PREVENTI

ON
dr. Yudityarini SpS

Global Burden of Stroke

1990

2020

Lower resp. infections

Diarrhoeal diseases

Conditions arising
3
during the perinatal period

Ischemic
1
heart disease
Unipolar
2
major depression
Road
3
traffic accidents
Cerebrovascular
4
disease

Unipolar major depression

Ischemic heart disease

5Chronic obstructive
pulmonary disease

Cerebrovascular disease

Lower
6 respiratory infections

Murray JL et al. Lancet. 1997;349:1436-1442.

Prevalence of Stroke by Age and Sex

Source: CDC/NCHS.
7/26/16

Apa tanda stroke ?

MENDADAK

THE BASIC CLASSIFICATION OF STROKE

( Albers GW, et al 1998 )

Stroke

85%

15%

Primary hemorrhage
Intraparenchymal
Subarachnoid

Ischemic stroke

20%
Atherosclerotic
cardiovascular
disease

Hypoperfusion
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25%

20%

Penetrating
artery disease
(lacunes)

Cardiogenic
embolism
Atrial
fibrilation
Valve
disease
Ventricular
thrombi
Many others

30%
Cryptogenic
stroke

5%
Other, unusual
causes
Prothrombic
states
Dissections
Arteritis
Migrane /
vasospasm
Drug abuse
Many more

Arteriogenic
emboli
5

DIFFERENT KINDS OF STROKE

INCIDENCE OF THE MAIN CAUSES OF STROKE

Anatomi.

Vascularization :
Carotid artery (2)
80% supply for brain
demand.
Vertebral art (2) 20%
brain demand
kolateral formation
Willis circle constant
supply

ARTERIAL TERRITORRIES OF CEREBRAL HEMISPHERES

LEFT (FRONTAL); RIGHT (HORIZONTAL)

3
1

1 = nucleus lentiformis (globus pallidus + putamen); 2 = thalamus; 3 = nucleus caudatus

Red =a.cerebri ant. Green =a.cerebri med. Yellow =a.cerebri post. Light blue =a.choroidea
ant. Dark green =a.choroidea post. Dark blue =a.commun.post

Acute Ischemic Stroke (AIS)

IS A MEDICAL :
Major damage occurs in
the first 3 hours
The most effective drug
can not be used after 3 hours
The patient is rarely seen
before 3 hours after onset
of the insult
Dr.J.Husada 11-2003

CBF decrement Ischemic Brain Injury

( series of interlocking threshold )

CBF
%
50

NORMAL
RANGE

Maintained by autoregulation;
higher CBF in gray matter

80

40

OLIGEMIA

Increased O2 extraction
may maintain normal CMRO2

60

30

40

20

20
0

10
0

ISCHEMIA

100

MILD

? Glycolysis
? Protein synthesis
THRESHOLD OF ELECTRICAL FAILURE

MODERATE
SEVERE

The Penumbra
THRESHOLD OF IONIC FAILURE
Anoxic deporalization
( ECF K+ & ECF Ca++)

Depiction of hypothetical flow gradient over the

convexity of a primate hemisphere subjected to acute
proximal middle cerebral artery (MCA) occlusion

E
T
A
L
L
CO

L
A
R

W
O
FL

Normal
Oligemia
Mild Ischemia
The Penumbra
Severe Ischemia

Diagram of a human brain showing an area of infarction where

blood flow is very low ( 0 to 20 ml/1000 g/min) surrounded by an
area called the penumbra where blood flow is reduced (20 to 50
ml/100 g/min) below normal

Penumbra (20-50)

Core (0-20)

Outcomes After Ischemic

Stroke
Stroke Recurrence
30 day
3%-10%
1 year
5%-14%
5 year
25%-40%
Mortality
30 day
8%-20%
1 year
15%-25%
5 year
40%-60%

acco RL. Neurology. 1997;49(suppl 4):S39-S44.

