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Curriculum Vitae

Dr. Mursyid Bustami, SpS(K), KIC.


Riwayat Pendidikan
Dokter : FK UGM Yogyakarta, th 1987.
Spesialis Saraf : FKUI Jakarta, th 2000.
Intensivist : Program Pendidikan KIC, Kolegium Anestesiologi
dan Reanimasi Indonesia, th 2003 2005.
Fellow : Neurosonology dan Stroke, NCVC, Osaka, Japan, th
2002.
Konsultan Neurotrauma dan Neuroemergensi, PERDOSSI, th
2007.
Kajian Administrasi Rumah Sakit, FKMUI Jakarta 2014.

Pekerjaan
Dirut RS. Pusat Otak Nasional, Jakarta.

Update in Management
of TIA and Stroke Patient
Mursyid Bustami
RS. Pusat Otak Nasional
Jakarta

Background
Stroke is the most important cause of
morbidity and long term disability1
Demographic changes are likely to result in an
increase in both incidence and prevalence
Stroke is also the 2nd most common cause of
dementia, the most frequent cause of
epilepsy in the elderly, and a frequent cause
of depression2,3
1. Lopez AD et al. Lancet (2006) 367:1747-1757
2. Rothwell PM et al. Lancet (2005) 366:1773-1783
3. O'Brien JT et al. Lancet Neurol (2003) 2:89-98

Proporsi Penyebab Kematian pada group 45-54 Tahun


menurut Tipe Daerah, RISKESDAS 2007
No Pedesaan (n=252)

Perkotaan (n=259)

Stroke

15,3

TB

12,3

Diabetes mellitus

14,7

11,5

Penyakit Jantung Iskemi

8,7

Stroke
Hipertensi

7,9

Penyakit Jantung Iskemi

8,8

TB
Hipertensi

7,1

Penyakit Hati

8,5

Penyakit Jantung lainnya

7,1

Diabetes mellitus

5,8

Penyakit Hati

6,3

Cancer (paru-paru, hati,


payudara, rahim, prostat)

4,4

Kecelakaan

5,2

Ulcus pepticum

4,2

Kanker (Breast, cervic,


uterus)

4,8

Penyakit Kronik infeksi Saluran


nafas Bawah

4,2

10

Penyakit Kronik infeksi


Saluran nafas Bawah

3,2

Tifoid

3,8

9,2

Proporsi Penyebab Kematian pada goup


55-64 tahun menurut Tipe Daerah, Riskesdas 2007
No

Pedesaan (n=295)

Perkotaan (n=337)

Stroke

26,8

Stroke

17,4

Hipertensi

8,1

Hipertensi

11,4

TB

7,1

TB

10,5

Penyakit hati

6,1

Penyakit hati

8,4

Penyakit jantung iskemik

5,8

Penyakit lain

6,0

Penyakit saluran pernafasan


bawah kronik

5,1

Penyakit jantung iskemik

5,7

Penyakit jantung lain

4,7

Penyakit jantung lain

5,1

NEC

3,4

Penyakit saluran pernafasan bawah


kronik

4,8

Tumor ganas (hati, paruparu, leher rahim,


payudara, rahim, prostat)

3,2

Tumor ganas (hati, paru-paru, leher


rahim, payudara, rahim, prostat)

3,9

10

Penyakit lain

2,7

NEC

3,3

5
Riskesdas Depkes 2008

RISKESDAS
2013

Stroke Type
Hemorrhagic stroke

Ischemic stroke
Lacunar small vessel
disease (25%)

Intracerebral
hemorrhage (59%)
Atherothrombotic
disease (20%)

SAH (41%)
Embolism (20%)

Albers GW et al. Chest. 1998;114:683S-698S.


Rosamond WD et al. Stroke. 1999;30:736-743.

Cryptogenic (30%)

Incidence of Ischemic vs Hemorrhagic


Stroke and Rates of Death within 30 d.
The majority of strokes are ischemic
Hemorrhagic stroke

Ischemic stroke
40

12%
88%

30-day mortality (%)

36%-37%

30
20
10

8%-12%

Incidence
American Heart Association Heart Disease and Stroke Statistics2005 Update.

Mortality

Emergency Management of Stroke

10

Emergency Management
The time window for treatment of patients with
acute stroke is narrow
T ime is the most important factor

11

Emergency Management
The initial examination should include
Observation of breathing and pulmonary function and
concomitant heart disease
Assessment of BP and HR
Determination of SaO2
Blood samples for clinical chemistry, coagulation and
haematology studies
Observation of early signs of dysphagia
Targeted neurological examination
Careful medical history focussing on risk factors for
arteriosclerosis and cardiac disease

12

Ancillary Diagnostic Tests


In all patients
Non contrast head CT/MRI
ECG
Laboratory Tests
Haematology (RBC, WBC, platelet count)
Basic clotting parameters
Electrolytes
RFT
Blood Glucose

