EXECUTIVE SUMMARY

Stroke can affect all ages. The most productive age peak is between the ages of
40-60 years. Slightly more men than women at age <60 years and became just as
much at the age of> 60 years. In case someone has a stroke, comprehensive
treatment should start from the hyperacute phase to the chronic. This
comprehensive governance aims to reduce mortality and disability. Treatment was
started from pre hospital, emergency room, treatment in a stroke unit / stroke
corner, the plan to return to the restoration / rehabilitation with the ultimate goal
can be more independently andpatients have a good quality of life. Treatment
measures duly carried out on the basis of evidence based. In the application of
evidence-based is preferably adjusted to the maximum conditions of service
centers that we have. Stroke PNPK book is generally intended to provide a
comprehensive governance manual includes pre-hospital stroke treatment,
definitive therapy in the hospital and referral systems. PNPK is expected to be a
reference guide for the neurologist or general practitioner who handle cases /
issues stroke.

Pre-hospital stroke treatment

1. Introduction quickly and reaction to the signs of stroke and TIA. The first
complaint most patients (95%) started from outside the hospital. It is
important for the general public (including patients, those closest to the
patient) and professional health workers (eg general practitioner and
receptionist, nurse or emergency telephone receiver) recognize stroke and
emergency care. The concept of "Time is brain" means the treatment of stroke
is an emergency situation. The introduction of complaints and symptoms of
stroke for patients and people nearby. For ease of use the term FAST (Facial
movement, movement Arm, Speech, Test all three).
2. If the suspicion of a stroke immediately call an emergency ambulance.
Emergency ambulance very important role in the delivery of patients to the

Page 1 of 44

appropriate facility for treatment of stroke. All actions in ambulance patients

should be guided by the protocol.
3. Prioritize transportation (including air transport) for sending patients to the
hospital in question. Emergency ambulance officers must have competence in
the assessment of pre-hospital stroke patients.

GENERAL GUIDANCE OF STROKE PATIENT SERVICE OF

INTRA HOSPITAL
A.
B.
C.
D.
E.

Scope of Hospital services with Stroke disease services

Scope of Class D Hospital Service / health
Scope of Class C Hospital Services
Scope of Class B Home Services
Scope of Class A Hospital services / Trustees

Service Recommendation of stroke patients intra hospital

1. Make a referral from the patient care system in the house until the patient
is in the hospital with emergency care system forming stroke.
2. Form a team of stroke involving multidisciplinary physician.
3. Establish the availability neurologist and stroke consultant physician who
is authorized, full responsibility and adhered to by all members of the team
in every hospital.
4. Provide a general practitioner or a nurse with training certification module
stroke treatment provided by Pokdi stroke, according to the number of
health centers and hospitals in Indonesia Class D (number of health clinics
in 2011 was 8 931 650 units and 22 units of sub-health centers, the number
of RS Class D 2009: 92 units).
5. Completing and add health personnel in accordance with hospital grade
(RS Class A, B, C, D / PHC).
6. Complete and add facilities and hospital facilities in accordance with
hospital grade (RS Class A, B, C, D / PHC).
7. Provide Medical Air Ambulance as proactive measures to deal with cases
of stroke quickly.

Page 2 of 44

8. Educate more neurologist, consultant stroke neurologist agreed by

Perdossi and the Ministry of Health.
9. Establish an integrated referral system in Indonesia between health
facilities, referral could include referral science, specialist referral and
referral of patients.

MANAGEMENT IN THE EMERGENCY ROOM

1. Evaluation of rapid and diagnosis. Evaluation of clinical symptoms and
signs of acute stroke include: history taking, physical examination,
neurological examination and stroke scale, diagnostic studies, brain
imaging, such as cerebral vascular imaging Substraction Digital
Angiography (DSA). (Class I, Level Evidence B).
2. General Therapy (supportive)
Stabilization of the airway and breathing.
-

Provision of oxygen is recommended in a state with oxygen saturation

<95% (ESO: Class IV, GCP).

Fix the airway including the installation of pipes oropharynx in patients
who are not aware of. Provide ventilatorry support in patients with loss of
consciousness or bulbar dysfunction with impaired airway (Class I, Level
Evidence C).

Hemodynamic stabilization (circulation).

-

Give or kolloid intravenous crystalloid fluids (avoid administration of

hypotonic fluids such as glucose). Recommended installation of CVC
(Central Venous Catheter). Try CVP 5-12 mmHg. Optimizing blood
pressure. If the systolic blood pressure below 120 mmHg, and has
sufficient liquid can be given as a vasopressor drugs such as dopamine
dose titration medium / high, nor-epinephrine or epinephrine to a target
systolic blood pressure of 140 mm Hg range. Monitoring the heart (cardiac

Page 3 of 44

monitoring) should be performed during the first 24 hours after the onset
of ischemic stroke (Class I, Level Evidence B).
Early general physical examination
-

Blood pressure, heart examination, neurological examination initial

general, the degree of consciousness, pupillary examination and
ocuolomotor, severity of hemiparesis.

ICT Elevation Control

-

Close monitoring of the patient to the risk of cerebral edema should be

conducted with respect to per-neurologic symptoms and signs of

deterioration in the first days after stroke (Class I, Level Evidence B).
Monitor intra-cranial pressure should be in pairs in patients with GCS <9
and patients who experienced loss of consciousness due to the increase in

intra-cranial pressure. (Class V, Level Evidence C).

Osmotherapy above indications: o Mannitol 0. 25 - 0. 50 g / kg, for> 20
minutes, on-repeat every 4-6 hours with a target of 310 mOsm / L.

