Monitoring Intra dan Paska Trombolisis.pdf

Monitoring Intra dan Paska Trombolisis.pdf

1. dr. Lenny Octavinawaty, Sp. N, FINA
Monitoring Intra dan Paska
Thrombolisis Intravena
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Riwayat Pekerjaan
2019-sekarang
2023-sekarang
2023-sekarang
RSU Hermina Palembang
RSU Mohamad HoesinPalembang
RSUD Siti Fatimah palembang
Organisasi
PerdosniCabang Palembang
AINA (AseanNeurointerventionAssociation)
Riwayat Pendidikan
DokterUmum(Fak. KedokteranUniversitas Kristen KridaWacana)
DokterSpesialis(Fak. KedokteranUniversitas Sriwijaya)
Fellowship of NeurointerventionRS PELNI Jakarta
dr. Lenny Octavinawaty, Sp.N, FINA
Dokter Spesialis Neurologi

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TREATMENT OF ACUTE STROKE PATIENTS CAN BE DIVIDED INTO FOUR PHASES EACH WITH ITS
OWN PRIMARY OBJECTIVES AND THERAPEUTIC FOCUS
PRE-HOSPITAL PHASE
FROM SYMPTOM ONSET TO HOSPITAL DOOR
HYPER ACUTE PHASE
DOOR –HOUR 1
ACUTE PHASE
1 –24 HOURS AFTER ADMISSION
POST-ACUTE PHASE
24 –72 HOURS AFTER ADMISSION
Selama fase akut pasien
masih berisiko mengalami
infark serebral sehingga
status neurologis perlu
dipantau secara ketat untuk
mengetahui adanya
perburukan gejala.

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REKANALISASI
•Memperbaikialirandarahpada daerahotakiskemik
sehinggadarah kembali mengalir ke area yang
tersumbat sehingga otak yang iskemik berfungsi
kembali
•Menurunkanangkakematian
•Menurunkankecatatan
Tujuan
•TrombolisisIV/ IA
•Mechanical trombectomi
Jenis

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Staff
In-Service
Step 1 Step 2 Step 3 Step 4 Step 5
IV Thrombolysis
Patient
Outcomes
Time is Brain
MODERN MANAGEMENT OF ACUTE ISCHEMIC STROKE
(SPECIFIC TREATMENT)
6 hours3-4,5
hours
>6 -24
hours
acute/sub
acute
secondary
prevention
Mechanical
Thrombectomy
IA
Thrombolysis
Intracranial
Stent
Carotid /Vertebral
Angioplasty & Stenting

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Alteplase (rt-PA) mengubahparadigmapengobatanAIS &
menjadikanAIS keadaandaruratmedis!
1.Powers WJ, et al. Stroke 2018;49(3):e46-e110.
2.The European Stroke Organisation (ESO) Executive Committee and the ESO Writing Committee. CerebrovascDis 2008;25(5):457-507.
3.Karolinska Stroke Update 2008, Final draft per 20081118 ESO GC Statement on revised guidelines for intravenous thrombolysis.
Direkomendasikanoleh pedoman
internasionaluntukpasienyang
memenuhisyarat: Hingga3 jam
setelahtimbulnyaAIS dan dalam3-
4,5 jam pada pasientertentu
Hingga4,5 jam setelahtimbulnya
AIS 2,3
Actilyse® (alteplase, rtPA) disetujui
di 85 negara di seluruhdunia dan
satu-satunyaobatyang
direkomendasikanuntuk
trombolisispada AIS oleh
pedomaninternasional1.2
Jaringanstroke merupakan
strategi pentinguntuk
mengefisienkanmanajemen
pasien, mengurangiwaktu
timbulnyagejalahingga
pengobatandan waktudaripintu
kejarum.
Emergency Services
Paramedics / Physicians
Central Admission
Neuro Emergency Room
Outpatient Care / GP
Rehabilitation
Geriatric Rehabilitation
Neuroradiology
Ultrasound
Stroke Unit
Neurocritical Care Unit
IV rt-PA (0,9 mg/kg beratbadan,
maks90 mg): 10% diberikansebagai
bolus diikutiinfus60 menit
AIS, acute ischaemic stroke; GP, general
practitioner; IV, intravenous

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MEKANISME TROMBOLISIS
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OBAT TROMBOLITIK ( AKTIVATOR PLASMINOGEN /OBAT
FIBRINOLITIK)
MENGIKAT DAN MENGAKTIFKAN PLASMINOGEN YANG
MENEMPEL PADA JAR. FIBRIN BEKUAN DARAH
PLASMIN
MEMUTUSKAN IKATAN ANTARA MOLEKUL FIBRIN
PECAH BEKUAN DARAH -> MELARUTKAN GUMPALAN
DARAH

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Trombolisis: NNT untuk mencapai
pemulihan yang sangat baik (mRS 0-1)
mRS, modified Rankin Scale
NNT, number needed to treat to achieve one additional patient with mRS 0-1
Lees et al. Lancet2010;375:1695-1703.
3 –4.5 h NNT=14
90 min –3 h NNT=9
≤ 90 mins NNT=4 to 5

