5. dr. Linda Suryakusuma, MA, SpS DIAGNOSIS AND INITIAL TREATMENT OF STROKE
DIAGNOSIS AND INITIAL TREATMENT
OF STROKE
Linda Suryakusuma
Department of Neurology
Faculty of Medicine
Atma Jaya Catholic University
September 2017
Background
• In the past decade, the definition of stroke has
been revised and major advances have been
made for its treatment and prevention
• Despite declining stroke mortality rates, the
global burden of stroke is increasing
• A more comprehensive approach to primary
prevention of stroke is required that targets
people at all levels of risk and is integrated with
prevention strategies for other diseases that
share common risk factors
Epidemiology
• Stroke is the second leading cause of death
and third leading cause of DALYs lost
worldwide
• Most of the global burden of stroke, in terms
of deaths and DALYs lost, was borne by lowincome and middle-income countries and
caused by haemorrhagic stroke
Definition
• The traditional definition of stroke is clinical
and based on the sudden onset of loss of focal
neurological function due to infarction or
haemorrhage in the relevant part of the brain,
retina, or spinal cord. (WHO 1970)
• Stroke is distinguished from transient
ischaemic attack (TIA) if the symptoms persist
longer than 24 hour (or lead to earlier death).
Updated Definition
• An updated definition of stroke is an acute
episode of focal dysfunction of the brain,
retina, or spinal cord lasting longer than 24h,
or of any duration if imaging (CT or MRI) or
autopsy show focal infarction or haemorrhage
relevant to the symptoms
• TIA has been redefined as focal dysfunction of
less than 24h duration and with no imaging
evidence of infarction (ASA 2013)
Diagnosis of Stroke
•
-
Typical symptoms of stroke:
Sudden unilateral weakness
Numbness
Visual loss
Diplopia
Altered speech
Ataxia
Non-orthostatic vertigo
• The Face Arm and Speech Test (FAST) or the
Recognition of Stroke in the Emergency Room
(ROSIER) is sensitive and specific
• Non-contrast cranial CT scan is very sensitive
for fresh intracranial haemorrhage but not
sensitive for recent, small or posterior fossa
ischaemic stroke
• Diffusion-weighted MRI detects acute brain
ischaemia in about 90% of patients with
ischaemic stroke and about a third of patients
with TIA
• About 20-25% of patients presenting with a
stroke syndrome have a stroke mimic; most
commonly seizures, syncope, sepsis,
peripheral vestibulopathy, and toxic or
metabolic encephalopathy
• The diagnosis of stroke is most difficult in the
initial hours, particularly if the onset is
uncertain, the features are atypical or
changing, the patient is unwell or agitated,
access to imaging is delayed, or brain imaging
is normal
Subtypes of stroke
• Clinical ischaemis stroke syndromes include
TACS, PACS, LACS, and POCS
• Pathologic subtypes comprise ischaemic
stroke (cerebral, retinal, and spinal infarction)
and haemorrhagic stroke (ICH and SAH)
• The proportions of pathological and
aetiological subtypes of stroke vary among
populations of different age, race, ethnic
origin, and nationality
Arterial teritories
of the cerebral hemispheres
Types of Stroke
Ischemic Stroke- 88%
Embolic (24%) :
Blood clot forms
somewhere in the
body and travels to the brain
Thrombotic (61%) :
Clot forms on blood vessel
deposits
• The thrombus itself can occlude blood flow
• An embolus can also break off from the thrombus, and
occlude circulation further in the vessel
Haemorrhagic stroke
Haemorrhagic stroke is classified according to
its anatomical site (85-95% supratentorial: 5075% deep and 25-40% lobar) or presumed
aetiology (30-60% hypertension, 10-30%
cerebral amyloid angiopathy, 1-20%
anticoagulant, and 3-8% vascular structural
lession). The cause is undetermined in 5-20%
of cases
Risk Factors
•
•
•
•
•
•
•
Hypertension
Hypercholesterolaemia
Carotid stenosis
Atrial fibrillation
Cigarette smoking
Alcoholism
Diabetes Mellitus
