Curiculum vitae
1. Lulus sebagai dokter umun di universitas
Brawijaya tahun 1993
2. Lulus sebagai dokter spesialis saraf di universitas
Diponegoro tahun 2009
3. Saat ini bekerja di RS AWS samarinda dan sebagai
dokter pendidik klinis di FK UNMUL
Hyper-acute Phase
dr Susilo Siswonoto Sp.N
Code Stroke
Suatu sistem layanan stroke akut yang timnya terdiri dari staf bidang stroke, dihubungkan lewat
SMS dan/atau telpon yang diaktivasi di IGD via single call (ke operator), dan memiliki target
untuk memberikan terapi definitif stroke di fase hiperakut akut.
Code Stroke teams increase thrombolysis rate and decrease DTN times
How To Perform Code Stroke in J Leimena Hospital
Treatment strategies
GOAL: A RAPID VESSEL RECANALISATION WITH SUBSEQUENT RESTORATION OF
BLOOD PERFUSION INTO THE ISCHAEMIC AREA AIMING TO SALVAGE THE
PENUMBRA (PORTION OF VIABLE TISSUE SURROUNDING THE INFARCTED CORE).
SYSTEMIC REPERFUSION THERAPIES:
NO EVIDENCE OF BLEEDING
ENDOVASCULAR TREATMENT
INTRA-ARTERIAL
INTRA-ARTERIAL (IA)
(IA) THROMBOLYTICS ADMINISTRATION
THROMBOLYTICS ADMINISTRATION
MECHANICAL
MECHANICAL THROMBECTOMY WITH
THROMBECTOMY WITHMEDICAL
MEDICALDEVICES
DEVICES
Phases of acute stroke treatment
TREATMENT OF ACUTE STROKE PATIENTS CAN BE DIVIDED INTO THREE PHASES
HYPER ACUTE TREATMENT
AIMED AT STABILIZING THE PATIENT AND/OR REMOVING
THE BLOOD CLOT TO PREVENT DEATH AND DISABILITY
CAUSED BY THE ACUTE STROKE
ACUTE TREATMENT
AIMED AT PREVENTING OTHER CAUSES OF DEATH IN THE
FIRST 24 HOURS
POST-ACUTE TREATMENT
AIMED AT PREVENTING RECURRENT STROKE AS WELL
AS OTHER CAUSES OF DEATH AND DISABILITY FROM
24 HOURS ONWARDS
Phase 1: Hyper acute treatment
THE ONLY LABORATORY
THE PRIORITY IN THIS PHASE
RESULTS REQUIRED IN ALL
IS TO SALVAGE THE
PATIENTS BEFORE
REMAINING PENUMBRA BY
FIBRINOLYTIC THERAPY IS
RECANALYZING THE
INITIATED IS A GLUCOSE
BLOCKED ARTERY IN
DETERMINATION AND INR;
ISCHEMIC STROKE OR TO
USE OF FINGER-STICK
REDUCE THE PRESSURE IN
MEASUREMENT DEVICES IS
HEMORRHAGIC STROKE
ACCEPTABLE
Acad Emerg Med. 1997 Oct;4(10):986-90.
European Stroke Organization guidelines 2008. Cerebrovasc Dis 2008;25(5):457-507.
Every second counts1
Cerebral blood flow pattern after middle cerebral artery occlusion
• The penumbra is
Infarct moderately
Penumbra ischaemic tissue
that may remain
salvageable for
several hours if
reperfusion
takes place1,2
Onset of stroke:
death of brain cells within minutes1
Thrombolysis needs to be given as early as possible to prevent the
conversion of potentially viable brain tissue in the penumbra from
becoming completely ischaemic and dying
1. Saver J. Stroke 2006;37:263-266.
2. Moustafa RR, Baron JC. Br J Pharmacol 2008;153:S44-S54.
Time is Brain Tissue1
Areas of ischaemia following middle cerebral artery occlusion before (left) and after (right)
reperfusion
Ischaemic core
(brain tissue
destined to die)2
Penumbra
(salvageable
brain area)2
An untreated patient loses
Reperfusion offers the potential
approximately 1.9 million neurons every
to reduce the extent of ischaemic injury3
minute in the ischaemic area1
Adapted from:
1. Saver J. Stroke 2006;37:263-266.
2. González RG. Am J Neuroradiol 2006;27:728-735.
3. Donnan G, Davis S. Lancet 2002;1:417-425.
Actilyse
ACTILYSE (ALTEPLASE, RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR,
RT-PA) IS A FIBRINOLYTIC, OR THROMBOLYTIC AGENT DESIGNED TO
DISSOLVE THE OCCLUSIVE BLOOD CLOTS (THROMBI) THAT CAN FORM IN
CORONARY AND CEREBRAL BLOOD VESSELS.
IS THE ONLY RECOMMENDED INTRAVENOUS THROMBOLYTIC FOR THE
TREATMENT OF AN ACUTE ISCHAEMIC STROKE.
IT IS INDICATED FOR THROMBOLYTIC TREATMENT IN THE FOLLOWING CONDITIONS:
ACUTE ISCHAEMIC STROKE
ACUTE MYOCARDIAL INFARCTION
ACUTE MASSIVE PULMONARY EMBOLISM
Red thrombi
Evidence - Based Guidelines of
Stroke Thrombolysis
I.V. rt-PA (0.9 mg/kg body weight, max. 90 mg), with 10% of the dose given as a
bolus followed by a 60-minute infusion, is recommended within 4.5 hours of
onset of ischaemic stroke (Class I, Level A)
ESO Guidelines 2021
Intravenous rt-PA is recommended for selected patients who may be treated
within 3 hours of onset of ischemic stroke (Class I Level A)
IV rt-PA should be administered to eligible patients who can be treated in the
time period of 3 to 4.5 hours after stroke (Class I Level B)
AHA/ASA Guideline 2019
Alteplase direkomendasikan pada stroke iskemik, onset pemberian trombolisis
direkomedasikan adalah ≤4,5 jam atau ≤6 jam (bukan wake up stroke) pada jalur
intravena dengan sirkulasi anterior
(PNPK Stroke 2019)
Pathway optimization to achieve
DTN < 60 min
Stroke patients pathway
DELIVERY DIRECTLY TO CT
SCANNER
STROKE PHYSICIAN EMERGENCY NURSE
“POINT OF CARE” BLOOD TESTS
VITAL SIGNS (INR, GLUCOSE)
MEDICAL HISTORY COMPLETE BLOOD TESTS, HB,
STRICT DOCUMENTATION
SHORT NEUROLOGICAL EXAM (NIHSS) ELECTROLYTE PANEL
AND CONSTANT REVIEW
(AVAILABLE DURING THROMBOLYSIS) OF DOOR-TO-NEEDLE
TIMES
MEDIAN DOOR-TO-
NEEDLE TIME 25 MIN
CT (LOCATED DIRECTLY AT ER)
IMMEDIATE READING OF CT
24/7 NEUROLOGICAL COVERAGE
START THROMBOLYSIS IN THE
CT-SCANNER
Köhrmann M., Schellinger P. et al, Avoiding in hospital delays and eliminating the three-hour effect in thrombolysis for stroke
International Journal of Stroke 6(6):493-7 February 2011.
4 Key actions to reduce DTN Time
1. AMBULANCE
2. DIRECT TO 4. TREAT AT CT
PRE- 3. POC TESTING
CT
NOTIFICATION
Pre- Notification
1. Pre-notification
BENEFITS HOW?
ALERT STROKE TEAM STROKE PHONE IN HOSPITAL
REDUCES IN-HOSPITAL DELAY HOSPITAL BUSINESS CARD IN AMBULANCES
STROKE TEAM PRESENT ON PATIENT
ARRIVAL AT THE DOOR
COLLECT RELEVANT INFO
(EMERGENCY RESPONSE TEAM FORM)
NOTIFY HOSPITAL OF PENDING STROKE
PATIENT ARRIVAL
Delivery Direct to CT
2. Direct to CT
BENEFITS HOW?
