CODE STROKE

“ An Attempt to Shorten Hospitalization “

YUDHI ADRIANTO, dr, SpS(K)

( Neurologist & Neurointerventionist )

Divisi Neurointervensi & Neuroimejing

Dep/KSM Neurologi RS Universitas Airlangga/ FK Unair
Surabaya
 Know Your Brain…..

• Weight: ±1350 gr, or 2% Body Weight

• Total Neuron: 130.000.000.000

• Synapses: 150.000.000.000.000

• Length of Fiber: 135.000 km

• Blood supply: 50mg/100gr/min= 972 L/day

• Oxygen Consumption: 3.7/100gr/min= 72L/day

• Glucose Consumption: 5.5mg/100gr/min= 107gr/day

 Stroke Facts

• The leading cause of morbidity and mortality

in the world

• On average, every 4 minutes, someone died

of a stroke

• Satu dari 6 pria akan menderita stroke

selama masa hidupnya. Pada wanita 1:5
(WSO campaign 2015)

• Riskesdas: 8.3/mil (2007) meningkat menjadi

10.9/mil (2018)

• Kecepatan dan ketepatan diagnosis dan

pengobatan stroke akut sangat berkaitan
dengan morbiditas dan mortalitas
- Mozaffarian D, Benjamin EJ, Alan S et al. Heart Disease and Stroke Statistics—2016 Update: A Report From the American Heart Association. Circulation.
2015;132:000-000. DOI: 10.1161/CIR.0000000000000350
- Srinivasan A, Goyal M, Azri FA et al. State of the Art Imaging of Acute Stroke. RadioGraphics 2006; 26:S75–S95
 Acute Stroke

• Defisit neurologis fokal/global, mendadak, spontan disebabkan gangguan

pembuluh darah otak (neurovaskuler), termasuk cerebral infarction,
intracerebral hemorrhage (ICH), dan subarachnoid hemorrhage (SAH)

• Bisa melibatkan serebral, spinal, atau retinal infarction

• Menetap ≥24 jam atau menyebabkan kematian

Sacco RL, Kasne SE, Croderick JP et al. An Updated De+inition of Stroke for the 21st Century: A Statement for
Healthcare Professionals From the American Heart Association/American Stroke Association.
Stroke.2013;44:2064-2089
 Acute Stroke

Ischemic 87% 13% Hemorrhage

Mozaffarian D, Benjamin EJ, Alan S et al. Heart Disease and Stroke Statistics—2016 Update:A Report From the
American Heart Association. Circulation. 2015;132:000-000. DOI: 10.1161/CIR.0000000000000350
 Stroke Iskemik

Minutes

Hours

Time Days and weeks

Gejala Klinis

Defisit neurologis fokal/global (Hemiparese, Hemihipestesi,

Disartria, Afasia, penurunan kesadaran)

Akut

Waspada stroke mimics : hipoglikemia, post ictal, neoplasma

cerebri, ME dll
 Stroke Perdarahan

Gejala Klinis

Defisit neurologis fokal/global (Hemiparese, Hemihipestesi,

Disartria, Afasia, penurunan kesadaran)

Sangat Akut, saat aktivitas

Gejala tambahan: Nyeri kepala hebat, muntah proyektil,

kejang, kaku kuduk
 How To Diagnose ???

1. Evaluasi Klinis Stroke

—Defisit neurologis fokal/global
—Akut (mendadak)
—Gejala penunjang lain
—Vital Sign

2. CT scan kepala, MRI kepala Menentukan Jenis Stroke,

WAJIB Opsional Rencana tindakan
 • An organized protocol for the emergency evaluation of patients with suspected
stroke is recommended (Class I; Level of Evidence B)

• Designation of an acute stroke team that includes physicians, nurses, and

laboratory/radiology personnel is recommended. Patients with stroke should have
a careful clinical assessment, including neurological examination (Class I; Level
of Evidence B)

• Multicomponent quality improvement initiatives, which include ED education and

multidisciplinary teams with access to neurological expertise, are recommended to
safely increase IV fibrinolytic treatment (Class I; Level of Evidence A)