(Class V, Level Evidence C).

Neuromuscular paralysis combined with adequate sedation can reduce the
rise in ICP by reducing the increase in intrathoracic pressure and venous
pressure due to coughing, suctioning, bucking the ventilator (Class III-V,

Level Evidence C).

Agent nondepolarized like vencuronium or pancuronium were little effect
on histamine and ganglion block on better use (Class III-V, Level

Evidence C).
Corticosteroids are not recommended to cope with brain edema and
intracranial high pressure in ischemic stroke, can be given if believed there

are no contraindications. (Class III, Level of Evidence A).

Ventricular Drainage recommended in acute hydrocephalus due to

cerebellar ischemic stroke (Class I, Level Evidence B).

Measures decompressive surgery in circumstances which give rise to the
effects of cerebellar ischemic period, an action that can save lives and give
backing good results (Class I, Level Evidence B).

Page 4 of 44

Treatment of hemorrhagic transformation

-

There is no specific recommendation about treatment transformation

asymptomatic bleeding (Class IIb, Level Evidence B).

Control of seizures
-

When seizures, slow bolus diazepam give intravena5 - 20 mg as much as

2x the provision at intervals of 5-10 minutes, and if still seizures followed
by phenytoin loading dose of 15-20 mg / kg bolus with a maximum speed
of 50 mg / min. If the seizure is not resolved then need to be treated in
the ICU. Provision of prophylactic anticonvulsants in patients with
ischemic stroke without seizures is not recommended (Class III, Level

Evidence C).
On the stroke of intracerebral hemorrhage can be given prophylactic
antiepileptic drugs, for 1 month and then lowered and stopped when no
seizures during treatment (Class V, Level Evidence C).

Control of body temperature

-

Every stroke patients with febrile should be treated with antypiretics and
addressed the cause (Class I, Level Evidence C).

Supporting investigation
-

ECG, Laboratory of Chemistry blood, kidney function, hematology and

hemostasis physiology, blood sugar levels, urinalysis, blood gas and
electrolyte analysis. If necessary on suspicion of PSA do lumbar puncture
for CSS examination. Radiological examination: chest x-ray, CT scan.

GENERAL MANAGEMENT IN THE HOSPITAL

Fluid
-

Give isotonic fluids such as 0, 9% saline in order to maintain euvolemi.

Central venous pressure in maintained between 5-12 mmHg.

Page 5 of 44

In general, the fluid requirements of 30 ml / kg / day (parenteral or

enteral).
Fluid balance calculated by measuring the production of urine a day plus
the discharge that is not perceived (daily urine output plus 500 ml of fluid
loss is not visible and added another 300 ml per degree Celsius in patients

with heat).
Electrolytes (sodium, potassium, calcium, magnesium) should always be
checked and replaced if there is a shortage of all to achieve the normal

value.
Acidosis and alkalosis should be corrected in accordance with the results

of blood gas analysis.

Hypotonic liquid or containing glucose must be avoided except in a state
of hypoglycemia.

Nutrition
-

Enteral nutrition has to be given at the latest within 48 hours, oral nutrition

should only be given after swallowing function tests either.

If there is a swallowing disorder or consciousness-descending me food

given by nasogastric tube.

In the acute situation calorie needs 25-30 kcal / kg / day with the

composition:
Carbohydrates 30-40% of total calories.
Fat 20-35% (on a breathing disorder may be higher 35-55%).
Protein 20-30% (in a state of stress protein requirement 1. 4-2. 0 g / kg /

day (on impaired renal function <0. 8 g / kg / day).

If the possibility of the use of nasogastric tube is estimated to> 6 weeks,

consider gastrostomy.
In certain circumstances that enteral nutrition is not possible, nutritional

support should be given parentally.

Note the diet of patients who did not stood in conflict with drugs that are
given (eg: avoid foods that contain lots of vitamin K in patients receiving
warfarin).

Prevention and management of complications

Page 6 of 44

Mobilization and early assessment to prevent complication subacute

(aspiration, malnutrition, pneumonia, DVT, pulmonary embolism,
decubitus, orthopedic complications and contraktur needs to be done.

(Level Evidence B and C).

Give antibiotics on indications and try to conform to the culture and
sensitivity test germs or minimal empirical therapy in accordance with the

pattern of germs (Evidence Level A).

Prevention of decubitus with limited mobilization and / or wear anti

-decubitus mattress.
Prevention of DVT and pulmonary embolism
In certain patients at risk for DVT should be given subcutaneous heparin
5000 IU twice daily or LMWH or heparinoid. (Level Evidence A).

Management of other medical

-

Monitoring blood glucose levels is needed. Hyperglycemia (blood

glucose> 180 mg / dl) in acute stroke should be treated with insulin

titration (Class I, Level Evidence C).

If restless do psychotherapy, if necessary, give-the minor and major

tranquilizers such as benzodiazepine short acting or propofol can be used.

Analgesics and anti-vomiting as indicated.
Give H2 antagonists or proton pump inhibitors (PPIs), if there are

indications (gastric bleeding).