Functional Disability
24%-53% of stroke
survivors with complete
or partial dependence
Quality of Life
27% decrement in mean
quality of well-being
score at 6 months
Dementia or Cognitive
Decline
34% at 52 weeks
poststroke

INTRA CEREBRAL HAEMORRHAGE

7/26/16

JHN

17

AVM

7/26/16

18

ANEURYSMA CEREBRAL

7/26/16

19

(Hematoma enlargement extremely rare after 24 hrs) (Mayer

STROKE RISK FACTORS

Stroke risk factors are divided
into:
1. Nonmodifiable stroke risk
factors
2. Modifiable stroke risk
factors
- Well documented
- Less well documented

NONMODIFIABLE STROKE RISK FACTORS

(Jamieson AAN 2000)

AGE
GENDER
HEREDITARY
RACE-ETHNICITY

FAKTOR RESIKO YANG TIDAK

DAPAT DIMODIFIKASI

UMUR
Determinan stroke yang paling kuat adalah umur.
Insiden stroke

Kebanyakan stroke terjadi pada usia > 65

th.
Contoh: di Taiwan, Age-specific incidence rates
10 x (25 th) yaitu 100 per 100.000 per
usia 38 th 1.000 per 100.000 (usia 63
th).
Di Rochester, Minnesoka, Incidence rate
10% per tahun usia.

JENIS KELAMIN
Perbedaan jenis kelamin dalam insiden dan mortalitas
stroke menunjukkan resiko lebih besar pada laki-laki.

Menurut jenis strokenya

Ratio laki-laki : wanita

1.3 : 1

Insiden stroke lebih besar pada laki-laki dari pada wanita

yaitu di Rocheser 70%, di Swedia 66% dan di Taiwan 16%
lebih besar pada laki-laki dari pada wanita.

HEREDITAS/ BAWAAN
Stroke

Penyakit yang kompleks

dipengaruhi
- faktor-faktor genetik &
- lingkungan.

Riwayat keluarga
stroke

Faktor determinan
mortalitas stroke

Resiko stroke pada

anak-anaknya.

SUKU BANGSA DAN ETNIK

Penelitian di
Alabama &
Pensylnavia

kulit hitam mempunyai insiden

stroke lebih besar dari pada
kulit putih.

Pada National Health and Nutrition Survey, resiko stroke

pada kulit hitam lebih besar dari pada kulit putih, bahkan
sesudah pengaturan usia, hipertensi dan diabetes.

WELL DOCUMENTED MODIFIABLE

RISK FACTORS (AHA 2001)
-

Hypertension
Smoking
Diabetes
Asymptomatic carotid stenosis
Sickle cell disease
Hyperlipidemia
Atrial fibrillation

HIPERTENSI TERJADI TANPA

GEJALA
BENAR!
Hipertensi juga dikenal
sebagai silent killer karena
sering kali muncul tanpa
gejala
90% pasien muncul tanpa
gejala

Tekanan darah tinggi tidak

dapat disembuhkan, namun
dapat dikontrol agar pasien
dapat hidup lebih baik

KONSEKUENSI TEKANAN DARAH YANG

TIDAK TERKONTROL

Sixth Report of the Joint National Committee on Detection, Evaluation, and

Treatment of High Blood Pressure (JNC VI). Arch Intern Med. 1997;157:2413-2446.

HIPERTENSI DAN RESIKO STROKE

Hipertensi : faktor resiko stroke yang kuat
ke-2.
Resiko stroke ~ peningkatan tensi.
Pada Framingham study

Resiko stroke pada orang dengan

hipertensi definit (tensi > 160/95)
adalah 3.1 pada laki-laki dan 2.9
pada
wanita.
Pada
hipertensi
borderline, resiko stroke adalah 1.5
dibandingkan normotensi.

Pada British Regional Heart Study, laki-laki

dengan tekanan darah sistolik (TDS) antara
160 180 mmHg mempunyai 4x resiko
stroke dari pada laki-laki dengan TDS < 160
mmHg. Orang dengan SBP > 180
mempunyai resiko stroke 6x.
Kontrol Hipertensi

Studi prospektif dan clinical trial

menunjukkan penurunan resiko stroke
dengan mengontrol Hipertensi ringan,
sedang maupun berat pada semua
umur.

