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

2. 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

3. 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

4. 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

5. INDONESIA 3.049.200 people 237 millions (2010) 146.000 people
National Stroke Prevalence
Tahun 2010
people
Stroke Prevalence
DKI Jakarta
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

6. 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

7. 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

8. 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

9. 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

10. Hemorrhagic Stroke (20%)

11. 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

12. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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)

22. 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

23. 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 hours of diagnosis for prevention of complications
Improve patient outcome and family education

24. 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.

25. Time is Brain and we must Act FAST !

26. 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)

27. 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

28. 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

29. 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:
NINDS NIH website. Stroke proceedings. Latest update 2008.

30. 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 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

31. 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 mg/kgBB
Berikan bolus 10% dosis
Sisanya di drip dalam 1 jam
START TROMBOLISIS
TRANSFER KE RUANGAN
(STROKE UNIT/Bangsal Neuro/HCU/ICU)

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

33. 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

34. 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

35. TIME IS BRAIN : DETECT EARLY & ACT FAST
THANK YOU