Be careful in moving, suctioning mucus or bathe the patient because it can

influencing ICT.
Mobilization stages if hemodynamic and respiratory stability.
Full bladder is emptied, preferably with intermittent catheterization.
Further investigations such as laboratory tests, MRI, MRA, CTA, Carotid
Duplex Sonography, Transcranial Doppler (TCD) (Class I, level A),
polysomnography (class IIb level B), Cerebral DSA (Class IIA, Level B),
Trans

thoracic

echocardiography

(TTE),

Trans

Esophageal

Echocardiography (TEE) (class III, level B), and others carried out in
-

accordance with the indications and to look for risk factors for stroke.
Rehabilitation.
Family education.
Discharge planning (management plan for patients outside the hospital)

Page 7 of 44

ACUTE STROKE SPECIAL TREATMENT

ISCHEMIC STROKE MANAGEMENT
-

Treatment of arterial hypertension in acute stroke.

Provision of drugs that can cause hypertension is not recommended in

most patients with ischemic stroke (Level Evidence A).

Treatment of hypoglycemia or hyperglycemia.
Strategies to improve blood flow to chance the characteristic with

increased pressure blood-perfused not recommended (Level Evidence A).

Provision of thrombolytic therapy in acute stroke.
Provision of anticoagulants: a. Anticoagulation (heparin, LMWH or
heparinoid) parenterally increase serious bleeding complications. (Class

III, Level Evidence A))

Provision of routine anticoagulation for acute ischemic stroke patients
with the aim to improve the neurologic outcome or as early prevention of

stroke re not recommended. (Class III Level Evidence A)

Treatment of anticoagulants within 24 hours of the patients who received

intravenous rt-Pa is not recommended Class III, Level Evidence B)

In general, administration of heparin, LMWH or hepari-noid after

ischemic stroke is not recommended. (Class I)

Provision of aspirin at a dose of 325 mg in the initial 12 hours after stroke
onset is recommended for any acute ischemic stroke (Class I, Level

Evidence A)
Aspirin should not be used as a substitute for acute stroke intervention

(such as administration of intravenous rtPA) (Class III, Level Evidence B)

If the planned administration of thrombolytics, aspirin should not be given.
Aspirin use as adjunctive therapy in the 24 hours after administration of

thrombolytic drugs are not recommended (Class III, Level Evidence A).
Provision of clopidogrel alone, or in combination with aspirin, in acute
ischemic stroke, is not recommended (Class III, Level Evidence C), except
in patients with specific indications (eg. Unstable angina or non-Q-wave
MI, or recent stenting: treatment must been given until 9 months after the
event (class I level evidence A).

Page 8 of 44

Provision of antiplatelets receptor inhibits intravenous glycoprotein IIb /

IIIa is not recommended (Class III, Level Evidence B)

Provision of clopidogrel compared with aspirin showed slightly better
results for the secondary prevention of stroke, but it was not statistically
significant. While the incidence of ischemic stroke, myocardial infarction
and death from vascular, clopidogrel 75mg better than 325mg aspirin

(CAPRIE STUDY) 10.

Hemodilution with or without venesection and volume expansion is not
recommended in the treatment of acute ischemic stroke (Class III, Level

Evidence A).
The use of vasodilators such as Pentoxifylline not recommended in the

treatment of acute ischemic stroke (Class III, Level Evidence A).

In certain circumstances vasopressor sometimes used to improve blood
flow to the brain (cerebral blood flow). In such circumstances should be
monitoring the condition of neurologic and cardiac strictly (Class III,

Level Evidence B).

Measures carotid endarterectomy in acute ischemic stroke can lead to
serious risks and outputs that are not fun. Actions such as endovascular
stenting in the brain blood vessels are not done in the acute phase, but can
be done after the acute phase to prevent the risk of recurrent stroke.
Measures emergency angioplasty or stenting can be performed on specific
conditions such as acute ischemic stroke due to dissection and cervical
atherosclerosis (Class IIb, Level Evidence C). Trombektomy mechanical
action using a single mechanical trombektomy tool like Merci, Penumbra
System, Solitaire FR, and Trevo; or in combination with fibrinolytic
therapy can be beneficial for recanalization in acute ischemic stroke (Class

IIa, Level Evidence B)

The use of drugs neuroprotectan has not demonstrated the effective results

so far have not recommended (Class III, Level Evidence A).

Recommendation surgical decompression therapy is done within 48 hours
after the onset of the complaint and recommended in patients over the age
of 60 years with Middle Cerebral Artery involving malignant (MCA)
infarcts (class I level evidence A).

Page 9 of 44

Recommended that can be used for therapy osmotherapy TTIK ahead of

surgery performed (grade III level evidence C).

No recommendation given hypothermia in patients with Space-occupying

infarctions (Class IV, GCP).

Recommended for ventriculostomy or surgical decompression therapy
cerebelli large infarcts that suppress the brainstem (Class III level evidence

C).
Anticoagulants may be effective in patients with acute cerebral venous

thrombosis (CVST) (ASA, class II A level of evidence B).

There is no research data on long anticoagulation for CVST, it is
reasonable to anticoagulation for at least 3 months, followed by
administration of antiplatelet therapy (ASA Class II A level of evidence
C).

8.2 Measures to prevent rebleeding after PSA.

a. Control and monitor blood pressure to prevent the risk of stroke,

hypertension is related to the occurrence of rebleeding. (Class I, Level
Evidence B)

b. Resting in bed alone is not enough to prevent rebleeding PSA, but can
generally be considered to be a treatment strategy that subsequently
become the gold standard (Class IIb, Level Evidence B).

c. Antifibrinolytic therapy to prevent rebleeding recommended in certain

clinical circumstances. For example, patients with a low risk for the
occurrence vasopasme or provide beneficial effects on the operation
ditunda.Bagaimanapun well, antifibrinolytic therapy has been associated
with a high incidence of cerebral ischemia, does not seem favorable to the
overall final result. For the foreseeable future are encouraged to conduct a
study using antifibrinolytic combination with other medicines to reduce
vasopasme. (Class IIB, Level Evidence B) .1,2,3,4,5

d. Binding (ligation) carotid not bermamfaat the prevention of rebleeding

(class I-III, Level Evidence A).