REDUCES IN-HOSPITAL DELAY PREHOSPITAL STROKE PROTOCOL BYPASSES THE ED: PATIENT
SHOULD BE MOVED FROM THE AMBULANCE STRETCHERS
NO TIME LOST WITH TRANSFER FROM ER TO CT ROOM STRAIGHT ONTO CT TABLE, INSTEAD
OF AN ER BED
DECREASE DOOR-TO-CT AND DOOR-TO-NEEDLE TIMES
CT ROOM SHOULD BE EMPTIED PRIOR TO PATIENT ARRIVAL
STROKE TEAM AND NEUROLOGIST MEET AT THE CT ROOM
RAPID NEUROLOGIC EVALUATION: PATIENT IS EXAMINED UPON
ARRIVAL, ON CT TABLE
NO DELAY CT INTERPRETATION:
STROKE PHYSICIAN INTERPRETS THE CT, NOT WAITING FOR
FORMAL RADIOLOGY REPORT
REDUCED IMAGING: CT ADVANCED IMAGING RESERVED FOR
UNCLEAR CASES ONLY
POC Testing
Priority bloods in the hyper acute phase
LABORATORY TESTS TO CONSIDER IN ALL PATIENTS INCLUDE:
POINT OF CARE: LAB TESTS:
Point of care: Blood glucose and international Complete Blood Count (with Platelet count)
normalized ratio (INR)
Electrolytes panel (Renal function studies)
Hypoglycemia may cause focal signs and symptoms
that mimic stroke, and hyperglycemia is associated Cardiac markers: TP
with unfavorable outcomes. Coagulation tests: prothrombin time (PT), activated
partial thromboplastin time (aPTT), TT or ECT
BECAUSE TIME IS CRITICAL, FIBRINOLYTIC THERAPY SHOULD NOT BE DELAYED WHILE AWAITING THE RESULTS OF THE PT,
APTT, OR PLATELET COUNT UNLESS:
THERE IS CLINICAL SUSPICION OF A BLEEDING ABNORMALITY OR THROMBOCYTOPENIA,
THE PATIENT HAS RECEIVED HEPARIN OR WARFARIN,
THE PATIENT HAS RECEIVED OTHER ANTICOAGULANTS (DIRECT THROMBIN INHIBITORS OR DIRECT FACTOR XA INHIBITORS).
THE ONLY LABORATORY RESULTS REQUIRED IN ALL PATIENTS BEFORE FIBRINOLYTIC THERAPY IS INITIATED IS A GLUCOSE DETERMINATION AND INR;
USE OF FINGER-STICK MEASUREMENT DEVICES IS ACCEPTABLE.
Jauch EC, Saver JL, Adams HP, Jr., et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline
Treat at CT
4. Treat at CT
BENEFITS HOW?
DECREASE DOOR-TO-NEEDLE TIME DELIVERY OF RTPA ON CT TABLE: STROKE BAG
REDUCES IN-HOSPITAL DELAY RTPA BOLUS ADMINISTERED ON CT TABLE FOLLOWED
BY INFUSION IN AN ADJACENT ROOM
NO TIME LOST WITH TRANSFER FROM CT ROOM TO ER
THE STROKE BAG CONTAINS ALL THE MATERIALS
AND DRUGS NEEDED TO START TREATMENT
THE STROKE BAG ALSO CONTAINS ALL CHECKLISTS
AND PROTOCOLS
“KILL”
Acute Ischemic Stroke
<4,5 hours, ≥18 y.o
BP : <185/110
Klinis NIHSS : 4<x<25
NCCT :
Imejing - No bleed
- ASPECTS (>7)
Blood Glucose :
Laboratoris 50<x<400
IV Thrombolysis KIL memenuhi kriteria : Langsung menuju check list
kontraindikasi
A. Firdaus Sani, 2021. Stroke Pathways: Recent evidences
TERIMA KASIH