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Pedoman Trombolisis Intravena
I.V.rt-PA(0,9mg/kgberatbadan,maks.90mg),dengan10%dosisdiberikansebagaibolus
diikutiinfusselama60menit,direkomendasikandalamwaktu4,5jamsetelahtimbulnya
strokeiskemik(KelasI,LevelA)ESOGuidelines2009Update.www.eso-stroke.org
Rt-PAintravenadirekomendasikanuntukpasientertentuyangdapatdiobatidalam
waktu3jamsetelahtimbulnyastrokeiskemik(KelasILevelA)
rt-PAharusdiberikankepadapasienyangmemenuhisyaratyangdapatdiobatidalam
jangkawaktu3hingga4,5jamsetelahstroke(KelasILevelB). AHA/ASA
Guideline2019
AlteplasedirekomendasikandalamotorisasipemasarannyauntukmengobatiAISpadaorang
dewasajikapengobatandimulaisedinimungkindalamwaktu4,5jamsejaktimbulnyagejala
stroke,danperdarahanintrakranialtelahdisingkirkandenganteknikpencitraanyangtepat.
NICEGuidline2012

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PedomanESO: Pasien dengan stroke LVO sirkulasianterior harus
menerima IVT sebagai tambahan MT dibandingkan MT saja
Recommendation StrengthLOE
Untukpasienyang langsungdirawatdi pusatyang mampumelakukan
trombektomiuntukstroke iskemikakut(≤4,5 jam sejaktimbulnya
gejala) denganoklusipembuluhdarahbesarsirkulasianterior dan
memenuhisyaratuntukkeduaperawatan, kami merekomendasikan
trombolisisintravenaplus trombektomimekanisdaripada
trombektomimekanissaja. StrongModerate
Keduaperawatanharusdilakukansedinimungkinsetelahpasientiba
di rumahsakit. Trombektomimekanistidakbolehmencegah
dimulainyatrombolisisintravena, dan trombolisisintravenatidak
bolehmenundatrombektomimekanis.
ESO Guidelines 2009 Update. www.eso-stroke.org

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PedomanESO untuk PenatalaksanaanStroke Iskemikdan
Serangan IskemikTransien
Pada pasienyang dirawatdalamwaktu3 jam setelahseranganstroke, CT otakharus
dilakukanuntukmemandupengobatantrombolisisrutindenganrt-PA (KelasI, Level A)
I.V. rt-PA (0,9 mg/kg beratbadan, maks. 90 mg), dengan10% dosisdiberikansebagaibolus
diikutiinfusselama60 menit, direkomendasikandalamwaktu4,5 jam setelahtimbulnya
stroke iskemik(KelasI, Level A)
Penggunaanpencitraanmultimodal mungkinbergunauntukpemilihanpasienuntuk
trombolisistetapitidakdirekomendasikanuntukpraktikklinisrutin(KelasIII, Level C)

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PedomanESO: Rekomendasiuntuk Layanan
Stroke dan Unit Stroke
Semuapasienstroke harusdirawatdi unit stroke (KelasI, Level A)
Pengembanganjaringanklinis, termasuktelemedicine, direkomendasikanuntukmemperluas
akseskeperawatanstroke spesialisteknologitinggi(KelasII, Level B)
Pasienstroke akutharusmemilikiaksesterhadapperawatanmedisdan bedahberteknologi
tinggisaatdiperlukan(KelasIII, Tingkat B)

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AHA/ ASA Guideline

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•Belum ada pedoman nasional
sebagai acuan penanganan stroke
secara komprehensif.
•Kurangnya rumah sakit dengan tim
stroke yang terlatih dan terampil
(ahli saraf, dokter gawat darurat,
perawat)
•Kurangnya rumah sakit dengan
unit stroke yang tersedia
PNPK Stroke 2019 Highlight
Background & Objective
Background Objectives
1.Mendorong tenaga kesehatan
untuk menggunakan PNPK
Stroke 2019 sebagai acuan
dalam penatalaksanaan stroke
komprehensif di Indonesia
(layanan pra-rumah sakit, terapi
definitif di rumah sakit, sistem
rujukan terpadu, termasuk
pencegahan primer dan
sekunder).
2.Meningkatkan pelayanan stroke
secara nasional untuk
menurunkan angka kejadian,
kecacatan, dan kematian akibat
stroke.

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•Untuk memulai manajemen perawatan stroke
yang komprehensif, diperlukan tim stroke yang
berdedikasi.
•Tim Stroke akan menerapkan PNPK Stroke 2019
berupa PPK, clinical pathway, dan protocol
checklist sesuai dengan fasilitas rumah sakit.
•Tim stroke akan merawat pasien di stroke
corner/stroke unit/ICU/HCU pada fase
hiperakut & akut.
•Setelah 24 jam, perawatan akan dilanjutkan di
ruang rawat inap.
Organized Stroke Team
Stroke Team Member Tugas
GP in Emergency Unit Initial patient admission
and diagnosis
Neurologist/
Stroke consultant
Treatment decision maker
Nurse/
Certified stroke nurse
Monitor24jam

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CHECK LIST SEBELUM, SELAMA DAN
SESUDAH TROMBOLISIS

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Inclusion
Criteriaof
Thrombolysis
Age >
18 years
sickle
cell
anemia
as a stroke
with obvious
neurological
abnormalities
NIHSS > 5
Onset <
4.5 hours
or <6
hours
No features of
intracranial
hemorrhage
on CT
Scan/MRI
Chronic
renal
failure with
N aPTT
Written
consent from
patient/family