Page 10 of 44

e. The use of intra-luminal coils and balloons still testing. Lebih lanjut
research is still required (class IV-V, Level Evidence C).

8.3 Operations on the aneurysm rupture

a) Operating clipping or coiling endovaskuler highly recommended to

reduce rebleeding after aneurysmal rupture of the PSA (class I, level of
Evidence B) 2.3

b) Although the operation that immediately reduces the risk of rebleeding

after PSA, many studies show that overall end result is no different from
that delayed surgery (class II-V, Level Evidence B). Recommended
immediate surgery in patients with "a better grade and location of the
aneurysm was not complicated. For other clinical circumstances,
immediate or delayed surgery is recommended depending on the specific
clinical situation. Early referral to a specialist center is highly
recommended. Handling and treatment of patients with early aneurysm is
recommended for most cases. (Class IIa, level Evidence B)

c) Patients with ruptured aneurysms determined neurosurgical team and

doctors endovaskuler to take action endovaskuler coilling clipping or
coiling +, endovaskuler coiling can be more useful (Class I, Level
Evidence B).

d) incompletely clipped aneurysms are at high risk for rebleeding. A

complete obliteration of the aneurysm surgery is recommended whenever
possible. (Class I, Level Evidence B)

8.4 Procedures for the prevention of vasospasm

a. Giving nimodipine started with a dose of 1-2 mg / h IV of the Day to 3

or orally 60 mg every 6 hours for 21 days. The use of oral nimodipine is
shown to improve neurological deficits caused by vasospasm. (Class I,
Level Evidence A). Other calcium antagonists given orally or
intravenously nonsignificant 3, (class I, level of Evidence B)

Page 11 of 44

b. Treatment begins with a treatment of cerebral vasospasm aneurysm

yang rupture, by maintaining normal circulating blood volume and avoid
hipovolemi. (Class IIa, Level Evidence B)

c. Management with hyperdynamic therapy known as triple H yairtu

hypervolemic--Hemodilution hypertensive, with the aim of maintaining
the "cerebral perfusion pressure" so as to reduce the occurrence of cerebral
ischemia due to vasospasm. (Class IIa, Level Evidence B). Beware of the
possibility of rebleeding in patients who do not do embolization or
clipping. (Class III-V, Level Evidence C)

d. Fibrinolytic intracisternal ,, antioxidant and anti-inflammatory are not so

significant (grade II-IV, Level Evidence C)

e. Transluminal angioplasty is recommended for the treatment of

vasospasm in patients who have failed conventional therapy (grade IV-V,
Level Evidence C)

f. Another way for the management of vasospasm is as follows:

Prevention of vasospasm:

Nimodipine 60 mg orally four times a day

3% NaCl intravenously 50 ml three times daily

Keep the electrolyte balance

- Delayed vasopasme

Stop Nimodipine, antihypertensives and diuretics

Give 5% albumin 250 ml intravenous

Attach the Swan-ganz (if possible), try to wedge pressure of 12-14

mmHg

Keep the cardiac index of about 4 L / min / sg.meter

Give Dobutamine 2-15 ug / kg / min

Page 12 of 44

8.5 antifibrinolytic

Anti-fibrinolytic drugs can prevent rebleeding.

The drugs most often used are epsilon-amino acid at a dose caproid 36
grams / day or tranexamat acid at a dose of 6-12 g / day.

8.6 Antihypertensive

a. Keep Mena Arterial Pressure (MAP) of about 110 mmHg or systolic

blood pressure (TDS) is not more than 160 and diastolic blood pressure
(TDD) 90 mmHg (before surgery aneurysm clipping.

b. Antihypertensive drugs are given if the TDS is more than 160 mmHg
and TDD over 90 mmHg or above 130 mmHg MAP

c. Antihypertensive drug that can be used is labetalol (IV) 0.5 to 2 mg /

min until reaching a maximum of 20 mg / hour or esmolol infusion dose of
50-200 mcg / kg / min. Nitroprussid usage is not recommended because it
causes vasodilation and tachycardia effects.

d. To keep the TDS not decreased (below 120 mm Hg) may be given
vasopressor, where it is to protect the ischemic penumbra tissue that may
occur due to vasospasm.

8. 7 Hyponatremia

8. 8 Seizures

8.9 hydrocephalus

a. Acute (Obstruction)

Can occur after the first day, but more often within the first 7 days. It
happened

approximately

20%

of

cases,

it

is

recommended

untukventrikulostomi (or external ventricular drainage), although the

possible risk of bleeding may occur again and infection. (Class IV-V,
Level Evidence C).

Page 13 of 44

b. Chronic (communicant).

Often occurs after PSA, do irrigation fluid cerbrospinalis temporarily or

permanently as ventriculo peritoneal shunt. (Class I, Level Evidence B).

8:10 Supplement Therapy

a. Laksansia (laxative) is required to soften the feces regularly. Prevent

deep vein thrombosis, wearing compression stockings or pneumatic
devides.

b. Analgesics:

- Asetominofen - 1 g / 4-6 hours with a maximum dose of 4 g / 4-6

hours.

- Codeine phosphate 30-60 mg orally or IM / 4-6 hours.