Powers, WJ, Rabinstein, AA, Ackerson, T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the
early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019;
50: e344–e418
 • All patients with suspected acute stroke should receive emergency brain imaging
evaluation on first arrival to a hospital before initiating any specific therapy to treat
AIS (Class I; Level of Evidence A)

• Noncontrast CT (NCCT) is effective to exclude ICH before IV alteplase

administration (Class I; Level of Evidence A)

• Magnetic resonance (MR) imaging (MRI) is effective to exclude ICH before IV

alteplase administration (Class I; Level of Evidence B)

Powers, WJ, Rabinstein, AA, Ackerson, T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the
early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019;
50: e344–e418
Ruled Out Hemorrhage
Cerebral Infarction
Cerebrovascular Territory
 Hyperdense Vessel Sign

HMCAS: 1. Worse clinical outcome

Density of flowing blood: 40 HU (35-60 HU)
2. Larger volume infarcts. Intraluminal clot (thrombus): 80HU (77-89 HU)
3. Prominent morbidity and mortality
 Insular Cortex

Sylvian Fissure
Loss of insular ribbon
Loss gray-white interface
Loss of sulci
Loss of insular ribbon
Loss gray-white interface
Loss of sulci
Loss of insular ribbon
Loss gray-white interface
Loss of sulci
Obscuration of Lentiform nucleus
Normal atau Tidak ???
 Code Stroke

Time is BRAIN
“ Time is Brain’ “ Time Loss is Brain Loss’

Code stroke is a term used to prioritize the hyperacute assessment and care
of a patient presenting with signs and symptoms concerning for stroke

Setiap keterlambatan 10 menit pemberian tPA pada stroke akut pada periode
1-3 jam time window, maka terdapat 1 satu diantara 100 pasien yang
disabilitasnya tidak mengalami perbaikan (Lansberg MG, 2009)
Keterlambatan tiap menit, terjadi kematian 1.9 juta neuron pada area yang
mengalami penyumbatan
 Door to needle time

• In patients eligible for intravenous rtPA, benefit of therapy is time dependent, and
treatment should be initiated as quickly as possible. The door-to-needle time (time
of bolus administration) should be within 60 minutes from hospital arrival (Class I;
Level of Evidence A)

• The use of a stroke severity rating scale, preferably the NIHSS, is recommended
(Class I; Level of Evidence B)

• Only the assessment of blood glucose must precede the initiation of IV alteplase in
all patients (Class I; Level of Evidence B)

Powers, WJ, Rabinstein, AA, Ackerson, T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the
early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019;
50: e344–e418
 ALUR CODE STROKE
Dugaan
IGD Ruang Rawat Inap
STROKE AKUT
Gejala KLINIS FAST
Gejala KLINIS FAST 1. Face (Facial Palsy)
1. Face (Facial Palsy) 2. Arm (Hemiparese/Hemihipestesi)
2. Arm (Hemiparese/Hemihipestesi) Triase IGD
3. Speech (Disartria/Afasia)
3. Speech (Disartria/Afasia) Dokter Ruangan
4. TIME (onset < 4,5 Jam), last time
4. TIME (onset < 4,5 Jam), last time normal
normal >> Pemasangan IV line, O2 nasal (prn)

1. Lab: GDA
2. EKG monitor Dalam 10 menit :
3. Riwayat Antikoagulan: FH, INR ? 1. Diagnosa Klinis Stroke
NEUROLOGIST/PPDS
2. History taking, Onset
(Aktivasi CODE
1. CT scan kepala tanpa kontras 3.Skoring NIHSS, Ceklist Status
STROKE)
2. MRI/MRA/MRP (jika perlu) Stroke
3. Inisiasi Lab dan Radiologi

1. Administrasi BPJS/Umum Pasien ELIGIBLE

2. Acc tindakan
Spesialis terkait, jika
3. Koordinasi tim Farmasi
indikasi
~30 menit Tim Farmasi
Menyediakan rTPa

Alteplase Dosis 0,9 mg/KgBB

Bolus 10% selama 1 menit Start TROMBOLISIS Transfer ke STROKE UNIT
Sisanya Drip dalam 60 menit
Spesialis terkait, jika indikasi
Penanganan UMUM
Penanganan UMUM