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GeneralSupportiveCareandEmergencyTreatment
3.5IVAlteplase
1
8
3.5.3MildStroke
Recommendations COR LOE
1.Forotherwiseeligiblepatientswithmildbutdisablingstroke
symptoms, IV alteplase is recommended for patients who can be
treated within 3 hours of ischemic stroke symptom onset or patient
last known welloratbaselinestate.
I B-R
2.Forotherwiseeligiblepatientswithmilddisablingstroke
symptoms, IValteplasemaybereasonableforpatientswhocan
betreatedwithin3 and 4.5hoursofischemic strokesymptomonset
orpatientlastknown welloratbaselinestate.
IIb B-NR
3.Forotherwiseeligiblepatientswithmildnon-disablingstroke
symptoms(NIHSSscore0-5),IValteplase isnotrecommended
for patientswhocouldbetreated within3hoursofischemicstroke
symptom onsetorpatientlast knownwelloratbaselinestate.
III:No Benefit B-R
4.Forotherwiseeligiblepatientswithmildnon-disablingstroke
symptoms(NIHSSscore0-5),IValteplaseisnotrecommended
for patientswhocouldbetreatedwithin3and4.5hoursof
ischemicstroke symptomonsetorpatientlastknownwellorat
baselinestate.
III:No Benefit C-LD

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GeneralSupportiveCareandEmergencyTreatment
3.5IVAlteplase
3.5.4OtherSpecificCircumstances
Recommendations
COR LOE
1.IValteplasefor adultspresentingwithanAIS
withknown sicklecelldiseasecan bebeneficial.
IIa B-NR
2.InpatientswithahyperdenseMCAsign,IV
alteplasecan be beneficial.
IIa B-NR

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Exclusion Criteria of Thrombolysis
-Systolicbloodpressure> 185 mmHg, diastolicblood
pressure> 110 mmHg
-Bloodglucose<50 mg/dLor >400 mg/dL
•Symptoms ofsubarachnoidhemorrhage
•Symptoms ofinfectiveendocarditis
•Symptoms or suspectedaorticdissection
•Recent punctureofa non-compressiblevesselor lumbar
puncturewithinthe last 1 week
•Plateletcount<100,000/mm3
•Heparin treatmentin the last 48 hoursor LMWH
treatmentin the last 24 hours
•Clinical features ofpericarditisaftermyocardialinfarction
•Myocardialinfarctionwithinthe last 3 months
•Pregnancy
•Currentoral anticoagulantconsumption(INR > 1.7)
•aPTT> 40 or PT > 15
•Mild neurologic deficit (NIHSS <5).
•History of severe head trauma or stroke within the last 3
months.
•Multilobarinfarction (hypodense features > 1/3
hemisphere).
•Seizures during a stroke.
•Seizures with postictal neurologic sequelae.
•Active bleeding or acute trauma (egfracture).
•History of major surgery or serious trauma in the last 2
weeks.
•History of gastro-intestinal or urinary tract bleeding in
the last 3 weeks.
•History of intracranial/spinal surgery within the last 3
months.
•History of intracranial hemorrhage
•Patients with intra-axial intracranial tumors

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Tata laksana
hipertensisaat
trombolisis
Tekanandarahsistolik>185
mmHg ataudiastolic >110
mmHg
Infusnikardipin5 mg/jam,
apabila5-15 menittekanan
darahbelumresponsive
naikkandosisnikardipindrip
2,5 mg/jam, saattekanan
darahyangdiinginkan
tercapai, turunkanmenjadi3
mg/jam
Monitor tekanandarahtiap
15 menitpada2 jam
pertama, monitor tekanan
darahtiap30 menitselama6
jam berikutnya, kemudian
setiapjam selama16 jam.

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Acute
Phase
Managem
ent
BP
HYPO
GLIKE
MIA
Ventriculostomy
or
decompression
surgery if
needed
Monitori
ng after
thrombo
lysis

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Petunjuk untuk rekonstitusiTrombolisisIV
Informasi Produk Lokal Actilyse® 2021
Larutkansegerasebelum
diberikan.
Lepaskan tutup pelindung pada dua
botol kecil berisi air steril dan zat
kering Actilyes dengan cara
membaliknya menggunakan ibu jari.
Bersihkanbagianataskaret
setiapbotoldengantisu
alkohol.
Lepaskankanulatransfer*dari
penutupnya.Janganmendisinfeksi
ataumensterilkankanulatransfer;
kanulatersebutsteril.Lepaskan
satututupnya.
Letakkanbotolairsteriltegaklurusdiatas
permukaanyanglembut.Dariatas,tusuk
sumbatkaretsecaravertikaldibagiantengah
sumbatdengankanulatransfer,dengan
menekandenganlembutnamunkuat,tanpa
menggoyangkannya.
Pegangbotolairsteril
dankanulatransfer
dengansatutangan
menggunakan kedua
penutupsamping.
Lepaskantutupyang
tersisadiataskanula
transfer.
Pegangbotolberisizatkering
Actilysediataskanulatransfer
danposisikanujungkanula
transfertepatditengahsumbat.
Dorongvialberisizatkeringke
kanulatransferdariatas,tusuk
karetnyadengankuattanpa
memutar.
Balikkankeduabotoldanbiarkan
airterkurasseluruhnyakedalam
zatkering. (*jikakanulatransferdisertakan
dalamkit.Rekonstitusijugadapat
dilakukandenganspuitdanjarum)
Step 1 Step 2 Step 3 Step 4 Step 5
Step 6
Step 7A
Step 7B Step 8A Step 8B