- Tylanol with codeine 20

- Avoid aspirin

- In very agitated patients may be given:

haloperidol im 1-10 mg every 6 hours

Pethidine Im 50-100 mg or morphine SC or IV 5-10 mg / 4-6 jam.4,20

Midazolan 0.06 to 1.1 mg / kg / h

propofol 3-1 mg / kg / h. 20

- Prevent the occurrence of "stress ulcer" by providing:

H2 Antagonist

Antacids

Proton Pump Inhibitors for several days.

Pepsid iv 20 mg 2 times daily or Zantac 50 mg iv 2 x daily.

sucralfate 1 g in 20 ml of water 3 times a day

Page 14 of 44

Bibliography

Appendix 1.

Subarachnoid hemorrhage degrees.

A. The degree of subarachnoid hemorrhage (Hunt and Hess)

Grade 0: No symptoms and yet aneurysm rupture

Grade 1: mild Headaches

Grade 2: severe headache with excitatory sign meningial and the

possibility of cranial nerve deficits

Grade 3: awareness of focal neurological deficit decreased with light

Grade 4: Stupor, moderate to severe hemiparesis, early decerebrate

Grade 5: deep coma, decerebrate.

B. The degree of subarachnoid hemorrhage (WFNS)

DEGREE OF CLINICAL GCS

I 15 Headaches (-), focal deficit (-)

II 15 Headache, stiff neck, focal deficit (-)

III 13-14 Headache, stiff neck, focal deficits (+)

IV a 13-14 Headache, stiff neck, focal deficits (+)

IV b 9-12 Headache, stiff neck, focal deficits (+)

V <8 Headache, stiff neck, focal deficits (+)

IX. GENERAL GUIDELINES FOR STROKE PATIENT SERVICES

AFTER CARE HOSPITAL

9.1 Secondary Prevention of Ischemic Stroke

Page 15 of 44

Background

Control of risk factors that can not be modified can not be changed and
can be used as a marker (marker) stroke in a person.

9.1.1. Recommendations Control Risk Factors.

9.1.1.1 Hypertension

AHA / ASA

Class I Level A:

Decreased blood pressure both for the prevention of stroke in patients

with repeated or other vascular complications've got ischemic stroke or
TIA before the first 24 hours.

Provision of optimal drug dosing to achieve the recommended blood

pressure level is still uncertain because of the knowledge of the direct
comparison of these drugs is limited. The data indicate that diuretics or
diuretics combination with ACEI showed benefit.

Class II level B:

These recommendations can be used by all patients with ischemic stroke

and TIA are eligible to decrease blood pressure.

Target absolute decrease in blood pressure can not be ascertained and

depending on the circumstances of each patient, but the benefits seen if the
average decline of about 10 / 5mmHg, with normal blood pressure is
defined <120 / 80mmHg by JNC VII.

The choice of specific drugs and targets selected by individuals based on

the pharmacological effects by considering the specific characteristics of
the patients, which is associated with a specific drug, and the effect of
treatment in accordance with the indications (eg extracranial vascular
disease, kidney disorders, heart disease and diabetes).

Page 16 of 44

Class II, Level C:

Some lifestyle modification has been demonstrated reduce blood

pressure and is part of a comprehensive treatment of antihypertensive
(restriction of salt intake, weight loss, diets rich in fruits, vegetables and
low fat dairy products, regular exercise and limiting alcohol consumption).

9.1.1.2 Diabetes

Class I: Recommendation Class I have not found sufficient evidence.

AHA / ASA

1. Class II level B:

Target blood sugar control and blood pressure levels in patients with
diabetes is recommended for patients who have suffered a stroke or TIA.
ESO 2008.

2. Class III level B:

Patients with type 2 diabetes who do not need insulin, treatment with
pioglitazone is recommended after stroke.

3. Class IV GCP

Blood sugar checked regularly. Diabetes treated with lifestyle modification

and pharmacologic therapy individually.

9.1.1.3 Lipids

AHA / ASA

a. Class I level A:

ischemic stroke or TIA patients with elevated cholesterol levels or suffer

from coronary heart disease must be dealt with according to the NCEP III
guidelines including lifestyle modification, dietary guidelines and drugs
recommended.

Page 17 of 44

Treatment with statins is recommended in subjects with stroke non

kardoemboli

b. Class I level B:

Statin treatment with an effective lipid lowering effect is recommended to

reduce the risk of stroke and cardiovascular disease in patients with
ischemic stroke and TIA are also accompanied by atherosclerosis, LDLe
"100 mg / dl, and without coronary heart disease.

Class II A level B:

Patients with atherosclerosis or TIA without coronary heart disease, LDL

C reduction target of at least 50% or target level of LDL C <70mg / dl to
achieve optimum benefits.

Patients with ischemic stroke or TIA with low HDL C can be considered
the treatment with niacin or gemfibrozil.

9.1.1.4 Metabolic Syndrome

AHA / ASA

Class I level A:

Preventive therapy for the metabolic syndrome should include appropriate

treatment for each component of the syndrome, which is a risk factor for
stroke, especially dyslipidemia and hypertension.

Class I level C

Patients who clarified the current metabolic syndrome screening, action

needs to include counseling for lifestyle modification (exercise), and
weight loss to reduce the risk of vascular

Class II level C

The benefits of screening patients for metabolic syndrome is still no

agreement.

Page 18 of 44

9.1.1.5 Sleep Apnea

Class IIb level B

Examination of sleep disorders using polysomnography to detect sleep

apnea should be performed in patients with ischemic stroke or TIA due to
the high prevalence of sleep apnea (> 50%) in the population and there is
strong evidence that treatment of sleep apnea improve patient outcomes.

