Konsep Tatalaksana Strok di berbagai tatanan pelayanan serta

(1)

Konsep Tatalaksana Strok di berbagai

tatanan pelayanan serta pencegahan ulang

Perdossi

(2)

> 12,2 juta kasus stroke baru setiap tahun di dunia.

1 setiap 3 detik.

Global, 1 dari 4 orang > 25 tahun mengalami stroke

Insidensi

Insiden stroke di Asia bervariasi 116 - 483/100.000 per tahun

RISKESDAS 10,9 ‰ penduduk Indonesia mengalami stroke per 2018.

Angka tertinggi Kalimantan Timur yaitu, 14,7 ‰,

terendah di Papua 4,1 ‰.

(3)

Morbiditas & Mortalitas

Stroke peringkat kedua : penyebab kematian di dunia.

Angka mortalitas tahunan 5,5 juta.

Asia, tingkat kematian :

Jepang 43,3 per 100.000 orang-tahun

Singapura 47,9 per 100.000 orang-tahun, Indonesia 193,3 per 100.000 orang-tahun Mongolia 222,6 per 100.000 orang-tahun

Menurut Sample Registration System (SRS) Indonesia tahun 2016, stroke merupakan penyebab kematian tertinggi, yaitu sebesar 19,9%.

Stroke morbiditas yang tinggi

Disabilitas kronis hingga 50% penderita.

hipertensi, diabetes melitus, dan merokok

faktor risiko utama.

(4)

The number of deaths, incidence, prevalence, and disability (DALYs) of Stroke Patients

Katan M, Luft A. Global Burden of Stroke. 2018;208–11.

(5)

Rekurensi

Meta-analisis global 2011 :

11% individu mengalami kekambuhan 1 th stroke pertama

26% dalam waktu 5 tahun.

(6)

Definisi Stroke

WHO, 1970

rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin

AHA/ASA Expert Consensus, 2013

An episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction/ischemia, based on pathological, imaging, or other objective evidence in a defined vascular distribution; and/or clinical evidence of cerebral, spinal cord, or retinal focal ischemic injury based on symptoms persisting

≥24 hours or until death, and other etiologies

excluded

(7)

Patologi Stroke

(8)

.

The Pump “CARDIO”

The Wall “ENDOTHELIAL”

The Content “BLOOD”

VIRCHOW TRIAD

Imbalanced

1. Low perfusion 2. Oclusion

3. Rupture

Faktor risiko KONSEP PENYAKIT PEMBULUH DARAH

• Usia lanjut

• Hiperviscositas

• Obesitas

• Hipertensi

•CHF

•Atrial fibrilasi

•CAD

• Defisiensi Protein C, S or ATIII deficiency

• Activated protein C resistance

• Hyperhomocysteinaemia

• Antiphospholipid antibody

•Hiperglikemia, Anemia, ITP

(9)

Faktor Risiko

Strok

(10)

.

Stroke – Risk Factors

Boehme et al Stroke Risk Factors, Genetics, and Prevention Circ Res. 2017;120:472-495. DOI: 10.1161/CIRCRESAHA.116.308398.

% Probability

Men 8 15 18 30 40 60 85

Women 6 10 16 34 42 80 90

Impact of other risk factors Hypertension

medication - + + + + +

+

DM - +

+ + + +

Merokok - + + + +

CVD - + + +

AF - + +

ECG, LVH - +

Framingham Stroke Risk Profile : 10 Year Stroke Probability Men & Women Aged 70 yo with SBP 160 mmHg

American Heart Association, Inc

(11)

.

• UnModifiable

• Age

• Gender

• Race/Ethnic Disparities

• Modifiable (90 %)

• Hypertension

• DM

• Dyslipidemia

• CVD

• Genetic (17.3 % - 38 %)

• Lifestyle : Healthy diet, ↓BB , Smoking cessation, regular activity, alcohol

Susanna C Larsson,Rainer Malik, et.al BMJ. 2018; 363: k4168 doi: 10.1136/bmj.k4168 Diener and Hankey, JACC VO L . 7 5 , N O . 1 5 , 2 0 2 0 : 1 8 0 4 –1 8

Diet Intervention Risk of stroke RR (95% CI)

Folic acid Lower risk 0.8 (0.67 – 0.96)

Vitamin B complex Trend lower risk 0.9 (0.8 – 1.01) Mediterranean Diet Trend lower risk 0.65 (0.39 - 1.11) Vit D + Calcium Increased risk 1.17 (1.06 – 1.30) Low salt intake Trend lower risk 0.67 (0.46 – 0.99)

