consensus, 2013 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

Types of Stroke ISCHEMIC STROKE - 80% Embolic : Blood clot forms somewhere in the body and travels to the brain Thrombotic : Clot forms on blood vessel deposits

Hemorrhagic Stroke (20%)

outlines Consequencies & Impacts of Stroke Stroke : Definition and Type Recognizing Signs and Symptoms Scope of Stroke Care & The Role of GP Defining Risk Factors & Primary Prevention Early Detection & Pre Hospital Management First Response in Emergency Setting After Hospital Stroke Care

Signs & Symptoms Motoric symptoms Sudden weakness of face, arm or leg, esp. on one side of the body Sensory symptoms Sudden numbness/tingling of face, arm or leg, esp. on one side of 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 Increased intracranial pressure Cushing, decreased concsiousness, pupil anisochoria

outlines Consequencies & Impacts of Stroke Stroke : Definition and Type Recognizing Signs and Symptoms Scope of Stroke Care & The Role of GP Defining Risk Factors & Primary Prevention Early Detection & Pre Hospital Management First Response in Emergency Setting After Hospital Stroke Care

Scope of stroke care Primary Prevention Early Detection Screen for signs and symptoms  Using screening tools Fast Definitive Diagnosis - Knowing neurologic symptoms & examination - Brain CT-Scan Reperfusion/Recanalization & Acute Stroke Care Secondary Prevention Neurorestoration/Rehabilitation

outlines Consequencies & Impacts of Stroke Stroke : Definition and Type Recognizing Signs and Symptoms Scope of Stroke Care & The Role of GP Defining Risk Factors & Primary Prevention Early Detection & Pre Hospital Management First Response in Emergency Setting After Hospital Stroke Care

Modifiable risk factors Hypertension (RR : 4-6x) Elevated cholesterol level (statin decreased risk by 25%) Heart Disease Coronary Artery Disease Valve disease/replacement Atrial Fibrillation (3-4x risk) Previous stroke Obesity Alcohol intake Smoking (2x risk ischemic; 4x risk hemorrhagic) Oral contraceptives/HRT

Non - Modifiable Risk Factors Age : Risk doubles per-decade over 55 Gender : Men have greater risk Race : African-American, Asian and Hispanic have greater risk Diabetes Mellitus (RR 2-4x) Exacerbated by hypertension or poor glucose control Even diabetics with good control are at increased risk Family history of stroke or TIA

Primary StROKE Prevention Knowing and manage risk factors Risk stratification for more advance screening examination by specialist (e.g : Echocardiography, Carotid Doppler, Transcranial Doppler/TCD) Possible to implement in Primary Health Care Services (Puskesmas)

outlines Consequencies & Impacts of Stroke Stroke : Definition and Type Recognizing Signs and Symptoms Scope of Stroke Care & The Role of GP Defining Risk Factors & Primary Prevention Early Detection & Pre Hospital Management First Response in Emergency Setting After Hospital Stroke Care

WHY EARLY DETECTION ? ISCI Guideline 2010 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 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

Cincinnati Stroke Scale A Checklist for Emergency Medical Dispatchers 3-Question Checklist Score 1. Ask patient to smile Normal Slight difference 1 Obvious difference 3 Cannot complete at all 2. Ask patient to raise both arms above head Both arms raise equally One arm higher than the other Cannot complete request at all 3. Ask patient to say “the early bird catches the worm” Said correctly Slurred speech Garbled or not understood Total score: 3 Clear evidence of stroke 2 Strong evidence of stroke 1 Partial evidence of stroke 0 No evidence of stroke Govindarajan et al. BMC Neurology 2011;11:14.

Time is Brain and we must Act FAST !

PREHOSPITAL STROKE CARE Recommended Manage ABCs Cardiac monitoring (ECG) Intravenous access (Ringer Lactate or Ringer Acetate) Oxygen (as required if O2 saturation <94%) Assess for hypoglycemia NPO (Nothing per oral) Alert receiving ED of nearest stroke center Rapid transport to closest appropriate facility capable of treating acute stroke Not Recommended Dextrose-containing fluids in non-hypoglycemic patients Excessive blood pressure reduction (hypotension decrease cerebral perfusion and worsen stroke) Excessive intravenous fluids (increased ICP)

outlines Consequencies & Impacts of Stroke Stroke : Definition and Type Recognizing Signs and Symptoms Scope of Stroke Care & The Role of GP Defining Risk Factors & Primary Prevention Early Detection & Pre Hospital Management First Response in Emergency Setting After Hospital Stroke Care

