Stroke Management

in resource limited setting

Rusdi Lamsudin

Department of Neurology
Faculty of Medicine
Indonesia Islam University
Yogyakarta
Prof.Dr.dr. H. Rusdi Lamsudin, M.Med.Sc
Neurologist (Consultant)
Medical Doctor, Faculty of Medicine, UGM, 1971
Neurologist, Unair-UGM, 1978
Master of Medical Sciences, New Castle Univ, Australia,
1986
Head of Executive Board Muhammadiyah Hospital,
Yogyakarta, 1993-1999
Vice Dean, Faculty of Medicine Muhammadiyah
Yogyaakarta University, 1993-1999
PhD, UGM, 1996
Short-course, Unit Stroke & Neuro-Intensive, Insburck,
Austria,1997
Head of Stroke Unit, Sardjito Hospital, Yogyakarta, 2001-
2005
Head of Neurology Department Faculty of Medicine, UGM,
2001-2005
Dean of Faculty Medicine, Indonesia Islamic University,
Yogyakarta, 2001-2006, 2006-2010
References
1. Guidelines for stroke management; ESO Guideline 2015

2. Clinical Guidelines for acute stroke; Stroke Management

Suppl. National Stroke Foundation, Australia 2014

3. Clinical Guidelines; the diagnosis and acute stroke

management of stroke and transient ischemic attack. NICE
2013

4. Guidelines for early management adult with ischemic stroke.

AHA/ASA 2015

5. Canadian Best Practice. Recommendation for stroke care.

Recommendation 4, 2006; acute stroke management

6. Neurologic emergencies in resource-limited setting: A

review of Stroke care. Clinical Review 2014
 outlines
Background
Acute stroke management
Critical intervention
Investigation
Acute stroke management
Stroke Management
in resource limited setting
Conclusion
 Background
Nearly 60% of all deaths worldwide
are asssociated with chronic diseases
Heart disease
Cancer
Stroke

WHO: Chronic diseases and health promotion.

Internet. WHO.cited 2014 Feb 2015
 STROKE
Acute brain disorder of vascular origin accompanied by
neurological dysfunction that persists for longer than 24
hours
Stroke 1990

One death every 4 seconds in the US

Circulation 2013
 CLASSIFICATION
Ischemic Stroke 87%
80% thrombotic
20% embolic

Hemorrhagic Stroke 13%

97% intracerebral
3% subdural
 Ischemic Stroke
Occlusion (50%)
Large vessel (ICA)
Branch (MCA)
Perforator (lacunar)
Embolization (25%)
Intra/Extracranial
Cardiac
Cryptogenic (25%)
 Background
Stroke, the second leading cause of
death, accounted for 5.7 million
deaths in 2005
The vast mayority (>85%) of these
deaths occur in lower and
middleincome countries with one
third under of 70

Factsheed3.pdf. Internet[cited 2013 Dec]

Feigin etl al. Lancet Neurol 2009(4)355-69
 Background
Current models of care for acute neurologic emergencies
are time sensitive and resource dependent.

Established global guidelines require prompt recognition

od symptoms, immediate transportation to an
emergency center, emergent brain imaging, laboratory
testing, and prompt thrombolytic interventions when
appropriate

Stroke guidelines primarily emanate from developed

systems with comprehensive stroke services limiting
uniform adoption in less austere settings.
 Critical Intervention
ABCs
Initial History and Physical (H&P)
Neurologic evaluation
 Investigation
Noncontrast brain CT (or MRI)
Serum glucose (bedside testing
recommended)
Oxygen saturation
ECG
Complete blood count including platelets
Basic metabolic panel
Coagulation studies
 Acute Stroke Management
Thrombolytics
Fluids
Hypoglycemia
Hyperglycemia
Swallowing assessment
Head and body position
Fever
Anticoagulation reversal in haemorrhagic strokes
Blood pressure management
Stroke Unit Care
 Stroke Management
in resource limited setting
No advanced imaging available
No antihypertensive medication
available
No thrombolytics available
No Stroke Unit available
No reversal agents available
 Stroke Management
in resource limited setting
No advanced imaging available
CT-Scanner is not available
DD acute stroke vs stroke mimics
Rosier Scale
Nor et al, Lancet Neurol 2005;4:727-34

DD acute ischemic/infarct stroke vs

hemorhage stroke
Gadjah Mada Stroke Algorithm
Lamsudin R, Berkala Ilmu Kedokteran, Des
1996, vol 28, no 4
 Early Management of CVA
5 suddens.weakness, speech,
visual loss, headache, dizziness

FASTface, arm, speech, time

http://mmcneuro.files.wordpress.com/2013/01/stroke.gif
 Rosier Scale
Has there been loss of consciousness or syncope?
y(-1) [ ] n(0) [ ]

Has there been seizure activity? y(-1) [ ] n(0) [ ]

Is there a new acute onset (or on awakening from sleep)?