ROKOK
Perokok dan peningkatan resiko stroke

Pada Honolulu Heart Study dan Nurses Health Study

Peroko
k

prediktor independen dari

stroke iskemik dengan resiko
2.5 (laki-laki) dan 3.1
(wanita)

Pada penelitian Framingham, perokok mempunyai resiko infark

otot 1.7 (sesudah dikontrol semua faktor resiko yang lain)
Perokok berat (> 10 btg / hari) resiko 2x lipat daripada
perokok ringan ( < 10 btg / hari)

Penghentian Rokok
Prospective
Cohort
Study

Penghentian
merokok dapat
resiko stroke

RATA-RATA PEROKOK MENINGGAL 10 THN

LEBIH MUDA
97

100

81

94

80
% Survival
From Age 35

91
NON- SMOKERS

81
59

59

60

10 years

SMOKERS

40

24

20

26

0
40

50

60

70
Years

Doll R et al. BMJ. 2004;328:15191527.

80

4
90

2
100

BAHAYA KOLESTEROL YG TIDAK TERKONTROL

Plaque akibat kolesterol yang tidak terkontrol
dapat menyebabkan:
Penyempitan pembuluh darah
Aliran darah ke jantung dan otak terganggu
Menyebabkan SERANGAN JANTUNG, STROKE,
dan KEMATIAN MENDADAK

ATHEROSCLEROSI
S
Terbentuknya plaque
(penumpukan substansi
lemak yang mengeras) di
dalam pembuluh darah
Bisa terjadi di seluruh
pembuluh darah

ATHEROSCLEROSIS: PENYEKIT YANG PROGRESIF

Plaque rupture

Monocyte

LDL-C

Adhesion Macrophage
molecule

Oxidized
LDL-C
Foam cell

CRP

Smooth muscle
cells

Endothelial
dysfunction

Inflammation

Oxidation

Plaque instability
and thrombus

CRP=C-reactive protein; LDL-C=low-density lipoprotein cholesterol.

Libby P. Circulation. 2001;104:365-372; Ross R. N Engl J Med. 1999;340:115-126.

LESS WELL DOCUMENTED

MODIFIABLE RISK FACTORS (AHA 2001)
--------------------------------------------------------------------------------------- Obesity
- Hypercoagulability
- Physical activity
- Antiphospholipid antibody
- Alcohol abuse
- Factor V Leiden
5 drinks/day(not moderate)
- Prothrombin
2021D mutation

- Hyperhomocysteinemia
- Protein C deficiency
- Drug abuse
- Protein S deficiency
- Hormone replacement therapy
- Antithrombin III
deficiency

- Oral contraceptive use

- Inflammatory
processes
----------------------------------------------------------------------

OTHER STROKE RISK

FACTORS
Personality type; geographic
location; season; climate; high Na
intake; low K intake; hyperuricemia
(suggestive); hypothyroidism; migraine; plasma
fibrinogen.
Severe psychical stress; snoring
(obstructive sleep apneu); plasma
vitamin C concentration; depression;
protein-Z deficiency

Diagram
hubungan
antara
stadium
dan
pregesifitas
stroke
dan
tindakan
pencegahannya.
0-30
th

Foam
Cells

30-50 th

Fatty Intermediate
Streak
Lesion

> 50
th

Atheroma FibrousComplicated
Lesion/Rupture
Plaque

HOMOCYSTEINE AND RELATIVE

RISK OF STROKE
-------------------------------------------------------------------------------------------------Study Sex Cases/
Major endpoints tHcy (mol/L) RR (95% CI)
control
Cases Controls
-------------------------------------------------------------------------------------------------British Regional M 107/118
Fatal/nonfatal
13.7
11.7
2.8 (1.3-5.9)
Heart Study
stroke
(Pery 1995)

Physician's
M 109/427
Ischemic stroke
11.4
10.6
1.2 (0.7-2.0)
Health Study, USA
(Verhoef 1994)
North Karelia
M/F 265/269
Fatal/nonfatal
M 9.9 M 9.8 M 1.05 (0.56-1.95)
Project, Finland
MI, stroke
F 9.6 F 9.3
F 1.22 (0.6-2.78)
(Alfthan 1994)
--------------------------------------------------------------------------------------------------