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Petunjuk untuk rekonstitusiTrombolisisIV
Keluarkanbotolairkosong
besertakanulatransfer.
Botol-botoltersebutdapat
dibuang.
AmbilbotolkecilberisiActilyse
yangtelahdilarutkan,laluaduk
perlahanuntukmelarutkansisa
bubuk,tetapijangandikocok
karenaakanmenimbulkanbusa.
Jikaadagelembung,diamkan
larutanselamabeberapamenit
agargelembunghilang.
Larutannyaterdiridari1mg/mL
Actilyse.Larutannyaharusbening
dantidakberwarnahinggakuning
pucatdantidakmengandung
partikelapapun.
Keluarkanjumlahyangdibutuhkan
menggunakanjarumdanspuit.Jangan
gunakanlokasitusukandarikanula
transferuntukmenghindarikebocoran.
Gunakansegera.
Buangsemualarutanyangtidak
digunakan.
Step 9
Step 10A
Step 10B Step 11 Step 12
Step 13

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Andria L. Ford, MD Expanding the Therapeutic Window for Acute Ischemic Stroke: New Agents, New Approaches
GEJALA STROKE < 24 JAM BOLEH DILAKUKAN
TROMBEKTOMI MEKANIK (2018)

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MONITORING PASCA IV THROMBOLISIS
Perdarahan (stroke perdarahan, retroperitoneal atautraktusgastrointestinal, genitourinariadan
respiratori, tempattusukaninfusvena maupunarteri, bekasoperasiyang masihbaru
Reaksi alergi atau angioedema
Lakukanpenilaianneurologissetiap15 menit selamapemberianinfusdan setiap30
menitsetelahnyaselama6 jam berikutnya, kemudiantiapjamhingga24 jamsetelah
terapi→catatvsdalamkertasobservasi. Pantau tanda vital dan status neurologis
nyerikepalaberat, tekanandarahmeningkat, mual, ataumuntah
Apabiladiperlukanpemasangantube nasogastrik, kateter urin tundasampai24 jam
paskapemberianrtPA(Alteplase) kecualitindakantersebutsangat diperlukan.
Pemberianantikoagulanatauantiplateletsebagaiprevensisekunderdiberikandalam24
jam pertama.
ischemia ulang atau re-occlusion (stroke sumbatan berulang)

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GeneralSupportiveCareandEmergency
Treatment
2
9
3.1Airway,Breathing,andOxygenation
Recommendations COR LOE
1.Airwaysupportandventilatoryassistancearerecommendedfor
thetreatmentofpatientswithacutestrokewhohavedecreased
consciousnessorwhohave bulbardysfunctionthatcauses
compromiseof theairway.
I C-EO
2.Supplementaloxygenshould beprovidedtomaintainoxygen
saturation>94%. I C-LD
3.Supplemental oxygenisnotrecommendedinnonhypoxicpatients
withAIS. III:No Benefit B-R
4.Hyperbaricoxygen(HBO)isnotrecommendedforpatientswith
AISexceptwhencausedbyairembolization.
III:No Benefit B-NR

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The main causes of death 10 years after first CI.
21.7
21
13.6
9
7.4
5.3
4.3
3.2
3.2
8
CARDIAC
PNEUMONIA
INITIAL STROKE
RECURRENT STROKE
MALIGNANCY
SEPSIS
RENAL FAILURE
COPD
SUD
GI BLEEDING
PE
ALL OTHER
FREQUENCY %
1.8
1.2
CAUSES OF DEATH IN STROKE PATIENTS DURING 10 YEARS OF FOLLOW-UP, 310 DEATHS OCCURRED AMONG 444 CI PATIENTS
CAUSE OF DEATH AFTER FIRST CI. DURING 10 YEARS OF FOLLOW-UP,
310 DEATHS OCCURRED AMONG 444 CI PATIENTS.
IDENTIFIED CAUSES OF DEATH ARE SHOWN IN ORDER OF FREQUENCY.
“CARDIAC” DEATH INCLUDES FATAL MYOCARDIAL INFARCTION, FATAL ARRHYTHMIA, AND
CONGESTIVE HEART FAILURE.
COPD INDICATES CHRONIC OBSTRUCTIVE PULMONARY DISEASE; SUD, SUDDEN
UNEXPECTED; GI BLEEDING, FATAL GASTROINTESTINAL TRACT BLEEDING; PE, FATAL
PULMONARY EMBOLISM.
Stroke. 2003;34:1828-1832

