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    Dr. Trunojoyo, SPS Stroke - The Rational Management of Stroke PDF

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    rizkhameilia
    Stroke is the leading cause of disability in Indonesia. Current treatments for ischemic stroke include intravenous thrombolysis (IVT) and thrombectomy, both of which must be administered within narrow time windows. IVT involves administering the clot-busting drug alteplase within 4.5 hours of symptom onset, while thrombectomy uses stent retrievers to mechanically remove clots and must be performed within 8 hours. Post-stroke care focuses on managing vascular cognitive impairment and its risk factors through exercise, blood pressure control, and medications like statins, blood thinners, and pentoxifylline.

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    Dr. Trunojoyo, SPS Stroke - The Rational Management of Stroke PDF

    Uploaded by

    rizkhameilia
    62 views37 pages
    Stroke is the leading cause of disability in Indonesia. Current treatments for ischemic stroke include intravenous thrombolysis (IVT) and thrombectomy, both of which must be administered within narrow time windows. IVT involves administering the clot-busting drug alteplase within 4.5 hours of symptom onset, while thrombectomy uses stent retrievers to mechanically remove clots and must be performed within 8 hours. Post-stroke care focuses on managing vascular cognitive impairment and its risk factors through exercise, blood pressure control, and medications like statins, blood thinners, and pentoxifylline.

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    Stroke is the leading cause of disability in Indonesia. Current treatments for ischemic stroke include intravenous thrombolysis (IVT) and thrombectomy, both of which must be administered within narrow time windows. IVT involves administering the clot-busting drug alteplase within 4.5 hours of symptom onset, while thrombectomy uses stent retrievers to mechanically remove clots and must be performed within 8 hours. Post-stroke care focuses on managing vascular cognitive impairment and its risk factors through exercise, blood pressure control, and medications like statins, blood thinners, and pentoxifylline.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    62 views37 pages

    Dr. Trunojoyo, SPS Stroke - The Rational Management of Stroke PDF

    Uploaded by

    rizkhameilia
    Stroke is the leading cause of disability in Indonesia. Current treatments for ischemic stroke include intravenous thrombolysis (IVT) and thrombectomy, both of which must be administered within narrow time windows. IVT involves administering the clot-busting drug alteplase within 4.5 hours of symptom onset, while thrombectomy uses stent retrievers to mechanically remove clots and must be performed within 8 hours. Post-stroke care focuses on managing vascular cognitive impairment and its risk factors through exercise, blood pressure control, and medications like statins, blood thinners, and pentoxifylline.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 37

    Rational Management of Stroke

    Trunojoyo S
    RiNDU, November’18
    Introduction
    • Stroke → no.1 cause of disability

    • Stroke in Indonesia → no.1 cause of mortality


    – Indonesia : 193.3 /100,000
    – Malaysia : 84.3 /100,000
    – Japan : 43.4 /100,000

    • Stroke is treatable…
    – Current stroke treatment is time-limited.
    Stroke Overview
    Clinical Presentation
    Stroke Awareness Campaign
    Risk Factors
    Types of Stroke

    20% 80%
    Diagnostic Modalities
    • CT scan
    – in hyperacute stroke: to rule out bleeding
    • MRI
    – most sensitive for ischemic
    – time consuming
    • DSA
    – gold standard for vascular evaluation
    – invasive procedure.
    DSA
    (Digital Subtraction Angiography)

    → Endovascular procedure…
    • To evaluate brain vessels
    • To analyse intracranial circulation.
    DSA
    (Digital Subtraction Angiography)
    DSA: Carotid and VertebroBasilar
    Acute Stroke Management
    Plaque Thrombosis
    Patophysiology of Brain Ischemia
    Treatment for Hyperacute Ischemic Stroke

    Modality options :

    A. Intravenous Thrombolysis (IVT)

    B. Thrombectomy
    Treatment for Hyperacute Ischemic Stroke

    Modality options :

    A. Intravenous Thrombolysis (IVT)

    B. Thrombectomy
    Trombolisis
    Pengobatan Trombolisis :
    • Obat pengencer darah
    • Berbentuk cairan infus
    • Butuh persiapan khusus, ± 1 jam.

    Syarat Trombolisis :
    • Harus diberikan dalam waktu < 4,5 jam
    – Terhitung sejak mulai terjadi gejala stroke
    • Pasien tiba di RS dalam waktu < 3 jam.
    Alteplase (rt-PA)
    Clinical Trials of IVT
    Recommendation for IVT
    Recom for Extended-time IVT
    Candidate patient for IVT :
    • Onset within 3-4.5 hour
    • NIHSS score 4-25
    Alteplase (rt-PA)
    • Standard dose: Alteplase 0.9 mg/kg
    – 10% bolus, 90% infuse 60min
    • For Asian population → 0.6 mg/kg
    – Non-inferior efficacy
    – Lower bleeding risk
    Contraindication to Thrombolysis
    Treatment for Hyperacute Ischemic Stroke

    Modality options :

    A. Intravenous Thrombolysis (IVT)

    B. Thrombectomy
    Thrombectomy Devices

    2008

    2004

    2012
    Trombektomi
    Prosedur Trombektomi :
    • Dilakukan di ruang CathLab
    • Menggunakan stent-retriever
    • Butuh persiapan khusus, ± 2 jam.

    Syarat Trombektomi :
    • Dilakukan dalam waktu < 8 jam
    – Terhitung sejak mulai terjadi gejala stroke
    • Pasien tiba di RS dalam waktu < 6 jam.
    Clinical Trials of Thrombectomy
    Trials of Extended-time Thrombectomy
    Recommendation for Thrombectomy
    Advantage of Thrombectomy:
    → Lower bleeding risk.
    Case: Pre- dan Post Thrombectomy
    Post Stroke
    Post Stroke:
    Vascular Cognitive Impairment (1)
    Typical VCI syndromes include:
    • Slow thinking
    • Difficulty switching attention
    • Judgement decline
    • Continuously low mood and mood swings
    • Gait apraxia:
    – Slow, short and uneven steps
    – Difficulty in the start of movements
    – Instability during turns and
    – Increased breadth of stance.
    Post Stroke:
    Vascular Cognitive Impairment (2)
    Treatment of VCI:
    • General:
    – Regular physical exercises
    – Normalization of BP
    – Statins (if atherosclerotic lesion is assumed)
    – Blood thinner
    • Antiplatelet (ASA, clopidogrel)
    • Warfarin or NOAC (apixaban, dabigatran, rivaroxaban)
    • PDE3 inhibitors
    – Pentoxifylline, cilostazol, triflusal.
    Post Stroke:
    Vascular Cognitive Impairment (3)
    Pentoxifylline (Trental)
    • Therapeutic doses: 400 mg, three times daily
    – Increase cAMP
    • Improves the rheological properties of the blood
    – reduces viscosity (due to decreased fibrinogen)
    – increases the elasticity of erythrocytes
    – reduces platelets aggregation
    • Protective effect on endothelium and blood-brain
    barrier
    – inhibit the synthesis of pro-inflammatory cytokines
    – inhibit the atherosclerotic process.
    Conclusion
    • Time is Brain
    – Time Lost is Brain Lost

    • Current stroke treatment modalities:


    – Intravenous Thrombolysis
    – Thrombectomy.

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