Download stroke - pdui pusat

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
National Stroke
Prevalence
Stroke Prevalence
DKI Jakarta
Tahun
2010
146.000 people
•
•
•
3.049.200 people
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
Blockage of one blood vessel will
cause ischemia within 5 minutes
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
1.2 billion
8.3 trillion
7140 km
36 years
Time
Complete
TIME IS BRAIN!
STROKE
Time lost is Brain lost
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
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
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
1. Primary Prevention
2. Early Detection
Screen for signs and symptoms  Using screening tools
3. Fast Definitive Diagnosis
- Knowing neurologic symptoms & examination
- Brain CT-Scan
4. Reperfusion/Recanalization & Acute Stroke Care
5. Secondary Prevention
6. 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 2448 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
0
Slight difference
1
Obvious difference
3
Cannot complete at all
2. Ask patient to raise both arms above head
Both arms raise equally
0
One arm higher than the other
1
Cannot complete request at all
3. Ask patient to say “the early bird catches the worm”
Total score:
Said correctly
0
3 Clear evidence of stroke
Slurred speech
3
2 Strong evidence of stroke
Garbled or not understood
3
1 Partial evidence of stroke
Cannot complete request at all
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
≤10 min
≤ 15 min
Suspected Initial MD evaluation Stroke team
stroke patient (including patient
notified
arrives at
history, lab work
(including
stroke unit
initiation, & NIHSS) neurologic
expertise)
≤ 25 min
CT scan
initiated
≤ 45 min
CT & labs
interpreted
≤ 60 min
rt-PA
given if
patient
is eligible
NINDS NIH website. Stroke proceedings. Latest update 2008.
INCLUSION CRITERIA
The Golden Hour
1.
2.
3.
4.
5.
6.
THROMBOLYSIS PATHWAY
➊ Arrival to ED
EXCLUSION CRITERIA
➋ A&PE assessment
➌ Neurologist & Stroke team
notified
➍ Order priority CT Brain
➎ Lab & ECG exams
➏ CT scan performed
➐ CT report obtained
➑ Patient informed and
consent obtained
➒ Reconstitution and drawing
up of Alteplase
➓ Thrombolysis is initiated
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)
DTN
60 min
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
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, arterialaneurysm, arterial/venous malformation.
Severe liver disease including cirrhosis, acute hepatitis
CODE STROKE RSCM/FKUI
 IGD (Triage)
 Ruang Rawat
Pasien dicurigai
Stroke
DOKTER EMERGENSI
CURIGA STROKE AKUT < 4.5 jam)
Gejala FAST : (Lihat Ceklis)
-Face (mulut mencong)
-Arm (lemah separuh badan)
-Speech (pelo/afasia)
-Time last normal (< 6 jam)
Dalam 10 menit :
ACTIVATE CODE STROKE
Urgent
CT/MRI Brain
Konsul / Refer cito !
Neurologi
DPJP NEUROLOGI
ELIGIBILITAS TROMBOLISIS
Lihat Ceklis
START TROMBOLISIS
TRANSFER KE RUANGAN
(STROKE UNIT/Bangsal
Neuro/HCU/ICU)
1. EKG
2. GDS (stick)
3. Lab (bila perlu)
(Warfarin  INR ; NOAC  APTT)
4. Order Urgent CT/MRI Brain
5. Nilai NIHSS
6. Pasang iv-line
7. Call Neurologist
DPJP Neurologi
 Konfirmasi Stroke Iskemik
 Klarifikasi onset gejala
 NIHSS
 Order Obat Alteplase (Actilyse®)
 Dosis Alteplase 0.6-0.9
mg/kgBB
 Berikan bolus 10% dosis
 Sisanya di drip dalam 1 jam
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