13

Ancillary Diagnostic Tests


In selected patients
Duplex / Doppler ultrasound
MRA or CTA
Diffusion and perfusion MR or perfusion CT
Echocardiography, Chest X-ray
Pulse oximetry and BGA
LP
EEG
Toxicology screen

14

Emergency Diagnostic Tests


Differentiate between different types of stroke
Provide a basis for physiological monitoring of the
stroke patient
Identify concurrent diseases or complications
associated with stroke
Rule out other brain diseases

15

General Stroke Treatment


Monitoring
Pulmonary and airway care
Fluid balance
Blood pressure
Glucose metabolism
Body temperature

16

Monitoring
Continuous monitoring (24 hours)
HR
RR
SaO2

Discontinuous/intermitten monitoring
BP
Blood glucose
Vigilance (GCS), pupils
Neurological status (e.g. NIHSS or Scandinavian stroke
scale)

17

Pulmonary Function
Adequate O2 is important
Administration O2 for the hypoxic patients, target
SaO2 >94%.
Risk for aspiration in patients with side positioning
Hypoventilation may be caused by pathological
respiration pattern
Risk of airway obstruction (vomiting, oropharyngeal
muscular hypotonia): mechanical airway
protection

18

Blood Pressure
Elevated in most patients with acute stroke
BP drops spontaneously during the first days after
stroke
Blood flow in the critical penumbra passively
dependent on the MAP
There are no adequately sized randomised,
controlled studies guiding BP management
Avoid and treat hypotension, hypovolemia
should be corrected with IV normal saline

19

Hypertension in Acute Ischemic Stroke1


Decreasing BP in certain conditions
Acute ischemic stroke *):
SBP >220 ; DBP > 120 (Class I, Level of evidence C)

rtPA candidate **):


SBP >185 ; DBP > 110 (Class I, Level of evidence B)

Acute Ischemic Stroke with hypertension :


Hypertensive encephalopathy; Aortic dissection; Acute
MCI; Acute lung edema; ARF

Goal is to lower blood pressure by 15% during the


first 24 hours after onset of stroke.
1. AHA/ASA Guideline, Stroke 2013;44:870-947

20

Hypertension in Hemorrhagic Stroke1


Decreasing BP in certain conditions
SBP >200 mmHg or MAP >150 mmHg aggressive reduction of BP
with cont. i.v., BP monitoring every 5.
SBP >180 mmHg or MAP >130 mmHg and elevated ICP
monitoring ICP and reducing BP using intermittent or cont. i.v. to
keep CPP > 60 - 80 mmHg.
SBP >180 mmHg or MAP >130 mmHg and no elevated ICP
modest reduction of BP (eg, MAP of 110 mmHg or target BP of
160/90 mmHg) using intermittent or cont. i.v. medications to
control BP, and clinically reexamine the patient every 15.
For ICH patients with SBP between 150 and 220 mm Hg who lack
contraindications to BP lowering, decreasing SBP to <140 mm Hg is
safe (Class I, Level A) and can improve functional outcome (Class
IIa, Level B).

1. ASA Guideline. Stroke. 2015;38: 2001-2023.

21

Glucose Metabolism
High glucose levels in acute stroke may increase
the size of the infarction and reduce functional
outcome
Hypoglycemia can mimic acute ischaemic
infarction
It is common practise to treat hyperglycemia with
insulin when blood glucose exceeds 140-80mg/dl1

1. AHA/ASA Guideline, Stroke 2013;44:870-947

22

Body Temperature
Fever is associated with poorer neurological
outcome after stroke
Fever increases infarct size in experimental
stroke
Many patients with acute stroke develop a
febrile infection
It is common practice treat fever (and its
cause) when the temperature reaches 38C

23

Specific Stroke Treatment

Thrombolytic therapy
Early antithrombotic treatment
Treatment of elevated intracranial pressure
Prevention and management of complications

24

Thrombolytic
Therapy
(NINDS1, ECASS III, ATLANTIS4)

I.v. rtPA (0.9mg/kg, max 90mg) given within 3-4.5


hours of stroke onset, significantly improves
outcome in patients with acute ischemic stroke
Exclution criteria:
patients older than 80 years,
those taking oral anticoagulants, even with INR 1.7 ,
those with a baseline NIHSS > 25, or
those with both a history of both stroke and diabetes, the
effectiveness of IV treatment with rtPA is not wellestablished, and requires further study.
1.
2.
3.
4.
5.