Pencegahan
Stroke

primer

sekund
er

PENCEGAHAN
PRIMER

PENCEGAHAN PRIMER PADA STROKE

Meliputi :
- Perbaikan gaya hidup
- Pengendalian berbagai faktor resiko
Ditujukan kepada:
- orang sehat
- kelompok resiko tinggi yang belum
pernah terserang stroke

Pola makan sehat

Penanganan stres & istirahat
cukup
Pemeriksaan kesehatan teratur
Aktivitas fisik

Mengatur pola makan sehat

1. Makanan biji-bijian, membantu

menurunkan kadar kolesterol
Serat larut seperti beras merah,
jagung, gandum
Oat (beta glucan) : kolesterol total
& LDL, tekanan darah, nafsu
makan krn memperlambat
pengosongan usus
Kacang kedele beserta olahannya :
lipid serum, kolest.total, LDL & TG,
tetapi tidak mempengaruhi TG

 Kacang-kacangan, termasuk biji

kenari & kacang mede : LDL &
mencegah aterosklerosis.

Mekanisme kerja: menambah ekskresi asam

empedu, meningkatkan aktifitas estrogen
dari isoflavon, memperbaiki elastisitas arteri
dan meningkatkan aktivitas antioksidan
yang menghalangi oksidasi LDL.

2. Makanan lain untuk prevensi

stroke
Makanan yg mencegah peningkatan
homosistein, c : asam folat, B6, B12 ,
riboflavin
Susu mengandung protein, Ca, Zn,
B12 efek proteksi thd stroke
Ikan tuna & salmon mgd omega-3,
EPA, DHA menurunkan TG,
mencegah adesi platelet, prekursor
PG, inhibisi sitokin, stimulasi NO.
minimal 2x/minggu.

 Makanan kaya vitamin & antioksidan

spt sayur-sayuran & buah-buahan.
Minimal 5 porsi / hari. Contoh :
- sayuran hijau, jeruk : resiko stroke
- pisang : sumber kalium, prediktor kuat
mencegah mortalitas pada stroke
- apel : mgd quercetin dan
phytonutrient resiko stroke.
Teh hitam & teh hijau : mgd antioksidan

3. Anjuran terkait makanan

1. Menambah Kalium dan mengurangi
Natrium. Anjuran pada Px hipertensi :
Natrium 2,3 gram/hari, Kalium 4,7
gram/hari.
2. Mengurangi makanan tinggi lemak jenuh
& trans fatty acids, c : kue, crackers, telur,
gorengan, mentega
3. Mengutamakan makanan yg mgd
polisakarida, c : nasi, roti, pasta, kentang,
sereal. Hindari mono/disakarida (gula)

Penanganan Stres dan Istirahat

Cukup

 Istirahat cukup dan tidur teratur antara 6

8 jam sehari.
Pengendalian stres, akan menghasilkan
respon relaksasi yang menurunkan denyut
jantung dan tekanan darah. dg cara :
- berdoa pada Allah SWT
- mensyukuri hidup
- berpikir positif
- menyelesaikan pekerjaan satu demi satu
- ramah

Pemeriksaan Kesehatan secara

Teratur

 Faktor-faktor resiko seperti penyakit

jantung, hipertensi, dislipidemi, DM
harus dipantau teratur.
Dikoreksi dg pengobatan teratur, diet
dan gaya hidup sehat.
Pengendalian Hipertensi : target <
140/90 mmHg. Jika disertai DM atau
PGK < 130/80 mmHg

 Pengendalian kadar gula darah pd Px

DM : target HbA1C < 7 %.
Pengendalian kadar kolesterol pd
dislipidemi dg diet dan obat. Target
kadar kolesterol LDL <100 mg/dL.
Bila beresiko tinggi stroke target LDL
<70 mg/dL.

