Definisi

Stroke is classically characterized as a neurological deficit attributed to an acute focal

injury of the central nervous system (CNS) by a vascular cause, including cerebral
infarction, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH), and is a
major cause of disability and death worldwide.(1)
Epidemiologi
The majority (approximately 80%) of strokes are ischemic, although the relative burden of
hemorrhagic versus ischemic stroke varies among different populations.(2)
There is evidence that a high proportion of hemorrhagic stroke, relative to ischemic stroke,
can be found in developing countries, where the burden of hypertensive disorders is
greater(2)
in hemorrhagic stroke patients, the incidence increases after the age of 45

Faktor resiko
The Framingham Stroke Profile (FSP)
The cooperative studies of the Veterans
Administration (see Freis et al) and the report
by Collins and associates (collating 14
randomized trials of antihypertensive drugs)
convincingly demonstrated that the long-term
control of hypertension decreased the
incidence of both ischemic infarction and
intracerebral hemorrhage
Risk factors for hemorrhagic and ischemic
stroke are similar, but there are some
notable differences; there are also differences
in risk factors among the etiologic categories
of ischemic stroke.
Estimating stroke risk based on an
individual’s particular combination of risk
factors, particularly for a first stroke event,
is an important component of primary care.
Patients indicate a preference for knowing
their stroke risk.12 Investigators have
therefore sought to create valid risk scoring
systems to identify those patients at greatest
risk for stroke, with the aim of both
modifying these risk factors to reduce the
risk of stroke and identifying thresholds of
risk that would indicate a role for
preventive therapies.13, 14 The Framingham
Stroke Risk Profile (FSRP), a continuously-
updated, well-known and widely used score, combines stroke predictors such as age, systolic
blood pressure, anti-hypertensive therapy, diabetes, cigarette smoking, left ventricular
hypertrophy by electrocardiogram, and the presence of cardiovascular disease (coronary heart
disease, peripheral vascular disease, congestive heart failure), and can be used to estimate 10
year stroke risk stratified by sex (Table 1)
The use of a risk assessment tool such as the AHA/ACC CV Risk Calculator
(http://my.americanheart.org/cvriskcalculator) is reasonable because these tools can help
identify individuals who could benefit from therapeutic interventions and who may not be
treated on the basis of any single risk factor. These calculators are useful to alert clinicians
and patients of possible risk, but basing treatment decisions on the results needs to be
considered in the context of the overall risk profile of the patient
The incidence of stroke increases with age, with the incidence doubling for each decade after
age
At young ages, women have as high or higher risk of stroke as men, though at older ages, the
relative risk is slightly higher for men
Genetic factors are also known to be non-modifiable risk factors for stroke with parental
history and family history increasing the risk of stroke.
In one study, a blood pressure(BP) of at least 160/90 mmHg and a history of hypertension were
considered equally importantpredispositions for stroke, with 54% of the stroke-affected population
having these characteristics

Weinberger and colleagues and Roehmholdt and coworkers found diabetic patients to be
twice as liable to stroke as age-matched nondiabetic groups . prognosis for diabetic
individuals after a stroke is worse than for non-diabeticpatients, including higher rates of severe
disability and slower recovery. stroke accounts for approximately 20% of deaths in diabetics.

As for embolic strokes, the most important risk factors are structural cardiac disease and
arrhythmias, mostly atrial fibrillation, which increases the incidence of stroke about 6-
fold, and by 18-fold if, as was common in the past, there is also rheumatic valvular disease. It
contributes to 15% of all strokes andproduces more severe disability and higher mortality than non-
AF-related strokes