STROKE IS TIME CRITICAL ABC & Fast Diagnosis Maintain ABC Knowing neurologic signs & symptoms Perform focused neurologic exams Clinical exams in 10 minutes time !!! If suspected stroke  perform urgent Brain CT-Scan This part must be done in Health Facility which has CT-Scan Consult to neurologist for Reperfusion/Recanalization Therapy and Acute Stroke Care Intravenous thrombolysis Intraarterial thrombolysis Mechanical thrombectomy

NIH-Recommended ED Response Time 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 US National Institute of Health recommends that a stroke patient eligible for thrombolysis has a door to needle time of one hour or less. However, these 60 minutes can even further be reduced by optimising the ER algorithm. 30 minutes door-to-needle time is a target that has been reached by highly specialised stroke centres. NINDS NIH website. Stroke proceedings. Latest update 2008. Point-of-care coagulometry to measure INR values and patient-adapted prothrombin complex administration, if necessary, has recently been shown to be a fast and economic method to reverse anticoagulation in patients with acute subdural haemorrhage induced by oral anticoagulants. Rizos et al. Neurocrit Care 2010; 13: 321-325. NINDS NIH website. Stroke proceedings. Latest update 2008.

The Golden Hour THROMBOLYSIS PATHWAY Arrival to ED A&PE assessment INCLUSION CRITERIA Clinical signs and symptoms of definite acute stroke Clear time of onset Presentation within 3 hrs of acute onset Haemorrhage excluded by CT scan Age 18 - 80 years old Consent to treat (every effort must be made to contact next of kin) EXCLUSION CRITERIA Rapidly improving or minor stroke symptoms (NIHSS 1-4) NIHSS < 5 or >25 Stroke or serious head injury within 3 months Major surgery, obstetrical delivery, external heart massage in last 14 days Seizure at onset of stroke Prior stroke and concomitant diabetes Severe haemorrhage in last 21 days Increase bleeding risk History of central nervous damage (neoplasm, haemorrhage, aneurysm, spinal or intracranial surgery or haemorrhagic retinopathy) Blood pressure above 185 mmHg systolic or 110 mmHg diastolic Symptoms suggestive of SAH (even if CT is normal) Known clotting disorder APTT abnormal, INR>1.5 Suspected iron deficient anaemia Thrombocytopenia <100,000 Hypoglycaemia or hyper glycaemia <50 mg/dL >400 mg/dL Bacterial endocarditis, pericarditis Acute pancreatitis Ulcerative GI disease in last 3 months, oesophageal varices, arterial-aneurysm, arterial/venous malformation. Severe liver disease including cirrhosis, acute hepatitis THROMBOLYSIS PATHWAY Arrival to ED A&PE assessment Neurologist & Stroke team notified Order priority CT Brain Lab & ECG exams CT scan performed CT report obtained Patient informed and consent obtained Reconstitution and drawing up of Alteplase Thrombolysis is initiated DTN 60 min

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

ACUTE STROKE care Restoration of brain function and prevention of complications Starting after thrombolysis or within 24-48 hours after diagnosis Hospitalized for 5-7 days Blood pressure management Treat hyperthermia Treat hypo- or hyperglycemia (BG target : 100 - 150 mg/dL) Initiate deep vein thrombosis (DVT) prophylaxis Initiate early neurorestoration/rehabilitation Nutritional management Starting secondary stroke prevention Antithrombotic Control risk factors

outlines Consequencies & Impacts of Stroke Stroke : Definition and Type Recognizing Signs and Symptoms Scope of Stroke Care & The Role of GP Defining Risk Factors & Primary Prevention Early Detection & Pre Hospital Management First Response in Emergency Setting After Hospital Stroke Care

AFTER HOSPITAL CARE Secondary Prevention In order to prevent stroke after stroke According to BPJS Policy : After acute stroke care and 6 month neurorestoration by neurologist Antiplatelet & Anticoagulation as prescribed by neurologist Control all risk factors Can be done in Primary Health Care Consult to neurologist Every 6 month for advance risk factor management, or If there is suspicion of new stroke event

TIME IS BRAIN : DETECT EARLY & ACT FAST THANK YOU