@ ↓ Systolic 10 mmHg + Diastolic 5 mmHg : Risk stroke reduction 41% (CI 33 – 48)

Hyperglycemia :

Reduce the risk of microvascular complication LDL Reduction + Statin :

↓ 1 mmol/L : Risk stroke reduction 21 % (6-33%)

(12)

Joseph et al. Stroke. 1999;30:16-20

2 years modification risk factors : little improve

Redfern et al Stroke. 2000;31:1877-1881

1 year after stroke : 22 % still smoked, 36 % obese, 4 % excessive drink

(13)

Tatalaksana Stroke

Multidisiplin : Perawat terlatih, Neurorestorasi, terapi wicara, terapi fisik, Dietisien, Neurologi, Intervensionist Vascular, Bedah Vaskular, Cardiologi, Interna, Bedah Saraf, Radiologi

Mencegah Komplikasi

– Multi faktorial

(14)

Time is Brain!

Blockage of one blood vessel will cause ischemia within 5 minutes

Saver JL, Stroke 2006

Time Neurons Lost

Synapses Lost

Myelinated

fibers Lost Premature Aging

1 second 32,000 230 million 200 m 8.7 hours

1 minute 1.9 million 14 billion 12 km 3.1 weeks

1 hour 120 million 830 billion 714 km 3.6 years

Complete 1.2 billion 8.3 trillion 7140 km 36 years

(15)

15

Decrease of 15 minutes in the management of acute ischemic stroke can prevent 1 month disability in

patients during recovery.

Zuckerman SL, Magarik JA, Espaillat KB, Kumar NG, Bhatia R, Dewan MC, et al. Implementation of an

institution - wide acute stroke algorithm : Improving stroke quality metrics. 2016;

Middleton S, Grimley R, Hons M. State-of-the-Science

Nursing Review. 2015;18–25.

(16)

Detection

FAST: identification rate only 69-90%, BEFAST: identification rate>95%

Aroor S, Singh R, Goldstein LB. Mnemonic. 2017;479–81.

(17)

Kemenkes

(18)

Strategi Mencegah Stroke dan Serangan Ulang

PROMOTIF PREVENTIF KURATIF REHABILITATIF

EDUKASI (Hidup Sehat,

Faktor Risiko, Gejala, Segera ke RS, Deteksi

Dini

Prevensi primer, Tatalaksana Faktor Risiko,

Early Diagnosis, Fast Definitive

diagnosis, Neuroprotection

Sistim Rujukan

Neurorestorasi, fisioterapi,

Robotik,

Stemcell, Botox

PREVENTIF

Prevensi sekunder, Tatalaksana Faktor Risiko,

Home care, Hidup Sehat,

STROK

Jangan Menjadi Jangan Berulang

Biaya Rendah Biaya Tinggi Biaya Tinggi

(19)

Promotif -

Preventif Primer

• Edukasi dan penerapan hidup sehat : GERMAS

• Edukasi prevensi primer : modifikasi faktor risiko dan non modifikasi faktor risiko

• Edukasi Gejala Stroke : FAST – SEGERA

KE RS

(20)

Susanna C Larsson,Rainer Malik, et.al BMJ. 2018; 363: k4168 doi: 10.1136/bmj.k4168

.

Healthy lifestyle

DIET EXERCISE

WEIGHT CONTROL SMOKING CESSATION

Boehme et al Stroke Risk Factors, Genetics, and Prevention Circ Res. 2017;120:472-495. DOI: 10.1161/CIRCRESAHA.116.308398.

Behavior

modification effort

AHA guidelines:

(21)

.

Healthy lifestyle

Boehme et al Stroke Risk Factors, Genetics, and Prevention Circ Res. 2017;120:472-495. DOI: 10.1161/CIRCRESAHA.116.308398 Meschia et al Guidelines for the Primary Prevention of StrokeStroke. 2014;45:3754-3832.

• How to count :

• Energy expenditure = Metabolic equivalence (METs)

• Sedentary : 1- 1.5 METs

• Light : 1.6 -2.9 METs (video game)

• Moderate : 3 – 5.9 METs ( ballet / dancing)

• Vigorous : > 6 METs ( outdoor bicycling )

• Activity :

• Inactive : < 600 MET minutes / week

• Highly active : > 8000 MET minutes / week

• EXERCISE

25 – 30 %

Risk Reduction of Stroke ( @ day : 1150 MET minutes ~ 2 -3 H vigorous activity )

AHA Guideline Class I; Level of Evidence B

at least moderate- to vigorous-intensity aerobic physical activity at least 40 min/d

3 - 4 days / week

(22)

.