Hiperlipidemia Total cholesterol is associated with risk of stroke, whereas high-density

lipoprotein(HDL) decreases stroke incidence

Klasifikasi
TIA = mini stroke, temporal occlusion, warning sign 
TIAs are typically referred to as mini-strokes with symptoms being
transient (i.e. lasting from minutes to hours but less than 24 hours)
Patofisiologi
Blood flow dibawa oleh 2 karotis internal di anterior dan 2 verterbal arteri di posterior.
Secara singkat stroke iskemik disebabkan oleh deficiensi suplai darah dan oksigen ke otak,
sementara SH disebabkan pendarahan atau kebocoran dari pembuluh darah di otak
Okliso iskemik disebabkan oleh trombotik (narrowing vessel due to atheroscleroisi) and
embolic condition
Cerebral infarction basically comprises two pathophysiologic processes: one,
a loss of the supply of oxygen and glucose secondary to vascular occlusion,
and the other, an array of changes in cellular metabolism consequent to the
collapse of energy-producing processes, ultimately with disintegration of cell
structures and their membranes, a process subsumed under the term necrosis
excitotoxicity, mitochondrial response, free radical release, protein misfolding,
and inflammatory changes,
CNS ischemia results in a deficiency of glucose and oxygen leading to the
inability of neuronal cells to maintain normal ionic gradients.
Depolarization of these neurons leads to excessive glutamate release
resulting in the intracellular influx of calcium, triggering cell death pathways
such as apoptosis, autophagocytosis, and necrotic pathways. mediated
largely through the glutamatergic pathways involving N-methyl-D-aspartate
receptors (NMDARs), α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid
receptors (AMPARs), and kainate receptors. The intracellular increase in
calcium triggers mitochondrial dysfunction and activation of free radicals,
phospholipases, and proteases, which lead to cell death or injury
The rapid influx of calcium experienced with excitoxicity leads to excess
accumulation in the mitochondria, causing dysfunction, which leads to
mitochondrial permeability transition pore (mtPTP) opening and cytochrome
c release. These events create mitochondrial swelling and membrane
collapse, initiating cell death cascades such as apoptosis
The influx of calcium triggers nitric oxide (NO) production by nitric oxide
synthase (NOS) that leads to injury through the formation of oxygen free
radicals and the production of peroxynitrite. Free radicals trigger the PI3-
kinase/Akt pathway as well as upregulate the transcription factor NF-κB. Not
only do free radicals contribute to initial toxicity, they also prevent recovery,
which makes them an important post-stroke therapeutic target
During ischemic injury, glial cells are damaged by similar injury pathways to
neurons including glutamate toxicity
An intricate cascade of immune cells and inflammatory factors cause blood-
brain barrier breakdown
SAH is predominantly caused by bleeding from an aneurym located along the circle of
Willis. The most common sites of cerebral aneurysms are shown in Figure 14-6
Manifestasi klinis
Pasien ini dikatakan hiperakut apabila masih berada dalam rentang waktu 6 jam
Manajemen pra-rumah sakit diawali dengan pengenalan gejala stroke, Dengan menggunakan
FAST (face, arm, speech, time), bawa secepatnya. , tindakan stabilisasi dan resusitasi
(airway, breathing, circulation / ABC), intubasi (perlu dipertimbangkan pada pasien dengan
koma yang dalam, hipoventilasi dan aspirasi), memposisikan pasien setengah duduk bila
kardiopulmoner stabil, memeriksa dan menilai gejala dan tanda stroke
Beberapa hal yang perlu diperhatikan oleh petugas (ambulans, perawat, medis) yang
membawa pasien stroke, diantaranya : a. Jangan terlambat membawa ke rumah sakit yang
mempunyai fasilitas pelayanan stroke. b. Cairan kristaloid yang diinfuskan hanya pada pasien
yang mengalami dehidrasi, pre-syok, maupun syok. c. Hindari pemberian cairan glukosa /
dekstrosa kecuali pada pasien hipoglikemia. d. Jangan menurunkan tekanan darah. Hindari
hipotensi, hipoventilasi, atau anoksia. (Catat waktu onset serangan). e. Manfaatkan
telemedisin melalui jaringan pelayanan stroke komprehensif yang tersedia, antara lain unit
gawat darurat, unit stroke atau ICU sebagai tempat tujuan penanganan definitif pasien stroke.
sistem ini mampu memprediksi risiko stroke dalam 2-90 hari pascaTIA melalui penjumlahan 5 faktor
independen
stroke merupakan penyakit kegawatdaruratan dimana tujuan dari perawatanya adalah untuk
menurunkan resiko disabilitas pasien dan meningkatkan kualitas hidupnya pasca kejadian stroke.
Sehingga penting untuk mengenali tanda tanda stroke dan membedakan jenis stroke