• Environmental air pollution
• Childhood health
circumstances and fitness
• Poor nutrition
• Physical inactivity
• Obesity
• Blood pressure variability
• Sleep-disordered breathing
• Chronic inflammation
• Chronic Kidney Disease
• Migraine
• Hormonal contraception
• Psychosocial stress
• Depression
• Long working hours
Prognosis after stroke and TIA
• Case fatality rates after all stroke are about 15%
at 1 month, 25% at 1 year and 50% at 5 years
• Case fatality rates after ICH are 55% at 1 year and
70% at 5 years
• The risk of recurrent stroke without treatment is
10% at 1 week, 15% at 1 month and 18% at 3
months ABCD score
• With appropriate treatment, the risk is 80% lower
• The long-term risk of recurrent stroke is 10% at 1
year, 25% at 5 years, and 40% at 10 years
Specific Treatment
For Acute Ischaemic Stroke
• Intravenous alteplase (rtPA) 0.9 mg/kg,
administered within 4.5 hours of ischaemic
stroke, increases the odds of no significant
disability (mRS 0-2) at 3-6 months by a third and
does not affect mortality, despite increasing the
odds of symptomatic intracerebral haemorrhage
• Using a lower dose of alteplase (0.6 mg/kg)
reduces the incidence of ICH but does not lead to
better functional outcome at 90 days compared
with standard-dose alteplase
Specific Treatment
For Acute Haemorrhagic Stroke
• Intensive blood pressure reduction within 3-6 h
of onset of ICH to a systolic target of lower than
140 mmHg may not be safe for all patients, nor
more effective in reducing death and disability,
compared to a systolic target of lower than 180
mmHg
• Early open-surgery evacuation of supratentorial
haematomas might be beneficial for patients with
a GCS score of 9-12 who are treated within 8h of
symptom onset
General Treatment
of Acute Stroke
• Stroke-unit care
• Review by a stroke consultant within 24h of admission
• Nutrition screening and formal swallow assessment
within 72h
• Antiplatelet therapy
• Adequate fluids and nutrition in the first 72h
• Crystalloids fluids
• There is no urgency to restart pre-existing antihypertensive therapy in the first days, unless for
comorbid disorders
Preventing and Managing
Complications
• Cerebral oedema can be a secondary
consequence of a large area of brain infarction
• Early decompressive hemicraniectomy for
malignant MCA infarction significantly
decreases 12 month mortality, death or severe
disability, but is associated with nonsignificantly higher major disability among
survivors compared with conservative
treatment
• The trade-off between improved survival at the
expense of substantial disability is greater for
patients older than 60 years than for those of a
younger age
• The optimum criteria for patient selection, timing
of surgery, and acceptable degree of disability in
survivors remain undefined
• However, if decompressive hemicraniectomy is to
be undertaken, it should be before there is major
midline shift causing secondary ischaemic brain
injury and bleeding in the brainstem
Preventing recurrent ischaemic stroke
of arterial origin
• Urgent initiation of effective secondary
prevention after TIA and minor ischaemic stroke
can reduce the risk of early recurrent stroke by
80%
• Immediate aspirin, 160-300 mg a day, reduces the
rate and severity of early recurrent stroke by at
least half within the first 6-12 weeks
• Dual antiplatelet therapy seems more effective
than monotherapy in reducing early recurrent
stroke
• The most effective combination is aspirin and
clopidogrel in Chinese patients with acute TIA or
minor ischaemic stroke, who are at low risk of
haemorrhagic complications
• Effective long-term antiplatelet regimens for
preventing recurrent stroke include aspirin 75150 mg a day and/or clopidogrel 75 mg a day
• Anticoagulation in acute ischaemic stroke does
not reduce early recurrent stroke, mortality or
death or dependency compared with control,