Healthy lifestyle

• Healthy Diet : ↓ 20 % Risk of Stroke

• Mediterranean or DASH diet

• Micro / Macronutrient : plant based

• Low calory intake of saturated / trans saturated fat

• High intake fruit and vegetables

• Low salt intake

• Mediterranean or DASH Diet trial :

• Mediterranean diet + high olive oil : 30 % reduction stroke incidence (p< 0.04)

• Mediterranean diet + high mix nuts : 50 % reduction stroke incidence (p< 0.006)

• DASH diet : 20% lowered risk of stroke (95% CI, 0.72–0.92)

• DIET

Boehme et al Stroke Risk Factors, Genetics, and Prevention Circ Res. 2017;120:472-495. DOI: 10.1161/CIRCRESAHA.116.308398 Meschia et al Guidelines for the Primary Prevention of StrokeStroke. 2014;45:3754-3832.

(23)

.

Healthy lifestyle • DIET

Boehme et al Stroke Risk Factors, Genetics, and Prevention Circ Res. 2017;120:472-495. DOI: 10.1161/CIRCRESAHA.116.308398 Meschia et al Guidelines for the Primary Prevention of StrokeStroke. 2014;45:3754-3832.

(24)

.

Healthy lifestyle

• Weight Control :

• Healthy : keep BMI 18.5 – 25 kg/m 2

• Overweight : target BMI < 25 kg/m 2

• Obese : target BMI < 30 kg/m 2

• Smoking :

• cessation leads to a decrease in stroke risk to levels similar to nonsmokers by 5 years

• WEIGHT CONTROL & SMOKING CESSATION

Boehme et al Stroke Risk Factors, Genetics, and Prevention Circ Res. 2017;120:472-495. DOI: 10.1161/CIRCRESAHA.116.308398 Meschia et al Guidelines for the Primary Prevention of StrokeStroke. 2014;45:3754-3832.

(25)

.

Healthy lifestyle

Wang et al Benefit of Healthy Lifestyle by Medication Use. J Am Heart Assoc. 2020;9:e016692. DOI:

10.1161/JAHA.119.016692

Kohort study : 121. 700

♀ (30 - 55 yo) in 1976 and 51.529 ♂ (40 - 75 yo) in 1986,

Association: healthy lifestyles - all-cause - cause-specific mortality (users and nonusers of common preventive medications)

NHS (Nurses’ Health Study) and HPFS (Health Professionals Follow-up Study).

Healthy Lifestyle and Medical Condition Risk factors

(26)

.

Healthy lifestyle

Zhang et al Lifestyle, Treatment, and Stroke Hypertension. 2012;60:906-912

The risks of stroke decreased who adhered to ≥3 healthy lifestyle factors vs

<3 healthy lifestyle factors within different hypertensive status.

Healthy Lifestyle and Medical Condition Risk factors

(27)

• 4 healthy lifestyle factors - AHA guidelines:

• no current smoking,

• healthy diet,

• body mass index <30 kg/m 2 ,

• moderate physical activity two or more times weekly.

• Healthy diet : increased

consumption of fruit, vegetables, and fish and the decreased

consumption of processed meats and red meats.

• Moderate physical activity : at least 150 minutes of moderate intensity activity weekly or 75 minutes of vigorous activity weekly.

.

Healthy lifestyle

(28)

(29)

(30)

.

The Pump “CARDIO”

The Wall “ENDOTHELIAL”

The Content “BLOOD”

VIRCHOW TRIAD

Imbalanced

1. Low perfusion 2. Oclusion

3. Rupture

Healthy lifestyle – Risk of stroke

Risk Factors

Healthy

lifestyle

(31)

Promotif → Deteksi Dini

ISCI Guideline 2010

• Meningkatkan % pasien strok datang < 3 jam dari onset, yang dievaluasi cepat dalam 10 menit saat datang ke IGD

• Meningkatkan % pasien menerima terapi thrombolisis and terapi prevensi sekunder antithrombotic

• Meningkatkan % pasien yang dilakukan manajemen

medis yang sesuai dalam waktu 24-48 jam terdiagnosis untuk mencegah komplikasi

• Memperbaiki luaran dan edukasi keluarga

(32)

Kuratif - 8D of Stroke

Detection Dispatch Delivery Door

Decision- Data Diagnosis Device-

Disposition Drug

Prehospital

Intrahospital

(33)

Evidence Based of Comprehensive Stroke Management

1. Intravenous thrombolysis 2. Mechanical thrombectomy

3. Decompressive Craniectomy (for Malignant MCA Stroke)

4. Secondary prevention : Antiplatelet, CEA, CAS 5. Stroke Units

AHA/ASA Guideline 2017

(34)

3/8D of Stroke

Detection Dispatch Delivery

Prehospital

PSC

PUBLIC SAFETY CENTER

KE RS ATAU ANTAR RS

?