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Fase 3: Fase pengobatanakut
0-7
(n=36)
7-30
(n=38)
31-365
(n=54)
CAUSE OF DEATH %
200 10 30 40 50
PULMONARY
CARDIAC
INITIAL CI
RECURRENT STOKE
PEMERIKSAAN NEUROLOGIS SECARA RUTIN DAPAT MENUNJUKKAN
KEMUNDURAN INFARK OTAK AWAL.
PENCEGAHAN TERJADINYA KEMATIAN JANTUNG AKIBAT INFARK MIOKARD,
GAGAL JANTUNG KONGESTIF DAN ARITMIA YANG FATAL DILAKUKAN MELALUI
PEMANTAUAN KETAT DAN PENGOBATAN YANG KOREKTIF TERHADAP PENANDA
DAN TANDA KEJAHATAN JANTUNG PADA PEMANTAUAN JANTUNG.
PENCEGAHAN KEMATIAN KARENA PENYEBAB PERNAPASAN TERMASUK
PNEUMONIA, INFEKSI DADA, DAN PPOK DAPAT DILAKUKAN MELALUI
TINDAKAN SEPERTI MEMBAWA PASIEN NPO SAMPAI PEMERIKSAAN TELAN
TELAH DILAKUKAN. HIPERTERMIA DAPAT MENJADI INDIKASI INFEKSI.
Steven Vernino et al. Stroke. 2003;34:1828-1832

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FASE 3: Fase pengobatanakut
Guidelines Ischaemic Stroke 2008
SUHU TUBUH
KESEIMBANGAN
CAIRAN
STATUS
NEUROLOGI
TEKANAN
DARAH
PERAWATAN
PARU-PARU
DAN JALAN
PERNAPASAN
METABOLISME
GLUKOSA

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Fokus pada fase perawatan akut
KEMUNDURAN NEUROLOGIS
GCS, PUPIL
STATUS NEUROLOGIS
PENYAKIT KARDIOVASKULAR
GDS,
TD
DETAK JANTUING
PENYAKIT PERNAFASAN
O
2 SATURASI
RR
PEMANTAUAN BERKALA TERHADAP STATUS NEUROLOGIS, NADI, TEKANAN DARAH, SUHU DAN SATURASI OKSIGEN
DIREKOMENDASIKAN SELAMA 72 JAM PADA PASIEN DENGAN DEFISIT NEUROLOGIS BERKELANJUTAN YANG SIGNIFIKAN (KELAS IV, GCP)

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1a. LEVEL OF CONSCIOUSNESS:
0 Alert
1 Not alert, but arousable by minor stimulation
2 Not alert, requires repeated stimulation to attend
3 Coma
1b. LOC QUESTIONS:
Ask the patient the month and their age
0 Answers both correctly
1 Answers one correctly
2 Answers neither correctly
1C. LOC COMMANDS:
Ask the patient to open/close eyes and grip/release a fist
0 Performs both correctly
1 Performs one correctly
2 Performs neither correctly
2. BEST GAZE:
Only horizontal eye movements
0 Normal
1 Partial gaze paralysis
2 Forced gaze paralysis
3. VISUAL FIELDS:
0 No loss of visual field
1 Partial hemianopia
2 Complete hemianopia
3 Bilateral hemianopia (blind, including cortical blindness).
4. FACIAL PARALYSIS:
Ask the patient to raise their eyebrows, squeeze their eyes shut
and show their teeth
0 Normal symmetrical movement
1 Minor paresis (loss of nasolabial fold, asymmetry on smiling).
2 Partial paralysis (total or near-total paralysis of lower face).
3 Complete paralysis of one or both sides (absence of facial
movement in the upper and lower face)
5. ARM MOTOR FUNCTION:
Right and left
0 Normal (extends arm 90º if sitting/45º if supine for 10
seconds without dropping)
1 Drifts
2 Some effort against gravity
3 No effort against gravity
4 No movement
9 Untestable –not scored (joint fusion or limb amputation)
NIHSS
6. LEG MOTOR FUNCTION:
Right and left
0 Normal (holds leg at 30º for 5 seconds without dropping)
1 Drifts
2 Some effort against gravity
3 No effort against gravity
4 No movement
9 Untestable –not scored (joint fusion or limb amputation)
7. LIMB ATAXIA
0 No ataxia
1 Present in one limb
2 Present in two limbs
8. SENSITIVITY:
Use needle. Examine face, arms, trunk and legs, comparing both sides
of body
0 Normal
1 Mild to moderate reduction in sensitivity
2 Severe or total loss of sensitivity
9. LANGUAGE:
Ask the patient to describe a picture and to name objects
0 No aphasia
1 Mild to moderate aphasia
2 Severe aphasia
3 Mute or global aphasia
10. DYSARTHRIA:
Ask the patient to read various words
0 Normal articulation
1 Mild to moderate dysarthria
2 Speech almost unintelligible or impossible to understand
(anarthria)
9 Intubated or other physical barrier (do not add to score)
11. EXTINCTION AND INATTENTION:
Use double sensory stimulation
0 Normal
1 Inattention or extinction to simultaneous bilateral stimuli in one
sensory modality
2 Severe hemi-inattention or in more than one sensory
modality

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8 208 20
MILD
NIHSS
(National Institute of Health Stroke Scale)
01234567 910111213141516171819 21222324
SEVEREMODERATE

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Skala Neurologis
GCS
TINGKAT KESADARAN
MENILAI RESPON VISUAL, RESPON VERBAL DAN RESPON MOTOR
RESPONSE RESULT
Visual 4 -Spontaneous
3 -Verbal order
2 -Pain
1 -No response
Verbal 5 -Orientated and conversing
4 -Disorientated and talking
3 -Inappropriate words
2 -Incomprehensible sounds
1 -No response
Motor 6 -Verbal order –obeys
5 -Locates pain
4 -Withdrawal and flexion
3 -Normal flexion
2 -Extension
1 -No response