even among patients at higher risk of thrombosis
or lower risk of haemorrhage
• Stenting of recently symptomatic
atherosclerotic intracranial stenosis and
extracranial vertebral stenosis is associated
with unacceptable periprocedural risks of
stroke or death, compared with intensive
medical therapy
• Sustained lowering of blood pressure by 5
mmHg systolic and 2.5 mmHg diastolic
reduces recurrent stroke by about 20%
• The optimal targe blood pressure might be
120-128 mmHg systolic and 65-70 mmHg
diastolic after lacunar stroke
• Visit-to-visit blood pressure variability is
reduced in a dose-dependent fashion by
calcium-channel blockers and diuretics, and
increased by B-blockers
• Lowering of LDL cholesterol concentration by
about 1 mmol/L (38 mg/dL) with statins
reduces the risk of recurrent stroke by about
12%
• More intensive lowering of LDL cholesterol
concentration is associated with further
reductions in stroke risk
• Long-term intensive glucose lowering does not
reduce non-fatal stroke risk compared with
standard care in patients with type 2 diabetes
• Insulin sensitivity can be improved by exercise,
diet, weight reduction and peroxisome
proliferator-activated receptor γ agonists
(pioglitazone)
• Pioglitazone reduces the risk of recurrent
stroke or myocardial infarction but might
increase the risk of bladder cancer, which
might preclude its use
Preventing recurrent ischaemic stroke
of cardiac origin
• In patients with atrial fibrillation, oral
anticoagulation with vitamin K antagonists, such
as warfarin, to maintain an INR of 2.0-3.0,
decreases the odds of recurrent stroke by twothirds
• The four direct oral anticoagulants that inhibit
thrombin (dabigatran) and factor Xa (rivaroxaban)
reduce recurrent stroke and systemic embolism
by about a sixth, without increasing major
bleeding, compared to warfarin in nonvalvular
atrial fibrillation
• The optimal time to start oral anticoagulation
in acute cardioembolic stroke is uncertain, but
probably between 4-14 days after stroke
onset, depending on the balance between the
risk of recurrent stroke (CHA2DS2-VASc score)
and the risk of haemorrhagic transormation of
the infarcted brain (NIHSS and infarct size)
Recovery and rehabilitation
• Stroke rehabilitation is a progressive, dynamic,
goal-orientated process aimed at enabling a
person with impairment to reach their optimal
physical, cognitive, emotional, communicative,
social and functional activity level
• Stroke survivors and their caregivers should be
encouraged to join their local stroke support
organisation
• Support and advice from organisations and from
other stroke patients and their family can reduce
social isolation and depression and improve
quality of life
THANK YOU
OF STROKE
Linda Suryakusuma
Department of Neurology
Faculty of Medicine
Atma Jaya Catholic University
September 2017
Background
• In the past decade, the definition of stroke has
been revised and major advances have been
made for its treatment and prevention
• Despite declining stroke mortality rates, the
global burden of stroke is increasing
• A more comprehensive approach to primary
prevention of stroke is required that targets
people at all levels of risk and is integrated with
prevention strategies for other diseases that
share common risk factors
Epidemiology
• Stroke is the second leading cause of death
and third leading cause of DALYs lost
worldwide
• Most of the global burden of stroke, in terms
of deaths and DALYs lost, was borne by lowincome and middle-income countries and
caused by haemorrhagic stroke
Definition
• The traditional definition of stroke is clinical
and based on the sudden onset of loss of focal
neurological function due to infarction or
haemorrhage in the relevant part of the brain,
retina, or spinal cord. (WHO 1970)
• Stroke is distinguished from transient
ischaemic attack (TIA) if the symptoms persist
longer than 24 hour (or lead to earlier death).