? ?

(35)

Delivery: Where?

AHA/ASA Joint Comission International. Stroke Certification.

(36)

Pilihan Sistim Rujukan Stroke Akut

(37)

Drip n Ship vs Mothership

• Drip n ship: transfer patients to nearest primary stroke center (PSC) that can give IV-tPA within 30 minutes → if fail → comprehensive stroke care (CSC)

• Mothership: straight to the CSC for IV-tPA or endovascular treatment.

• These principles are depends on the geographic condition and patient condition. Mothership treatment can be advantage for shorten the door to needle (IV-tPA) and door to groin puncture (mechanical thrombectomy) time.

Milne MSW, Progress I, Holodinsky JK, Hill MD, Nygren A, Qiu

C, et al. Drip ’n Ship Versus Mothership for Endovascular

Treatment: Modeling the Best Transportation Options for Optimal Outcomes. Stroke. 2017;48:791–4.

(38)

Higashida, R., Alberts, M., Alexander, D., Crocco, T., Demaerschalk, B., Derdeyn, C., et al. (2013). Interactions Within Stroke Systems of Care: A Policy Statement From the American Heart Association/American Stroke Association. Stroke, 1-24

(39)

SKEMA PENGAMPUAN STROKE

39

(40)

STRATIFIKASI RS JEJARING STROKE

40

(41)

Kriteria Stratifikasi RS Layanan Stroke

No Strata Kriteria SDM SARANA PRASARANA

1 Paripurna Mampu melakukan

pelayanan stroke

komprehensif dan sebagai koordinator pengampuan

• Bedah Saraf Subspesialis Neurovaskular

• Neurointervensi (Sp.N, Sp.Rad, Sp.BS)

• Perawat neurosains tersertifikasi TOT keperawatan neurosains

• MS CT Scan minimal 128 slice (include CTP+CTA)

• MRI

• Cathlab

• Microscope

• ICU Level 3 (Neuro-ICU)

2 Utama Mampu melakukan

pelayanan neurovaskular intervensi bedah dan non bedah serta melakukan pengampuan

• Bedah Saraf Subspesialis Neurovaskular

• Perawat neurosains tersertifikasi intraoperatif dan neurocritical care

• MRI

• Cathlab

• Microscope

• ICU Level 3 (Neuro-ICU)

3 Madya Mampu melakukan

pelayanan neurovaskular intervensi non bedah

• Perawat Neurosains tersertifikasi Cath Lab

• Radiografer terlatih

• Neurolog

• Radiolog

• GP Terlatih

• Perawat Neurosains tersertifikasi Askep Stroke

• Cathlab

• ICU Level 2 (Neuro-ICU/ICU)

• HCU/Stroke Unit/Stroke Corner

4 Dasar Mampu melakukan

Trombolisis Intravena

• Neurolog

• Radiolog

• GP Terlatih

• Perawat Neurosains tersertifikasi Askep Stroke

• MS CT Scan Minimal 64 Slice

• HCU/Stroke Unit/Stroke Corner

(42)

Sebaran RS Pengampu Stroke

42

(43)

Strategi Mencegah Stroke dan Serangan Ulang

PROMOTIF PREVENTIF KURATIF REHABILITATIF

EDUKASI (Hidup Sehat,

Faktor Risiko, Gejala, Segera ke RS, Deteksi

Dini

Prevensi primer, Tatalaksana Faktor Risiko,

Early Diagnosis, Fast Definitive diagnosis, IVT, MT, Unit Strok Neuroprotection

Sistim Rujukan

Neurorestorasi, fisioterapi,

Robotik,

Stemcell, Botox

PREVENTIF

Prevensi sekunder, Tatalaksana Faktor Risiko,

Home care, Hidup Sehat,

STROK

Jangan Menjadi Jangan Berulang

Biaya Rendah Biaya Tinggi Biaya Tinggi

Fasilitas Kesehatan berbagai strata Paripurna Fasilitas Kesehatan berbagai strata

(44)

Terimakasih