Code Stroke & Hyperacute Stroke Treatment
dr. Dedi Sutia, Sp.N(K), FINA, MARS
Subdivisi Neurovaskular - Neurosonologi - Neurointervensi
FK UNAND/RSUP DR M Djamil Padang
Why Important?
Code Stroke
A term used to prioritize the hyperacute
assessment and care of a patient presenting
with signs and symptoms concerning for stroke.
The word code brings forward a sense of
nuance with measured urgency without
compromising precision in diagnosing and
treating patients with stroke.
System
Commitment
Chalenges Budget
Public awareness
Sense of emergency
Komposisi Tim Code Stroke
Jam Kerja Di luar jam kerja
▪ GP IGD • GP IGD
▪ GP Unit Stroke • GP Jaga Unit Stroke
▪ Dokter Radiologi • Petugas Jaga Radiologi
▪ Perawat Mahir Stroke • Perawat Mahir Stroke
(Stroke Liaison Nurse)
▪ Spesialis Saraf (Stroke Liaison Nurse)
▪ Spesialis bedah saraf jika ada • Dokter Spesialis Saraf
▪ Spesialis Radiologi • Konsulen Jaga Radiologi
▪ Tim laboratorium • Tim laboratorium
▪ Tim cathlab/OK Hybrid • Tim cathlab/OK Hybrid
▪ Operator (yang memiliki nomor • Operator (yang memiliki nomor
hotline khusus) hotline khusus)
Aktivasi Code Stroke :
• GP di IGD akan mengontak operator hotline dan meminta untuk mengaktifkan CODE STROKE
• Operator hotline akan mengontak (sms dan telpon) nomor-nomor khusus
dari setiap anggota Tim CODE STROKE
Alur Layanan
Pasien dicurigai stroke
EKG
10 menit Triase IGD GDS (Stick)
Dokter Emergency Laboratorium
Activated Code Stroke
15 menit
Konsul Neurologi :
Anamnesis
pemeriksaan Fisik
Edukasi (Informed consent
20 menit
Brain CT scan Emergency
Cont
Cont’d
Brain CT scan Emergency
15 menit 3
0
m
IV Trombolisis 15 menit e
3 3 n
i
0 0 t
30 menit
m m
Ruang Operasi
e e
(Bedah Syaraf)
n Transfer ke Cathlab Emergency n
i (neurointervensi) i
t ✓ IA Trombolisis t
✓ Mechanical trombectomy
30 menit 30 menit
Rawat Bangsal / HCU
Rawat ICU (Intensive)
Neurologi
1
Ischemic Stroke
Classification of Ischemic Stroke
Miocard Infarct Cerebral Infarct
• STEMI • LVO
• Non STEMI • Non LVO
• UAP • TIA
Clinical score for LVO (large vessel occlusion):
Hemiplegia + one of afasia, neglect, visual disturbance
Unconsious
EKG
Darah Rutin
Examination Gula Darah
on ED Ureum / Kreatinin
PT/INR, aPTT
Brain CT Scan
CTA – CTP
Brain MRI
MRA-MRP
TCD – Carotid
DSA
ASPECT SCORE
≥ 8 (40% mRS 0-1 in 90
days)
IV thrombolysis if score
>8
Mechanical
thrombectomy in score≥ 6
Acute Ischemic Stroke Treatment Modality
Intravenous Thrombolysis
01 W/O Sonothrombolysis
02 Intraarterial thrombolysis
03 Mechanical trombectomy
04 Rescue stenting-angioplasty
Thrombolytic
Therapy
INTRAVENOUS • IV rtPA (Alteplase) dosis 0,6-0,9 mg/kg BB (max
THROMBOLYSIS 90 mg)
in 4,5 Hours • 10-15% innitial dose in 1 minute
Onset • The rest in 60 minute
Old New
Trans Cranial Doppler &
Carotid Duplex in Emergency
Setting
Diagnostic:
• bedsite, non invasive neurovascular imaging, without special preparation, realtime,
very fast.
• Pada stroke hiperakut di emergency unit, modalitas ini digunakan untuk mendeteksi
stroke akut dengan LVO, yg menentukan opsi penatalaksanaan stroke:
konservatif/invasif.
Therapeutic:
• Walaupun angka rekanalisasi IV trombolitik rendah pada kasus-kasus LVO, modalitas
TCD dapat digunakan sebagai ultrasound enhanced thrombolysis / sonothrombolysis
untuk membantu memecahkan trombus pada kasus-kasus stroke akut LVO dengan red
thrombus (thrombus lunak).
Role of TCD / TCCD in the hyperacute
stroke care pathway
NEUROSONOLOGY in EMERGENCY
Male 66Y, Decrease
consiousnes(somnolen) with right
hemiplegia onset 30 min, LV thrombus (+),
late onset Stemi (1 week)
IntraArterial
Thrombolytic
Recommendation
Case 39 Y Female, Post laparotomy, high D dimer (10.000), VSD
Right Hemiplegia, Global Aphasia followed by decreased of
consiousness, 5 Hours Onset
DSA: Total Oclussion Right rTPA 15mg/cc trans
MCA segment M2 microcatheter into left ICA
Mechanical
Thrombectomy
Recommendation
Mechanical Thrombectomy
Tindakan
dilakukan • Skor mRS prestroke 1
dengan sampai 2
• LVO
stent
retriever • Usia ≥18 tahun
• Terapi dapat dimulai
& aspiration
(puncture) dalam 6-24
catheter
jam setelah onset stroke
jika • Skor NIHSS ≥6
memenuhi • Skor ASPECTS ≥6
kriteria :
2304 patients screened for eligibility, 1604 patients were included
Case Male 39y, CA thyroid, AF, CHF with
low EF, Cardiogenic shock, CKD
stage II, Autoimmune disease, GCS
7-8, left hemiplegia, onset 3,5h
Case
Stroke on table
Female 48y, Late
onset Stemi on
PTCA, right
hemiplegia, onset
30 min, delirium,
Labile blood
pressure, High D-
Dimer(4000)
Case
51 Y Male, aphasia,
right hemiplegia,
followed by decrease
of consiousness in
10 Hour onset
Complicated case of Acute stroke
with Basilar artery Occlussion
• Mechanical thrombectomy
• Intraarterial thrombolysis Rescue treatment
• Rescue Balloon Angioplasty
2
Stroke Hemoragik
Hemorrhagic Stroke
Perdarahan
Intraserebral
Perdarahan
Subaraknoid
Problems :
Rebleeding, Hematoma, Hydrocephalus
Early
Triple H coiling (<72
hours)
VP shunt / EVD / Lumbar
Decompressive
Craniectomy Drainage
47 Y, Male, SHA, ICH, Hyndrochepalus, GCS 7.
Case VP Shunting + Mechanical thrombectomy + Aneurysm coiling
Dx. ICH + IVH + SAH ec aneurysm rupture (Acomm) narrow neck reccurent (3x)
Woman, 66Y, GCS 4, SAH with
communicans hydrochepalus
Thank You
Now… Stroke is Treatable
Case
51 Y Male, Hemineglect,
Left hemiplegia,
followed by decrease of
consiousness in
13 Hour onset
Male 68y, AF RVR, left
hemiplegia, GCS 8, onset 8h, High
D-Dimer(3300)
Balloon angioplasty in treatment symptomatic vasospasm in SAH
with intracranial balloon