Updated Definition
• An updated definition of stroke is an acute
episode of focal dysfunction of the brain,
retina, or spinal cord lasting longer than 24h,
or of any duration if imaging (CT or MRI) or
autopsy show focal infarction or haemorrhage
relevant to the symptoms
• TIA has been redefined as focal dysfunction of
less than 24h duration and with no imaging
evidence of infarction (ASA 2013)
Diagnosis of Stroke
•
-
Typical symptoms of stroke:
Sudden unilateral weakness
Numbness
Visual loss
Diplopia
Altered speech
Ataxia
Non-orthostatic vertigo
• The Face Arm and Speech Test (FAST) or the
Recognition of Stroke in the Emergency Room
(ROSIER) is sensitive and specific
• Non-contrast cranial CT scan is very sensitive
for fresh intracranial haemorrhage but not
sensitive for recent, small or posterior fossa
ischaemic stroke
• Diffusion-weighted MRI detects acute brain
ischaemia in about 90% of patients with
ischaemic stroke and about a third of patients
with TIA
• About 20-25% of patients presenting with a
stroke syndrome have a stroke mimic; most
commonly seizures, syncope, sepsis,
peripheral vestibulopathy, and toxic or
metabolic encephalopathy
• The diagnosis of stroke is most difficult in the
initial hours, particularly if the onset is
uncertain, the features are atypical or
changing, the patient is unwell or agitated,
access to imaging is delayed, or brain imaging
is normal
Subtypes of stroke
• Clinical ischaemis stroke syndromes include
TACS, PACS, LACS, and POCS
• Pathologic subtypes comprise ischaemic
stroke (cerebral, retinal, and spinal infarction)
and haemorrhagic stroke (ICH and SAH)
• The proportions of pathological and
aetiological subtypes of stroke vary among
populations of different age, race, ethnic
origin, and nationality
Arterial teritories
of the cerebral hemispheres
Types of Stroke
Ischemic Stroke- 88%
Embolic (24%) :
Blood clot forms
somewhere in the
body and travels to the brain
Thrombotic (61%) :
Clot forms on blood vessel
deposits
• The thrombus itself can occlude blood flow
• An embolus can also break off from the thrombus, and
occlude circulation further in the vessel
Haemorrhagic stroke
Haemorrhagic stroke is classified according to
its anatomical site (85-95% supratentorial: 5075% deep and 25-40% lobar) or presumed
aetiology (30-60% hypertension, 10-30%
cerebral amyloid angiopathy, 1-20%
anticoagulant, and 3-8% vascular structural
lession). The cause is undetermined in 5-20%
of cases
Risk Factors
•
•
•
•
•
•
•
Hypertension
Hypercholesterolaemia
Carotid stenosis
Atrial fibrillation
Cigarette smoking
Alcoholism
Diabetes Mellitus
• Environmental air pollution
• Childhood health
circumstances and fitness
• Poor nutrition
• Physical inactivity
• Obesity
• Blood pressure variability
• Sleep-disordered breathing
• Chronic inflammation
• Chronic Kidney Disease
• Migraine
• Hormonal contraception
• Psychosocial stress
• Depression
• Long working hours
Prognosis after stroke and TIA
• Case fatality rates after all stroke are about 15%
at 1 month, 25% at 1 year and 50% at 5 years
• Case fatality rates after ICH are 55% at 1 year and
70% at 5 years
• The risk of recurrent stroke without treatment is
10% at 1 week, 15% at 1 month and 18% at 3
months ABCD score
• With appropriate treatment, the risk is 80% lower
• The long-term risk of recurrent stroke is 10% at 1
year, 25% at 5 years, and 40% at 10 years
Specific Treatment
For Acute Ischaemic Stroke
• Intravenous alteplase (rtPA) 0.9 mg/kg,
administered within 4.5 hours of ischaemic
stroke, increases the odds of no significant
disability (mRS 0-2) at 3-6 months by a third and
does not affect mortality, despite increasing the
odds of symptomatic intracerebral haemorrhage
• Using a lower dose of alteplase (0.6 mg/kg)
reduces the incidence of ICH but does not lead to
better functional outcome at 90 days compared
with standard-dose alteplase
Specific Treatment
For Acute Haemorrhagic Stroke
• Intensive blood pressure reduction within 3-6 h
of onset of ICH to a systolic target of lower than
140 mmHg may not be safe for all patients, nor
more effective in reducing death and disability,
compared to a systolic target of lower than 180
mmHg
• Early open-surgery evacuation of supratentorial
haematomas might be beneficial for patients with
a GCS score of 9-12 who are treated within 8h of
symptom onset
General Treatment
of Acute Stroke
• Stroke-unit care
• Review by a stroke consultant within 24h of admission
• Nutrition screening and formal swallow assessment
within 72h
• Antiplatelet therapy
• Adequate fluids and nutrition in the first 72h
• Crystalloids fluids