Aktivitas Fisik

 Pada orang dewasa,

direkomendasikan melakukan
aktivitas fisik aerobik minimal selama
150 menit ( 2 jam 30 menit) setiap
minggu dg intensitas sedang
Atau,
75 menit ( 1 jam 15 menit) setiap
minggu dg intensitas berat.
(AHA/ASA, Class I, level of evidence B)

 Efek biologis : penurunan aktivitas

platelet, reduksi fibrinogen plasma
dan meningkatnya aktivitas tPA.
Penurunan BB dg target Body Mass
Index (BMI) < 25 kg/m2, garis lingkar
pinggang < 80 cm (wanita) & < 90
cm (pria)

PENCEGAHAN
SEKUNDER

Pengendalian Faktor Resiko

Modifikasi Gaya Hidup
Pendekatan Intervensional
TIA atau stroke berulang

GUIDELINES OR CONSENSUS MANAGEMENT (1)

(WELL DOCUMENTED MODIFIABLE RISK FACTORS)(AHA 2011)
FACTOR

GOAL

RECOMMENDATIONS

Hypertension

SBP < 140 mm/Hg

DBP < 90 mm /Hg

Measure BP at least every 2 yrs.

Life style modification: weight control,
physical activity, moderation
alcohol/NaCl intake.
BP > 140/90 after 3 mos of life: habit
modification
Initial BP > 180/100: add anti-HT.

Smoking

Cessation

Encouraged patient/ family to stop

smoking. Provide counseling, nicotine
replacement, & formal programs.

Diabetes

Glucose control;
Treat HT

Diet, oral hypoglycemics, insulin

Atrial fibrillation
< 65 y, no risk factors
< 65 y, with risk factors
65-75 y, no risk factors
65-75 y, with risk factors
> 75 y, with/without risk

Aspirin
Warfarin (INR 2.5; range 2.0-3.0)
Aspirin or warfarin
Warfarin (INR 2.5; range 2.0-3.0)
Warfarin (INR 2.5; range 2.0-3.0)

GUIDELINE OR CONSENSUS MANAGEMENT (2)

WELL-DOCUMENTED MODIFIABLE RISK FACTORS (AHA 2011)
FACTOR
Asymptomatic carotid stenosis

GOAL
-

EAT = endarterectomy

Lipid
Initial evaluation (no CHD)
TC < 200 mg% & HDL 35 mg%
TC < 200 mg% & HDL <35 mg%
TC 200-239 mg% & HDL 35
& < 2 CHD risk factors
TC 200-239 mg% and HDL < 35
or < 2 CHD risk factors
TC 240 mg%
LDL evaluation
No CHD & <2 CHD risk factors
No CHD but CHD risk factors
Definite CHD /other atherosclerotic disease

Gen. Educ.

RECOMMENDATIONS
CEA with >60-<100% carotid stenosis, performed by
surgeon with <3% morbidity /mortality.
Patient selection guided by comorbid conditions, life
expectancy, patient preference, & other individual
factors.
Asymptomatic stenosis evaluated for other treatable
causes of stroke.

Repeat TC / HDL within 5 yrs/with physical exam.

Lipoprotein analysis
Dietary modification, reevaluation in 1-2 yrs
Lipoprotein analysis
Lipoprotein analysis

LDL<160
LDL<130
LDL<100

6-mo trial of diet modification.

Drug therapy if LDL remains 190 mg%
6-mo trial of diet modification.
Drug therapy if LDL remains 160 mg%
6-to 12-wk trial of step II diet.
Drug therapy if LDL remains 130 mg%

GUIDELINE OR CONSENSUS STATEMENT (1)

LESS-WELL DOCUMENTED MODIFIABLE RISK FACTORS (AHA
2011)
FACTOR

GOAL

RECOMMENDATIONS

Obesity

Prevent abdominal
obesity

Weight reduction; BMI < 30 kg/m2

Physical inactivity

30 min.of moderateintensity activity daily

Moderate exercise (brisk walking, jogging,

cycling, or other aerobic activity.
Medically supervised programs for highrisk patients (eg.cardiac disease) and
adaptive programs depending on
physical / neurological deficit.

Poor diet/nutrition

A diet containing at least 5 servings of

fruits and vegetables per day.

Alcohol abuse

Moderation

No more than 2 drinks/d for men and 1

drink/d for non-pregnant women

Drug abuse

Cessation

An in-depth history of substance abuse

should be included as part of a complete
health evaluation for all patients.