• Airway support and ventilatory assistance are recommended for the treatment of patients
with acute stroke who have decreased consciousness or who have bulbar dysfunction that
causes compromise of the airway (Class I; Level of Evidence C)

• Supplemental oxygen should be provided to maintain oxygen saturation >94% (Class I;

Level of Evidence C)

• Supplemental oxygen is not recommended in nonhypoxic patients with AIS (Class III: No
Benefit)

• Hypotension and hypovolemia should be corrected to maintain systemic perfusion levels

necessary to support organ function (Class I; Level of Evidence C)

• Patients who have elevated BP and are otherwise eligible for treatment with IV alteplase
should have their BP carefully lowered so that their SBP is <185 mm Hg and their
diastolic BP is <110 mm Hg before IV fibrinolytic therapy is initiated (Class I; Level of
Evidence B)

• In patients with BP ≥220/120 mm Hg who did not receive IV alteplase or mechanical

thrombectomy and have no comorbid conditions requiring urgent antihypertensive
treatment, the benefit of initiating or reinitiating treatment of hypertension within the first
48 to 72 hours is uncertain. It might be reasonable to lower BP by 15% during the first 24
hours after onset of stroke (Class IIb; Level of Evidence C)
 Penanganan UMUM

• Sources of hyperthermia (temperature >38°C) should be identified and treated,

and antipyretic medications should be administered to lower temperature in
hyperthermic patients with stroke (Class I; Level of Evidence C)

• Hypoglycemia (blood glucose <60 mg/dL) should be treated in patients with

AIS (Class I; Level of Evidence C)

• Evidence indicates that persistent in-hospital hyperglycemia during the first 24

hours after AIS is associated with worse outcomes than normoglycemia, and
thus, it is reasonable to treat hyperglycemia to achieve blood glucose levels in a
range of 140 to 180 mg/dL and to closely monitor to prevent hypoglycemia in
patients with AIS (Class IIa;Level of Evidence C)

Powers, WJ, Rabinstein, AA, Ackerson, T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the
early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019;
50: e344–e418
Pengobatan Khusus
• In patients eligible for intravenous rtPA, benefit of therapy is time dependent, and
treatment should be initiated as quickly as possible. The door-to-needle time (time
of bolus administration) should be within 60 minutes from hospital arrival (Class I;
Level of Evidence A)

• IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of
dose given as bolus over 1 minute) is recommended for selected patients who can
be treated within 3 hours of ischemic stroke symptom onset or patient last known
well or at baseline state (Class I; Level of Evidence A)

• Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is recommended for

administration to eligible patients who can be treated in the time period of 3 to 4.5
hours after stroke onset (Class I; Level of Evidence B)
 Trombolisis Intravena

Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg)

Powers, WJ, Rabinstein, AA, Ackerson, T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the
early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019;
50: e344–e418
- Bhatia R, Hill MD, Shobha N, et al.: Low rates of acute recanalization with intravenous recombinant tissue
plasminogen activator in ischemic stroke: Real-world experience and a call for action. Stroke 2010; 41:
2254-2258.
Suzuki, Koga, Yamamoto et al. 2015. Early recanalization rates following intravenous recombinant tissue
plasminogen activator (rt-PA) therapy in acute ischemic stroke. Neurosonology 28(1):12 - 16
Bagaimana jika > 4.5 jam…..?
 Wake Up Stroke

• In patients with AIS who awake with stroke symptoms or have unclear time of onset > 4.5
hours from last known well or at baseline state, MRI to identify diffusion-positive FLAIR-
negative lesions can be useful for selecting those who can benefit from IV alteplase
administration within 4.5 hours of stroke symptom recognition (Class I; Level of Evidence
B)

• Eligibility required MRI mismatch between abnormal signal on DW-MRI and no visible
signal change on FLAIR (WAKE-UP study)
 Onset 0-6 jam

• Patients eligible for IV alteplase should receive IV alteplase even if mechanical

thrombectomy is being considered (Class I; Level of Evidence A)