Recommendation 9.1.2 Modification Lifestyle

9.1.2.1 Smoking

AHA / ASA

Class I level C

Health care should provide advice to every patient with stroke or TIA with
a history of smoking to quit smoking immediately.

Provide advice to avoid environmental smokers (passive smokers).

Counseling on nicotine products and can provide an oral medication for

smoking cessation as an effective way to help smokers quit smoking.

9.1.2.2 Consumption of alcohol

Patients with ischemic stroke or TIA who become heavy alcohol drinkers
should stop or reduce consumption of alcohol.

Consumption of alcohol is not recommended.

9.1.2.3 Physical Activity

Class I: Recommendation Class I have not found sufficient evidence.

AHA / ASA

Class IIb Level C

Page 19 of 44

Patients with ischemic stroke or TIA who are still able to perform
physical activity, at least 30 minutes of moderate-intensity physical
exercise can be considered to lower the risk factors and comorbid
conditions that increase the likelihood of recurrent stroke (moderate
intensity physical activity was defined as significant to sweating or
increasing the rate heart 1-3kali per week).

For individuals with a disability after ischemic stroke, supervision by a

health professional such as a physiotherapist or cardiovascular
rehabilitation in the form of physical training package can be considered.

Interventional Approach Recommendations For Patients With Large

Artery Atherosclerosis

Extracranial Carotid Disease 9.1.3.1 symptomatic

AHA / ASA

Class I level A

Patients with a history of TIA or ischemic stroke within the last six months
and patients with severe ipsilateral carotid artery stenosis (70-99%) is
recommended to undergo CEA (carotid endarterectomy), if the risk of
morbidity and mortality estimated periopreratif <6%.

Class I level B

Patients with a history of TIA or ischemic stroke with ipsilateral carotid

stenosis moderate (50-69%) is recommended to undergo CEA (carotid
endarterectomy), if the risk of morbidity and mortality estimated
periopreratif <6%.

Carotid Angioplasty and stenting (CAS) is indicated as an alternative to

CEA for symptomatic patients with a low risk of complications and risks
are, which is associated with endovascular intervention when the internal

Page 20 of 44

carotid artery lumen diameter was reduced> 70% by non-invasive

examination or> 50% with angioplasty catheter
-

optimal medical therapy, including antiplatelet, statin therapy and risk

factor modification is recommended in all patients with carotid artery
stenosis and TIA or stroke as in other guidelines.

Class IIA level B

If the degree of stenosis <50%, carotid revascularization, either CEA or

CAS, nothing is indicated.

CAS in symptomatic severe stenosis conditions (> 70%) can be

performed by the operator terhadapkesakitan periprocedural risk and
mortality of 4-6% according to research CEA and CAS.

Class IIB level B

Patients with symptomatic severe stenosis (> 70%) are difficult to access
surgically, a common condition that can increase the risk of surgery or
there are specific conditions such as radiation-induced stenosis or
restenosis after CEA, considered to undergo CAS.

Class III level A

Patients with symptomatic extracranial carotid occlusion, EC / IC bypass

(bypass extracranial / intracranial) is not routinely done. If the CEA is
indicated in patients with TIA or stroke, surgery within two weeks of an
option, than delaying surgery if not obtained contraindications to early
revascularization.

9.1.3.2 Disease Extracranial Vertebrobasilar AHA / ASA

Class I level B

Optimal drug therapy, including antithrombotic, statin therapy and risk

factor modification is recommended in all patients with vertebral artery
stenosis and TIA or stroke as contained in guiedeline.
Page 21 of 44

Class IIB level C

Surgical and endovascular treatment in patients with extracranial vertebral

stenosis may be considered if the patient still has symptoms after optimal
treatment (antithrombotic, statin therapy and risk factor modification).

9.1.3.3 Intracranial Atherosclerosis

AHA / ASA

Class I level B

Stroke or TIA patients with intracranial stenosis of blood vessels in the 5099%, recommended aspirin compared to warfarin. Based on data for the
general safety and effectiveness of the recommended dose of aspirin 50mg
to 325mg per day.

Class IIa level B

Stroke or TIA patients with intracranial stenosis of blood vessels in the 5099%, blood pressure <140 / 90mmHg and total cholesterol <200 mg / dl is
the maintenance of long-term targets that can be suggested.

Class IIb Level C

Stroke or TIA patients with intracranial stenosis of blood vessels in the 5099%, angioplasty and stenting unknown or benefits and still under further
investigation.

Class III level B

Stroke or TIA patients with stenosis of blood vessels in the 50-99%

intracranial, extracranial-intracranial bypass is not recommended.

9.1.4 Recommendations For Patients With Type cardioembolic stroke

9.1.4.1 Atrial Fibrillation

AHA / ASA

Page 22 of 44

Class I level A

Patients ischemic stroke or TIA are accompanied with intermittent atrial

fibrillation or paroxysmal permanent recommended anticoagulation
treatment with vitamin K antagonists (target INR of 2.5 to the range 2.03.0).

If the patient can not be given anticoagulants, aspirin alone then

recommended.

Class I level B

Patients who can not regularly check the INR can be given dabigatran
etexilate. This administration needs to be monitored carefully because
until now there is no medication that can stop bleeding complications.

Class II level C

Patients with atrial fibrillation and a high risk of stroke (stroke or TIA
within the last 3 months, CHADS score of 5 or 6, mounted mechanical
valves or rheumatic heart disease) who require oral anticoagulant therapy
may be considered temporary got bridging therapy with LMWH
subcutaneous administration .