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LevelDescription
0 Tidakadagejala
1
Tidakadadisabilitasyang signifikan, meskipunadagejala; mampu
melakukansemuatugasdan aktivitassepertibiasa
2
Disabilitasringan; tidakmampumelakukansemuaaktivitas
sebelumnyanamunmampumengurusdirisendiritanpabantuan
3
Disabilitassedang; memerlukanbantuan, tetapimampuberjalantanpa
bantuan
4
Disabilitassedangberat; tidakdapatberjalantanpabantuandan tidak
dapatmemenuhikebutuhantubuhnyasendiritanpabantuan
5
Disabilitasberat; berbaringdi tempattidur, tidakdapatmengendalikan
buangair kecildan memerlukanperawatandan perhatianperawat
PENILAIAN DISABILITAS DALAM JANGKA PANJANG
PENILAIAN PADA SAAT KELUAR RUMAH SAKIT DAN 3 BULAN
PENTING SAAT MEMUTUSKAN PENGOBATAN FASE AKUT
SKALA NEUROLOGIS
Modified
Rankin Scale

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Hyperglycaemia
1
Stöllberger C, et al. Ann Med 2005;37(5):357-364.
7
Allport L, et al. Diabetes Care 2006;29(8):1839-1844;
8
Scott JF, et al. Lancet1999;353(9150):376-377.
9
Capes SE, et al. Stroke2001;32(10):2426-2432;
10
Weir CJ, et al. Br Med J 1997;314(7090):1303-1306.
HINGGA 50% INSIDEN DALAM 48 JAM
PERTAMA
7,8
DI SELURUH SUBTIPES STROKE
8,9
GLUKOSA >8 MMOL/L PREDIKTOR
PENINGKATAN MORTALITAS & HASIL
FUNGSIONAL YANG LEBIH BURUK
10
PASIEN HIPERGLIKEMI NON-DIABETIK
YANG DIMASUKKAN KE RUMAH
SAKIT DENGAN STROKE ~3X LEBIH
BESAR KEMUNGKINAN MENINGGAL
DARIPADA YANG TIDAK
HIPERGLIKEMI9
0
< 5.7
35
25
10
5
50
45
40
30
20
15
5.7 –7.1 7.2 –9.2 > 9.2
Serum glucose levels (mmol/L)
Case fatality (%)
non-diabetic
diabetic
GLUCOSE LEVELS AT ADMISSION AND CASE FATALITY
1

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>56.000 PASIEN DENGAN STROKE DAN TROMBOLISIS I.V.
GLUKOSA DARAH > 140 MG/DL (DAN > 200 MG/DL) DAN PENINGKATAN HbA1c BERHUBUNGAN DENGAN TRANSFORMASI
PERDARAHAN YANG LEBIH BESAR DAN KEMATIAN DI RUMAH SAKIT
Hiperglikemiadan ICH/mortalitaspada stroke akut
Masruret al. J Am Heart Assoc. 2015;4:e002193
Diabetic patients
Non-diabetic patients
Mortality
0.00
0.05
0.10
0.15
0.20
Probability
15
HbA1c (5)
5 10
ICH
Probability
0.10
0.08
0.06
0.02
0.00
150
Glucose (mg/dL)
50 100 200
0.04
Mortality
0.12
0.08
0.06
0.02
0.00
150
Glucose (mg/dL)
50 100 200
0.04
0.10
Diabetic patients
Non-diabetic patients
Probability

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Metabolismeglukosa
BACKGROUND
HIPOGLIKEMIA DAPAT MENYERUPAI INFARK ISKAEMIK AKUT
KADAR GLUKOSA TINGGI PADA STROKE AKUT DAPAT MENINGKATKAN UKURAN INFARK DAN MENGURANGI HASIL FUNGSIONAL
PENGGUNAAN RUTIN REGIME INFUSI GLUKOSA KALIUM INSULIN (GKI) PADA PASIEN DENGAN HIPERGLIKEMIA
RINGAN HINGGA SEDANG TIDAK MENINGKATKAN HASIL
1
MENGOBATI HIPERGLIKEMIA DENGAN
INSULIN KETIKA GLUKOSA DARAH MELEBIHI 180 MG/DL2 (10 MMOL/L)
1: GrayCS et al.: Lancet Neurol(2007) 6:397-406
2: Langhorne P et al.: Age Ageing (2002) 31:365-71
Guidelines Ischaemic Stroke 2008
PEMANTAUAN KADAR GLUKOSA SERUM DISARANKAN (KELAS IV, GCP)

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BACKGROUND
BP TURUN SECARA SPONTAN PADA HARI-HARI PERTAMA SETELAH STROKE
MENINGKAT PADA >> PASIEN STROKE AKUT
ALIRAN DARAH DI PENUMBRA KRITIS SECARA PASIF TERGANTUNG PADA TEKANAN ARTERI RATA-RATA
TIDAK ADA STUDI ACAK DAN TERKONTROL YANG BERUKURAN CUKUP UNTUK MEMANDU PENANGANAN BP
Tekanandarah
Guidelines Ischaemic Stroke 2008
HINDARI PENURUNAN TD SECARA DRASTIS