• Patients should receive mechanical thrombectomy with a stent retriever if they meet
all the following criteria: (1) prestroke mRS score of 0 to 1; (2) causative occlusion
of the internal carotid artery or MCA segment 1 (M1); (3) age ≥18 years; (4) NIHSS
score of ≥6; (5) ASPECTS of ≥6; and (6) treatment can be initiated (groin puncture)
within 6 hours of symptom onset (Class I; Level of Evidence A)

• M2, M3, Vertebrobasiler artery, PCA (Class II; Level of Evidence B)

Powers, WJ, Rabinstein, AA, Ackerson, T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the
early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019;
50: e344–e418
 Onset 6-24 jam

Powers, WJ, Rabinstein, AA, Ackerson, T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the
early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019;
50: e344–e418
 CBV-CT CBF CTA

Multimodal CT

DWI TTP MRA

Multimodal MR
 Neurointervention:

The New Era of Neurology

Neurology enter minimal invasive era

Neurointervention has significant role in neurovascular disease

diagnostic also terapheutic
 Neurointervention Competencies

Neurointervensi merupakan sub-spesialisasi dari neurologi, yang

menggunakan teknologi kateterisasi, neuroimejing, dan pengalaman
klinis untuk mendiagnosa dan mengobati penyakit sistem saraf pusat
melalui teknik minimal invasif. Prosedur dilakukan melalui akses
arterial dan vena.

Prosedur Diagnostik
DSA Cerebral & Spinal

WADA test

Balloon Test Occlusion

Inferior Petrosal Sinus Sampling (IPSS)

 Vascular Disease Interventional Procedure

Trombolisis IV, Tombolisis IA selektif,

Stroke Iskemik Akut
Trombektomi Mekanik
Carotid/ vertebral/ intracranial,
Prevensi sekunder stroke iskemik
Angioplasty & Stenting
AVM serebral dan spinal Embolisasi AVM dengan N-BCA, PVA, Onyx

Aneurisma coiling, Pipeline embolization, Parent

Aneurisma Cerebral
vessel sacrifice

Tumor Otak yang hipervaskuler Pre-Op Embolisasi dengan PVA dan Gel-Foam

Selective chemical spasmolysis/IA, Angioplasty

Vasospasme berbagai penyebab (SAH, Mekanik) spastic vessel, IV drug infusion

Embolisasi transarterial/transvenous dengan Coil,

Dural AVFs N-BCA, Onyx, dan PVA

Malformasi Vaskuler di kepala dan Leher Embolisasi transarterial/transvenous, Skleroterapi

Transvenous selective thrombolytic theraphy,
Cerebral Venous Thrombosis Stenting, dan Trombektomi transvenous
Selamatkan Penumbra
 Neurointervention
Procedure of Acute
Stroke

• IA thrombolysis
• Mechanical Thrombectomy
 IA Thrombolysis

Freshly formed thrombi usually dissolve easily, thrombus from

others source may be older, become more resistant to lysis
 Mechanical Thrombectomy Devices

— The Concentric Retriever (Concentric Medical,Mountain View, Calif., USA)

— The EKOS MicroLys US infusion catheter (EKOS, Bothell, Wash., USA)
— The EPAR (Endovascular Photoacoustic Recanalization; Endovasix, Belmont,
Calif., USA)
— The Possis AngioJet system (Possis Medical, Minneapolis, Minn., USA)
— Solitaire FR
— Merci
— Penumbra system

Penggunaan stent retriever lebih diutamakan dibanding peralatan trombektomi

mekanik lainnya (Class I, Level of Evidence A)
 Product Overview

Push
Wire
Usable Length

53
 Kesimpulan

• Stroke masih merupakan penyebab kecacatan dan kematian

utama di dunia, khususnya di Indonesia

• Perkembangan tatalaksana stroke akut mengalami kemajuan

yang pesat. Namun screening/pencegahan serta deteksi dini
memegang peranan kunci

• Code stroke perlu kerja sama tim, mulai dari edukasi

masyarakat, screening faktor resiko, penanganan dokter UGD,
perawat, laboran, radiologi, dokter spesialis saraf, dan dokter
spesialis terkait lainnya, sangat penting untuk penanganan
stroke

• Time is Brain. Time lost is brain lost

• Stroke is TREATABLE !!
 Terima Kasih
Semoga Bermanfaat