Class III level B

The combination of clopidogrel with aspirin have the same risk of

bleeding with warfarin. Therefore, administration is not recommended for
patients who are contraindications to warfarin.

9.1.4.2 Acute Myocardial Infarction Risk Factors And Ventricular

Thrombus In

Left Heart

AHA / ASA

Class I level B

Page 23 of 44

Patients with acute ischemic stroke or TIA who accompanied acute

myocardial infarction as well as the formation of mural thrombus in the
left ventricle heart by echocardiography or with other cardiac imaging
examination should be given treatment with oral anticoagulation (target
INR 2.5; range 2.0 to 3, 0) for sekurangkurangnya for 3 months.

9.1.4.3 Risk Factors Cardiomyopathy

Class I: Recommendation Class I have not found sufficient evidence.

AHA / ASA

Class IIB level B

Patients who have suffered a stroke or TIA in sinus rhythm heart

condition and with cardiomyopathy and there are signs of systolic
dysfunction (left ventricular ejection fraction d "35%) the benefits of
warfarin has not been proven.

Warfarin (INR 2.0-3.0), aspirin (81mg / dl), clopidogrel (75mg / dl) or a

combination of aspirin (25 mg, 2 times a day) may be considered to
prevent re-ischemic attack in patients who had previously suffered a stroke
or TIA with ischemic cardiomyopathy.

9.1.4.4 Risk Factors of Heart Valve Disease

Class I: Recommendation Class I have not found sufficient evidence.

AHA / ASA

Class IIA level C

Patients with ischemic stroke or TIA who also suffered from rheumatic
mitral valve with or without the presence of atrial fibrillation, long-term
warfarin with a target INR of 2.5 is recommended (range 2.0-3.0).

AHA / ASA

Class IIB level C

Page 24 of 44

Patients with ischemic stroke or TIA are accompanied with aortic valve
disease or mitral valve disease nonreumatik and do not suffer from atrial
fibrillation, antiplatelet treatment is recommended.

Patients with ischemic stroke or TIA and mitral annular calcification may
consider granting antiplatelet treatment.

For patients with ischemic stroke or TIA who also suffered from mitral
valve prolapse, the provision of long-term antiplatelet therapy may be
considered.

AHA / ASA

Class III Level C

To prevent additional bleeding risk, antiplatelet drugs should not be

routinely added to warfarin.

9.1.4.5 Risk Factors Heart Valve Protestik

AHA / ASA

Class I level B

Ischemic stroke and TIA patients were also installed protestik mechanical
heart valves, warfarin with a target INR recommended 3.0 (range 2.5-3.5).

Class IIA level B

Patients with heart valve mounted mechanical protestik and had suffered a
stroke or systemic embolism, although it has received adequate treatment
with oral anticoagulants, aspirin 75mg / day to 100 mg / day may be given
in addition to maintaining a target INR of 3.0 (range 2,5- 3.5) if the patient
does not have a high risk of bleeding (bleeding history, varicose veins,
vascular anomalies or known to have a great risk of bleeding,
coagulopathy).

Class IIB level C

Page 25 of 44

Patients with ischemic stroke or TIA who also has a bioprosthetic heart
valve without there are other sources that have thromboembolic risk,
anticoagulant treatment with warfarin INR2,0 (2.5-3.5) may be considered.

9.1.5 History of TIA or stroke

AHA / ASA

Class I level A

Patients with acute ischemic stroke aterotrombotik / TIA or with a history

of stroke aterotrombotik / TIA recommended before administration of
antiplatelet more than anticoagulants to reduce the risk of recurrence of
stroke and other cardiovascular events.

ischemic stroke or TIA patients who did not receive anticoagulation

should be given antiplatelet such as aspirin (80-325mg) or clopidogrel
75mg or combination therapy with low-dose aspirin 25mg extendedrelease dipyridamole 200 mg.

The combination of aspirin and clopidogrel is not recommended in

patients with acute ischemic stroke, except in patients with specific
indications (eg unstable angina or non-Q wave MI, or recent stenting), the
treatment given to 9 months after the incident.

Class A level IIA

Compared with aspirin therapy alone, the combination of aspirin 25mg to

200mg extended release dipyridamole and clopidogrel is safe. The
combination of aspirin 25mg to 200mg extended release dipyridamole
confirmed better than aspirin alone.

Class IIA level B

In patients intolerant to aspirin, clopidogrel 75mg or extended-release

dipyridamole 2x200mg can be used.

Class IIB level B

Page 26 of 44

The use of clopidogrel is better than aspirin alone.

Class IIB level C

Patients with ischemic cerebrovascular being received aspirin, do not have

evidence that increased doses of aspirin provide more benefits. Although
often considered an alternative antiplatelet therapy for patients with noncardioembolic, no single drug or combination in patients who had received
aspirin.

Class III level A

The addition of aspirin to clopidogrel therapy given in high risk

populations will increase the risk of bleeding when compared with use of
clopidogrel therapy alone, so that the routine use of this kind is not
recommended for ischemic stroke or TIA.

(AHA / ASA STUDY CAPRIE) of 2011 Provision of clopidogrel

compared with aspirin showed slightly better results for the secondary
prevention of stroke, but not statistically significant.

Japanese Guidelines

Class I level A

The ratio of stroke and bleeding in the ratio of cilostazol significantly

lower than aspirin.

Cilostazol (100 mg) two times a day showed a significant effect on the
incidence penurinan recurrent stroke compared to placebo and effective to
prevent lacunar infarction in the differential analysis.

