Diagnosis dan Tatalaksana Awal

Stroke Hemorhagik dan

Iskhemik di IGD pada era
Intervensi Neurologi
Dr. Nurullah Armyta SpBS
STROKE
Initial Evaluation

Patients with suspected acute stroke should have a rapid initial evaluation for airway, breathing
and circulation [Evidence Level B]

A neurological examination should be conducted to determine focal neurological deficits and

assess stroke severity [Evidence Level B]. A standardized stroke scale should be used

Monitoring in the acute phase should include heart rate and rhythm, blood pressure,
temperature, oxygen saturation, hydration, swallowing ability, and presence of seizure activity
[Evidence Level B].
Acute blood work, including routine chemistry, electrolytes, hematology and coagulation should
be conducted as part of the initial evaluation [Evidence Level B]

Electrocardiogram and chest X-ray should be completed, especially where the patient has a
clinical history or evidence of heart disease or pulmonary disease [Evidence Level B]
 Neurovascular imaging

All patients with suspected acute stroke or transient ischemic attack should
undergo brain imaging (MRI or CT) immediately [Evidence Level A], and
vascular imaging of the brain and neck arteries as soon as possible [Evidence
Level B]
TIME is Brain
Aim door to needle <60 min (Class 1
level A)
On Arrival at Emergency
If approximate onset time is < 4 hour. Take blood for urgent.

Ensure that Responsible Consultant is aware that the patient may be

suitable for thrombolysis

Speak to the on call radiologist to request an urgent C.T. Scan and CTA if
available.
Record baseline observations and commence continuous monitoring
Within 30 minutes of Arrival
Determine definite onset time.
A word of caution with right sided strokes (i.e. left hemiparesis etc.) they
can be unreliable with time of onset and dont appreciate early signs of
stroke.
If collateral is not immediately available from the patient or relative contact
the person who contacted the GP or ambulance service. IF NECESSARY
SPEAK TO THE GP OR AMBULANCE CREW.
Confirm that consent can be obtained
Check availability of rt-PA
Insert 18G I.V. Cannulae into both arms.
45 minutes Arrival
Chase blood results
Record NIHSS, Pre stroke Rankin .Confirm that the patient meets all of the
inclusion and none of the exclusion criteria.
Calculate dose of rt-PA from either actual or estimated body weight. (See
weight / dose chart overleaf)
Scheduled Monitoring
Kriteria Inklusi
Stroke iskhemik yang mengakibatkan defisit neurologis yang terukur seperti
bahasa, motorik, kognitif, penglihatan dan harus dapat dibedakan secara
jelas dengan episode iskhemik general(syncope, kejang, migraine).

Onset gejala dalam 4,5 jam (class1,levelA)

Ct scan normal atau sesuai dengan fase akut

Mechanical Thrombectomy
 Sebaiknya dilakukan tindakan dengan stent retriever(mechanical
Trombektomi) apabila terpenuhi kriteria sbb:
- pre stroke mRS score 0 to 1
- telah mendapat r-tPA iv dalam 4,5 jam dari onset
- sumber oklusi di ICA atau MCA proximal (M1)
- usia lebih dari 18 tahun
- NIHSS lebih besar sama dengan 6
- ASPECTS lebih besar dari6
- Puncture dalam waktu 6 jam setelah onset
Pre Solitaire
solitaire
Solitaire
SAH
Acute Evaluation-Diagnosis
The worst headache of my life is described by ~80% of patients

Sentinel headache is described by ~20%

Nausea/vomiting, stiff neck, loss of consciousness, or focal

neurological deficits may occur

Misdiagnosis of SAH occurred in as many as 64% of cases prior to

1985

Recent data suggest an SAH misdiagnosis rate of approximately 12%

 The diagnostic sensitivity of CT scanning is not 100%, thus diagnostic
lumbar puncture should be performed if the initial CT scan is negative

Up to 14% of SAH patients may experience re-bleeding within 2 hours

of the initial hemorrhage

Re-bleeding was more common in those with a systolic blood

pressure >160mm Hg