• There is no urgency to restart pre-existing antihypertensive therapy in the first days, unless for
comorbid disorders
Preventing and Managing
Complications
• Cerebral oedema can be a secondary
consequence of a large area of brain infarction
• Early decompressive hemicraniectomy for
malignant MCA infarction significantly
decreases 12 month mortality, death or severe
disability, but is associated with nonsignificantly higher major disability among
survivors compared with conservative
treatment
• The trade-off between improved survival at the
expense of substantial disability is greater for
patients older than 60 years than for those of a
younger age
• The optimum criteria for patient selection, timing
of surgery, and acceptable degree of disability in
survivors remain undefined
• However, if decompressive hemicraniectomy is to
be undertaken, it should be before there is major
midline shift causing secondary ischaemic brain
injury and bleeding in the brainstem
Preventing recurrent ischaemic stroke
of arterial origin
• Urgent initiation of effective secondary
prevention after TIA and minor ischaemic stroke
can reduce the risk of early recurrent stroke by
80%
• Immediate aspirin, 160-300 mg a day, reduces the
rate and severity of early recurrent stroke by at
least half within the first 6-12 weeks
• Dual antiplatelet therapy seems more effective
than monotherapy in reducing early recurrent
stroke
• The most effective combination is aspirin and
clopidogrel in Chinese patients with acute TIA or
minor ischaemic stroke, who are at low risk of
haemorrhagic complications
• Effective long-term antiplatelet regimens for
preventing recurrent stroke include aspirin 75150 mg a day and/or clopidogrel 75 mg a day
• Anticoagulation in acute ischaemic stroke does
not reduce early recurrent stroke, mortality or
death or dependency compared with control,
even among patients at higher risk of thrombosis
or lower risk of haemorrhage
• Stenting of recently symptomatic
atherosclerotic intracranial stenosis and
extracranial vertebral stenosis is associated
with unacceptable periprocedural risks of
stroke or death, compared with intensive
medical therapy
• Sustained lowering of blood pressure by 5
mmHg systolic and 2.5 mmHg diastolic
reduces recurrent stroke by about 20%
• The optimal targe blood pressure might be
120-128 mmHg systolic and 65-70 mmHg
diastolic after lacunar stroke
• Visit-to-visit blood pressure variability is
reduced in a dose-dependent fashion by
calcium-channel blockers and diuretics, and
increased by B-blockers
• Lowering of LDL cholesterol concentration by
about 1 mmol/L (38 mg/dL) with statins
reduces the risk of recurrent stroke by about
12%
• More intensive lowering of LDL cholesterol
concentration is associated with further
reductions in stroke risk
• Long-term intensive glucose lowering does not
reduce non-fatal stroke risk compared with
standard care in patients with type 2 diabetes
• Insulin sensitivity can be improved by exercise,
diet, weight reduction and peroxisome
proliferator-activated receptor γ agonists
(pioglitazone)
• Pioglitazone reduces the risk of recurrent
stroke or myocardial infarction but might
increase the risk of bladder cancer, which
might preclude its use
Preventing recurrent ischaemic stroke
of cardiac origin
• In patients with atrial fibrillation, oral
anticoagulation with vitamin K antagonists, such
as warfarin, to maintain an INR of 2.0-3.0,
decreases the odds of recurrent stroke by twothirds
• The four direct oral anticoagulants that inhibit
thrombin (dabigatran) and factor Xa (rivaroxaban)
reduce recurrent stroke and systemic embolism
by about a sixth, without increasing major
bleeding, compared to warfarin in nonvalvular
atrial fibrillation
• The optimal time to start oral anticoagulation
in acute cardioembolic stroke is uncertain, but
probably between 4-14 days after stroke
onset, depending on the balance between the
risk of recurrent stroke (CHA2DS2-VASc score)
and the risk of haemorrhagic transormation of
the infarcted brain (NIHSS and infarct size)
Recovery and rehabilitation
• Stroke rehabilitation is a progressive, dynamic,
goal-orientated process aimed at enabling a
person with impairment to reach their optimal
physical, cognitive, emotional, communicative,
social and functional activity level
• Stroke survivors and their caregivers should be
encouraged to join their local stroke support
organisation
• Support and advice from organisations and from
other stroke patients and their family can reduce
social isolation and depression and improve
quality of life
THANK YOU