I. Asymmetric facial weakness y(+1) [ ] n(0) [ ]
II. Asymmetric arm weakness y(+1) [ ] n(0) [ ]
III. Asymmetric leg weakness y(+1) [ ] n(0) [ ]
IV. Speech disturbance y(+1) [ ] n(0) [ ]
V. Visual field defect y(+1) [ ] n(0) [ ]

Total Score ---(-2 to +5)

Rosier score of one or more suggest a stroke. A score of zero or less
indicates a stroke is unlikely but not completely excluded
 Algoritma Stroke Gadjah
Mada
1. Penurunan Kesadaran
2. Nyeri kepala
3. Refleks Babinski

1 (+) ,2 (+) , 3 (+) : Stroke perdarahan

1 (+), 2 (+) , 3 (-) : stroke perdarahan
1 (+), 2 (-), 3 (+) : stroke perdarahan
1 (-) , 2 (+), 3 (+) : stroke perdarahan
1 (+) , 2 (-), 3 (-) : stroke perdarahan
1 (-), 2 (+), 3 (-) : stroke perdarahan
1 (-), 2 (-), 3 (+) : stroke infark
1 (-), 2(-), 3 (-) ; stroke infark
1 (-), 2 (-), 3 (-) : stroke infark
 Stroke Management
in resource limited setting
No antihypertensive medication available

In the absence of ant IV antihypertensive medications,

benzodiazepines may be utilize to decrease the
sympathomimetic response to stroke based on the GABA-
agonist mechanism of them.

Care must be taken as these will decrease the respiratory

rate (hypercapnea) in the patient.

They should also be used judiciously with the elderly since

they may contribute to delirium and hence, mortality.
 Stroke Management
in resource limited setting
No thrombolytics available

Without thrombolytics, this treatment therapy (and secondary

prevention) would revert to antiplatelet therapy (aspirin 160-
325mg d risk of which may reduce the risk of early ischemic stroke
without major risk of early hemorrhagic complications.

Dual anti-platelet therapy, such as aspirin in addition to clopidogrel,

has not yet been established as standard of care in acute stroke
and is therefore not recommended (AHA/ASA Guidelines)

Otherthrombotics such as heparin and low molecular heparin are

not recommended.
 Stroke Management
in resource limited setting

No Stroke Unit available

The severity of stroke and the need for
additional resources, such as specialized
rehabilation (speech, swallowing, etc) should
guideof the decision the decision transfer.

In the case utilizing thrombolytics, the need

for continued BP control, or interventional
management, transfer may be essential.
 Summary
The fundamental goals for acute stroke care include
medical stability, identification of thrombolytic
candidates (if utilized), identification and reversal of
contributing condition, and coordinated transition of care
to a multidisciplinary stroke team to further identify the
pathophysiologic basis or the neurologic symptoms.

While further research is required to define evidence-

based outcomes when resources are limited, the
following represent foundational essentials for acute
stroke evaluation and care based on current best
practices and should serve as template for optimal care
based on available resources:
 Summary
Ensuring stabilization od the ABCs.

Prompt but accurate History and Physical (H&P)to

refine the differential diagnosis of the acute
neurological emergencies, specifically screening
for stroke mimics or other reversible pathology.

Obtaining emergent brain imaging and other

important laboratory studies. If no imaging
modality is available, recommendations are
limited to supportive care and transfer if possible.
 Summary
Lytic intervention when indicated. If none
available, early aspirin therapy for secondary
prevention should be implemented if the
stroke is ischemic.

Managing electrolyte disturbances while

maintaining euvolemia and euglycemia.

Assess swallowing and implement aspiration

prevention including head of bed positioning.
 Summary
Blood pressure management depending on the
type of stroke.

Consider infectious sources of fever and work

to maintain normothermia using methods such
as antipyretics and external cooling.

Establish a stroke protocol following the best

evidence-based practices, resources available
and coordinated with the nearest stroke center