NINDS rt-PA Grp: New Engl J Med (1995) 333:1581-1587


Hacke W et al.: JAMA (1995) 274:1017-1025
Hacke W et al.: Lancet (1998) 352:1245-1251
Clark WM et al.: Jama (1999) 282:2019-26.
AHA/ASA Guideline, Stroke 2013;44:870-947

25

Thrombolytic Therapy
Factors associated with increased bleeding risk1
elevated serum glucose
history of diabetes
baseline symptom severity
advanced age
increased time to treatment
previous aspirin use
history of CHF
NINDS protocol violations
1. Lansberg MG et al.: Stroke (2007) 38:2275-8

26

Antiplatelet therapy
Aspirin was tested in large RCTs in acute (<48 h)
stroke1,2
Significant reduction was seen in death and
dependency (NNT 70) and recurrence of stroke
(NNT 140)
A phase 3 trial for the glycoprotein-IIb-IIIa
antagonist abciximab was stopped prematurely
because of an increased rate of bleeding3
1. International-Stroke-Trial: Lancet (1997) 349:1569-1581
2. CAST-Collaborative-Group: Lancet (1997) 349:1641-1649
3. Adams HP, Jr. et al.: Stroke (2007)

27

Anticoagulation
UFH
No formal trial available testing standard i.v. heparin
IST showed no net benefit for s.c. heparin treated
patients because of increased risk of ICH1

LMWH
No benefit on stroke outcome for low molecular
heparin (nadroparin, certoparin, tinzaparin,
dalteparin)

Heparinoid
TOAST trial neutral2
1. International-Stroke-Trial: Lancet (1997) 349:1569-1581
2. TOAST Investigators: JAMA (1998) 279:1265-72.

28

Neuroprotection
No adequately sized trial has yet shown
significant effect in predefined endpoints for any
neuroprotective substance
A meta-analysis has suggested a mild benefit for
citocoline1

1. Davalos A et al.: Stroke (2002) 33:2850-7

29

Elevated ICP
Basic management
Head elevation up to 30
Pain relief and sedation
Osmotic agents (mannitol, hypertonic saline)
Ventilatory support
Barbiturates, hyperventilation
Achieve normothermia

Hypothermia may reduce mortality1


1. Steiner T et al.: Neurology (2001) 57(Suppl 2):S61-8.

30

Management of Complications
Aspiration and pneumonia
Bacterial pneumonia is one of the most important
complications in stroke patients1
Preventive strategies
Withhold oral feeding until demonstration of intact
swallowing, preferable using a standardized test
Nasogastric (NG) or percutaneous enteral gastrostomy
(PEG)
Frequent changes of the patients position in bed and
pulmonary physical therapy
1. Weimar C et al.: Eur Neurol (2002) 48:133-40

31

Management of Complications
Urinary tract infections (UTI)
Most hospital-acquired UTI are associated
with the use of indwelling catheters1
Intermittent catheterization does not reduce
the risk of infection
If urinary infection is diagnosed, appropriate
antibiotics should be chosen following basic
medical principles

1. Gerberding JL: Ann Intern Med (2002) 137:665-70c

32

Management of Complications
DVT and PE
Risk might be reduced by good hydration
and early mobilization
Low-dose LMWH reduces the incidence of
both DVT (OR 0.34) and PE (OR 0.36),
without a significantly increased risk of
intracerebral (OR 1.39) or extracerebelar
haemorrhage (OR 1.44)1,2

1. Diener HC et al.: Stroke (2006) 37:139-44


2. Sherman DG et al.: Lancet (2007) 369:1347-55

33

Management of Complications
Pressure ulcer
Use of support surfaces, frequent repositioning,
optimizing nutritional status, and moisturizing
sacral skin are appropriate preventive strategies1

Seizures
Prophylactic anticonvulsive treatment is not
beneficial

Agitation
Causal treatment must precede any type of
sedation or antipsychotic treatment
1. Reddy M et al.: JAMA (2006) 296:974-84

Transient Ischemic Attack

Mini Stroke
TIA Mild Stroke.
Mild Stroke:
Initial NIHSS 3 or,
mRS 1 month after stroke 2

TIA is warning stroke


The incidence of subsequent stroke is as high as 11%
over the next 7 days and 24-29% over the following 5
years.

Causes of transient focal neurological


attacks

TIA
Migraine with aura
Partial epileptic seizures
Structural intracranial lesions: tumor, chronic SDH, vascular
malformation, giant aneurysm
MS
Labyrinthine disorders: Menieres disease or benign positional
vertigo
Peripheral nerve or root lesion
Metabolic: hypo- or hyperglycemia, hypercalcemia, hyponatremia
Psychological

Mechanism of Ischemia
Ischemia

Arterial Stenosis

Severely stenosis
Occluded artery
in the neck

Antihypertensiv
e medication
Vasodilators

Cervical osteophytes

Low
Flow

BP

Atypical symptom
Dystonic
posturing (arm,
leg)
Monocular/
binocular visual
abnormality

After standing sitting quickly


After heavy meal or hot bath
On exercise
During cardiac arrhythmia

Intermittent obstruction of
vertebral artery

Focal
brainstem
ischemia

Management of TIA
The patients should be hospitalized (esp. ABCD2 score
>2).
Explored the risk factor (TCD, CT Angio, MRI/MRA, ECG,
Hematology, etc) (Class I, A)
Noninvasive imaging of the cervical vessels. (Class I, A).
Risk factor management.
Life style modification.
Antiplatelet (or anticoagulant).
1. AHA/ASA Guideline, Stroke 2013;44:870-947

ABCD2 Score for TIA

40

Thanks