GUIDELINE OR CONSENCUS MANAGEMENT (2)

LESS-WELL DOCUMENTED MODIFIED RISK FACTORS (AHA
2011)
FACTOR

GOAL

RECOMMENDATIONS

Hyperhomocysteinemia

Plasma homocystein < 16 Folate: 400 g/d; B6: 1.7

mol/L
mg/d; B12: 2.4 g/d

Hypercoagulability:
Antiphospholipid antibody
Factor V Leiden
Prothrombin 20210 mutation
Protein C & S deficiency
Antithrombin III deficiency

Decrease coagulability

Pending further study

Hormone replacement therapy

Pending further study

Oral contraceptive

< 50 g estradiol

Avoid oral contraceptive in

women with additional risk
factors (cigarette smoking or
prior thromboembolic events)

Inflammatory processes

Avoid chronic infection:

chlamydia pneumoniae;
gingivitis

Pending further study

TREATMENT OF HHCy
(HYPERHOMOCYSTEINAEMIA)
Irrespective of its cause, > 90% of
patients respond to multivitamin
treatment within 2-6 weeks (Level IV,
Grade C).

Folic acid: 400 g/day ; Vitamin B12 : 2,4

g/day; Vitamin B6 : 1,7 mg/day

Betaine serves as an alternative methyl

donor to folic acid in the recycling of
homocysteine to methionine

 Disabilitas - : aerobik int.sedang,

30, 1-3x/mgu
Disabilitas +: rehabilitasi KV oleh
fisioterapis

Stop alkohol
stop merokok
jauhi lingkungan perokok
produk nikotin / obat oral

Olah raga
alkohol
merokok

Modifikasi Gaya Hidup

BERHENTI MEROKOK & JANGAN

MAU MENJADI PROKOK PASIF
Nikotin dalam rokok dapat meningkatkan
tekanan darah anda sebanyak 10mmHg atau
lebih selama 1 jam setelah anda merokok.
Merokok sepanjang hari akan menjaga tekanan
darah anda tetap tinggi sepanjang waktu

Faktanya
70 % perokok ingin
berhenti merokok tetapi.
HANYA 5%-10% yang
dapat melakukannya
tanpa bantuan

1.
2.
3.

Hughes JR. New treatments for smoking cessation. CA Cancer J Clin. 2000;50:143-151
FoulisJ, Burke M, Steinberg M, William JM, Ziedonis DM. Advances in pharmacotherapy for tobacco dependence. Expert Opin
Emerg Drugs. 2004;9:39-53
Department of Health. Smoking kills: a White Paper on Tobacco. London, England: Stationery Office; 1998

SILKLUS ADIKSI NIKOTIN

73

 Lumen a.karotis interna berkurang >70%

dg pmx non invasif atau >50% dg
kateteryg sulit diakses dg pembedahan
atau kondisi spesifik pasien
S.Iskemik + Stenosis a. karotis ipsilat
berat (70-99%)- class I, level of evidence
A
rStroke iskemik + stenosis a. karotis
ipsilat sedang (50-69%) class I, level of
evidence B

CAS
CEA

Pendekatan Intervensional

Riwayat TIA atau Stroke

berulang
Antiplatelet lebih dianjurkan drpd
antikoagulan
Pilihan antiplatelet:
aspirin 80 -325 mg
Clopidogrel 75 mg
Dipyridamole 2 x 200 mg
Cilostazol 2 x 100 mg
Kombinasi aspirin dosis rendah 25 mg +
dipyridamole 200 mg
(AHA/ASA, Class I, level of evidence A)

SEMOGA
BERMANFAAT

DEFINITION OF TIA
(TIA WORKING GROUP)*

Acute brain ischemic attack either

transient when the symptoms recover &
there are no residual symptoms, or
persistent when there are residual
symptoms & neurological deficits.
In most instances, the transient symptoms
are brief, lasting only minutes, and rarely
persist > 1 hour. When symptoms persists
> 1 hour, there usuallly is a persistent
neurological deficits & brain imaging
usually shows a region of damage (brain
Easton et al. Neurology 2004; 62(8) suppl 6: 832
infarct)

Batasan dan pengertian

GPDO adalah gangguan fungsi otak (fokal
maupun global), yang timbul mendadak,
berlangsung lebih dari 24 jam (kecuali bila
mengalami tindakan pembedahan atau
meninggal sebelum 24 jam ), disebabkan oleh
kelainan peredaran darah otak (WHO MONICA
PROJECT, 1995)

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79