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GeneralSupportiveCareandEmergencyTreatment
4
2
3.2BloodPressure
Recommendations COR LOE
1.Hypotensionandhypovolemiashouldbecorrectedto
maintain systemicperfusionlevelsnecessarytosupport
organfunction.
I C-EO
2.PatientswhohaveelevatedBPandareotherwiseeligible
fortreatmentwithIValteplaseshouldhavetheirBPcarefully
lowered sothattheir SBPis <185mmHgandtheir diastolic
BPis <110mm Hgbefore IV fibrinolytictherapyisinitiated.
I B-NR
3.Inpatientsforwhommechanicalthrombectomyisplanned
and whohavenotreceivedIVfibrinolytictherapy,itis
reasonableto maintainBP≤185/110mmHgbeforethe
procedure.
IIa B-NR
4.Theusefulnessofdrug-inducedhypertensioninpatientswith
AIS is notwellestablished.
IIb B-R

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3.5IVAlteplase
3.5.6Post-AlteplaseTreatment
Recommendations
COR LOE
1.BPshouldbemaintainedat<180/105mm Hgforatleast
the
first 24hoursafterIValteplasetreatment.
I
B-R
2.Theriskofantithrombotictherapy(otherthanIV
aspirin) withinthefirst24hoursaftertreatmentwithIV
alteplase(with orwithoutmechanicalthrombectomy)is
uncertain.Usemight beconsideredinthepresenceof
concomitantconditionsfor whichsuchtreatmentgivenin
theabsenceofIValteplaseis knowntoprovide
substantialbenefitorwithholdingsuch treatmentis
knowntocausesubstantialrisk.
IIb B-NR
Mainelementsofpost-thrombolysiscarearelistedinseparatetable

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3.2BloodPressure
OptionstoTreatArterialHypertensioninPatientsWithAISWhoAreCandidatesforAcuteReperfusion
Therapy*
ClassIIb LOEC-EO
PatientotherwiseeligibleforacutereperfusiontherapyexceptthatBPis>185/110mm Hg:
Labetalol10–20mgIVover1–2min,mayrepeat1time;or
Nicardipine5 mg/h IV, titrate up by 2.5 mg/h every 5–15 min, maximum 15 mg/h; when desired BP reached, adjust to
maintain properBPlimits;or
Clevidipine1–2mg/hIV,titrateby doublingthedoseevery2–5minuntildesiredBPreached;maximum21mg/h
Otheragents(eg,hydralazine,enalaprilat)may alsobeconsidered
IfBPisnotmaintained≤185/110mm Hg,donotadministeralteplase
ManagementofBPduringand afteralteplaseorotheracutereperfusiontherapytomaintainBP ≤180/105mm Hg:
MonitorBPevery15min for2hfromthestartofalteplasetherapy, thenevery30 minfor6h,andtheneveryhourfor16
h
IfsystolicBP>180–230mm HgordiastolicBP>105–120mm Hg:
Labetalol10mg IV followedbycontinuousIV infusion2–8mg/min;or
Nicardipine5mg/hIV,titrateuptodesiredeffectby2.5mg/hevery5–15min, maximum15 mg/h;or
Clevidipine 1–2mg/hIV,titratebydoublingthedoseevery2–5minuntildesiredBPreached;maximum21mg/h
IfBPnotcontrolledordiastolicBP>140mm Hg,considerIVsodiumnitroprusside
*Different treatment options may be appropriate in patients who have comorbid conditions that may benefit from acute
reductionsin BPsuchasacute coronaryevent,acuteheartfailure,aorticdissection,orpreeclampsia/eclampsia.
DataderivedfromJauchetal.Stroke.2013;44:870-947

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SPECIFIC ISSUES
TEKANAN DARAH
TekananDarah HARUS DIPERTAHANKAN < 180/105 mmHg SEKURANG-KURANGNYA 24 JAM PERTAMA SETELAH TERAPI TROMBOLIT
1
HINDARI DAN OBATI HIPOTENSI
HINDARI PENURUNAN TD SECARA DRASTIS
1: 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke
-A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
Guidelines Ischaemic Stroke 2008
PADA STROKE ISKEMIK AKUT, TUJUAN TD 180/110

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Hypertension
POST-THROMBECTOMY
PADA STROKE ISKEMIK AKUT, TUJUAN TD 180/110
JIKA REKANALISASI SELESAI, DAPAT MENURUNKAN TD SISTOLIK HINGGA 140
mmHg, UNTUK MENCEGAH TRANSFORMASI HEMORAGIS
NORMAL SALINE (0,9%) DIREKOMENDASIKAN UNTUK PENGGANTIAN CAIRAN
SELAMA 24 JAM PERTAMA SETELAH STROKE (KELAS IV, GCP)
PENURUNAN TEKANAN DARAH SECARA HATI-HATI DISARANKAN PADA
PASIEN DENGAN SALAH SATU DARI YANG BERIKUT INI:
TEKANAN DARAH SANGAT TINGGI (>220/120 MHG) PADA PENGUKURAN
BERULANG, ATAU GAGAL JANTUNG YANG PARAH, DISEKSI AORTA, ATAU
ENSEFALOPATI HIPERTENSI (KELAS IV, GCP)

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vsHypertension
POST-THROMBECTOMY
TICI 0 TICI 1 TICI 2a TICI 2b TICI 3

