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" An Attempt To Shorten Hospitalization ": Code Stroke
" An Attempt To Shorten Hospitalization ": Code Stroke
" An Attempt To Shorten Hospitalization ": Code Stroke
• Synapses: 150.000.000.000.000
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
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
Gejala Klinis
Akut
Gejala Klinis
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)
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
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
• 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 is not recommended in nonhypoxic patients with AIS (Class III: No
Benefit)
• 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)
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)
• 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 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)
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
Multimodal MR
Neurointervention:
Prosedur Diagnostik
DSA Cerebral & Spinal
WADA test
Tumor Otak yang hipervaskuler Pre-Op Embolisasi dengan PVA dan Gel-Foam
• IA thrombolysis
• Mechanical Thrombectomy
IA Thrombolysis
Push
Wire
Usable Length
53
Kesimpulan
• Stroke is TREATABLE !!
Terima Kasih
Semoga Bermanfaat