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Hypertension vs
BP
180/105

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Dysphagia Assist & GUSS
GUSS: https://doi.org/10.1161/STROKEAHA.107.483933Stroke. 2007;38:2948–2952
ASSIST: Developed and prepared by E Katalinicand C Quinn, Price of Wales Hospital Speech Pathology Department, Sydney, NSW. Supported by the Quality in Acute Stroke
Care (QASC) Implementation Project Team. The QASC Implementation Project created by the NSW Agency for Clinical Innovation (ACI)in partnership with the Nursing
Research Institute (NRI), a joint initiative between St Vincent’s & Mater Health Sydney and the Australian Catholic University

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SATURASI OKSIGEN
JIKA SATURASI O2 ≤ 95, MULAI
TERAPI OKSIGEN
ANGKAT KEPALA HINGGA 30-45º,
TERUTAMA PADA PASIEN DISFAGIA
ASPIRASI SEKRESI BRONKIAL
RISIKO TERJADINYA OBSTRUKSI JALAN NAPAS
(MUNTAH, HIPOTONIA OTOT OROPHARING):
PERLINDUNGAN JALAN NAPAS MEKANIK
OKSIGENASI YANG CUKUP ADALAH
PENTING
JIKA TIDAK TERJADI HIPOKSEMIA, TERAPI
OKSIGEN PENCEGAHAN TIDAK
DIREKOMENDASIKAN

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BACKGROUND
DEMAM MENINGKATKAN UKURAN INFARK PADA STROKE EKSPERIMENTAL
DEMAM BERHUBUNGAN DENGAN HASIL NEUROLOGIS YANG LEBIH BURUK SETELAH STROKE
BANYAK PASIEN STROKE AKUT YANG MENGALAMI INFEKSI DEMAM
PerawatanantipiretikSEGERA diperlukan(parasetamol1 g / metamizol2 g iv.)
Temperature
Guidelines Ischaemic Stroke 2008

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GeneralSupportiveCareandEmergencyTreatment
3.3Temperature
Recommendations COR LOE
1. Sources of hyperthermia (temperature >38°C) should be
identified and treated, and antipyretic medications should be
administered to lower temperature in hyperthermic patients
withstroke.
I C-LD
2.In patientswithAIS,thebenefitoftreatmentwith induced
hypothermiaisuncertain.
IIb B-R

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3.5IVAlteplase
5
3
3.5.1General Principles
Recommendations COR LOE
1.InpatientseligibleforIValteplase,benefitoftherapyistimedependent,
and treatmentshouldbeinitiatedasquicklyaspossible. I A
2.Inpatientsundergoingfibrinolytictherapy,physiciansshouldbeprepared
totreatpotentialemergentadverseeffects,includingbleeding
complicationsandangioedemathatmaycausepartialairwayobstruction.
I B-NR
3. Thepotentialrisks should bediscussedduringIValteplaseeligibility
deliberation and weighedagainsttheanticipated benefitsduringdecision
making.
I C-EO
4.Treatingcliniciansshouldbeawarethathypoglycemiaand hyperglycemia
may mimic acutestrokepresentationsanddeterminebloodglucoselevels
beforeIV alteplaseinitiation.IValteplaseisnotindicatedfornonvascular
conditions.
III:No BenefitB-NR
5.Becausetimefromonsetofsymptomstotreatmenthassuch apowerful
impact onoutcomes,treatmentwithIValteplaseshouldnotbedelayedto
monitorfor furtherimprovement.
III:Harm C-EO

54. GeneralSupportiveCareandEmergencyTreatment
EligibilityRecommendationsforIVAlteplasein PatientswithAIS

55. GeneralSupportiveCareandEmergencyTreatment
EligibilityRecommendationsforIVAlteplase inPatientswithAIS
Continued

56. GeneralSupportiveCareandEmergencyTreatment
EligibilityRecommendationsforIVAlteplase inPatientswithAIS
Continued

57. GeneralSupportiveCareandEmergencyTreatment
EligibilityRecommendationsforIVAlteplase inPatientswithAIS

58. GeneralSupportiveCareandEmergencyTreatment Treatment
ofAIS: IVAdministrationofAlteplase

59. GeneralSupportiveCareandEmergencyTreatment
Managementof SymptomaticIntracranialBleedingOccurringWithin24
HoursAfterAdministrationofIVAlteplasefor TreatmentofAIS

60. GeneralSupportiveCareandEmergencyTreatment Managementof
OrolingualAngioedemaAssociatedwithIVAlteplaseAdministrationforAIS

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6
1
3.6OtherIVFibrinolyticsandSonothrombolysis
Recommendations COR LOE
1.Itmaybereasonable tochoosetenecteplase(single IVbolusof0.25
mg/kg,maximum25mg)overIValteplaseinpatientswithout
contraindicationsforIVfibrinolysiswhoarealsoeligibletoundergo
mechanicalthrombectomy.
IIb B-R
2.Tenecteplaseadministered asa0.4mg/kgsingleIVbolushasnot
beenproventobesuperior ornoninferiortoalteplasebut mightbe
consideredasanalternativetoalteplaseinpatientswithminor
neurologicalimpairmentandnomajorintracranialocclusion.
IIb B-R
3. TheadministrationofIVdefibrinogenatingagentsorIVfibrinolytic
agentsotherthanalteplaseandtenecteplaseisnotrecommended. III:No Benefit B-R
4.TheuseofsonothrombolysisasadjuvanttherapywithIVfibrinolysisis
notrecommended.
III:No Benefit
A

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TERIMA KASIH