ESO

Class IA

Page 27 of 44

Patients who do not require anticoagulation should be given antiplatelet,

when possible combination of aspirin and dipyridamole, or clopidogrel
alone, as an alternative can be given aspirin alone or trifusal alone.

Class IV, GCP

Stroke patients in antiplatelet therapy should be reevaluated weeks to

pathophysiology and risk factors. Trifusal provide the same benefit with
aspirin in the prevention of recurrent stroke, but trifusal have fewer side
effects.

9.1.6 Recommendations Stroke Patients With Other Specific Conditions

9.1.6.1 artery dissection

Class I:

Recommendations Class I have not found sufficient evidence. AHA / ASA

Class IIA level B:

Patients with ischemic stroke or TIA and dissection of the extracranial

carotid or vertebral arteries, anti-thrombotic therapy is given at least 3 to 6
months.

Class IIB level B:

Benefits over antiplatelet therapy for patients with ischemic stroke or TIA
and carotid dissection of the vertebral artery ektrakranial or unknown.

Class IIC level C

with ischemic stroke or TIA and dissection of the extracranial carotid or

vertebral artery experiencing recurrent cerebral ischemia, despite optimal
medical therapy, endovascular therapy (stenting) may be more appropriate.

Patients with ischemic stroke or TIA and extracranial carotid dissection

fails or does not allow endovascular therapy, surgical therapy is
recommended.

Page 28 of 44

Patent Foramen Ovale 9.1.6.2 (PFO)

Class I:

Recommendations Class I have not found sufficient evidence.

AHA / ASA

Class IIA level B

Ischemic stroke or TIA patients with PFO recommended antiplatelet

therapy.

Class IIB level B

There were no definitive data that anticoagulation has the same effect or
better than aspirin for secondary stroke prevention in patients with PFO.

Class IIB level C

Not found data that recommended for PFO closure in patients with stroke
and PFO.

9.1.6.3 hyperhomocysteinemia

Class I: Recommendation Class I have not found sufficient evidence.

AHA / ASA

Class IIB level B

Although folate supplementation can lower homocysteine levels and can

be used in patients with ischemic stroke and hyperhomocysteinemia, no
evidence that the reduction in homocysteine levels dapatmencegah
recurrent stroke.

9.1.6.4 Inheritage Trombophily

AHA / ASA

Class I level A

Page 29 of 44

Patients with ischemic stroke or TIA who proved inheritage trombophily

should be evaluated for the presence of deep venous thrombosis who
received anticoagulant therapy is indicated short-term or long-term
depending on the clinical picture and hematologic abnormalities.

Class IIA level C

Patients let get a full evaluation of the likelihood of a stroke. if no

thrombosis in patients with stroke or TIA and arterial thrombophilia,
anticoagulant therapy or antiplatelet therapy is recommended.

For patients with spontaneous cerebral venous thrombosis and / or a

history of recurrent thrombosis and inheritage trombophily, may be
indicated obtain long-term anticoagulation.

9.1.6.5 Sickle Cell Disease (SCD)

Class I: Recommendation Class I have not found sufficient evidence.

AHA / ASA

Class IIA level B

Adult patients with SCD and stroke recommended common therapy that
can be applied to control the risk factors and the use of anticoagulants.

Class IIB level C

Given additional therapy including blood transfusions to reduce HbS from

<30% to 50% of the total Hb, hydroxyurea or bypass surgery.

9.1.6.6 Cerebral venous sinus thrombosis (TSVs)

Class I: Recommendation Class I have not found sufficient evidence.

AHA / ASA

Class IIA level B

Anticoagulants may be effective for patients with acute TSVs.

Page 30 of 44

Class IIA level C

Found no research data that says the optimal duration of anticoagulation

therapy for acute TSVs. Therefore, it is reasonable to provide at least 3
months of anticoagulation followed by antiplatelet therapy.

9.1.6.7 Fabri Disease

AHA / ASA

Class I level B

Patients with ischemic stroke or TIA or disease fabri recommended

alfagalaktosidase enzyme therapy.

Class I level C

Other secondary prevention that have been published are also

recommended for patients fabri disease.

9.1.6.8 Pregnancy

Class I: Recommendation Class I have not found sufficient evidence.

AHA / ASA

Class IIB level C

In pregnancies with stroke or TIA coupled with a high risk for the
occurrence of thromboembolic processes (hypercoagulable state or
artificial heart valves), the following conditions may be considered.
Adjustment of the dose of heparin during pregnancy for example with
subcutaneous dosing every 12 hours while in monitor aPTT. Adjusted dose
of LMWH is accompanied by a monitor Xa anti-factor during pregnancy
progresses, or LMWH until week 13 followed by administration of
heparin until the second or third semester of pregnancy, and then given
back LMWH until delivery.

Page 31 of 44

If the conditions of high risk of thromboembolism is not the case,

pregnant women with stroke or TIA may consider granting LMWH during
the first trimester followed by low-dose aspirin in the remainder of the
pregnancy until delivery.

9.1.6.9 Hormone replacement therapy at menopause

Class I: Recommendation Class I have not found sufficient evidence.

Class II: Recommendations Class II has not obtained sufficient evidence.

AHA / ASA Class III level A

For women who have suffered an ischemic stroke or TIA, hormone

replacement therapy at menopause (with estrogen, with or without the
addition of a progestin) is not recommended.

9.1.7 Recommendations Treatment Anticoagulation After Intracranial

Hemorrhage.

AHA / ASA

Class I level B

Protamine sulfate should be given to treat intracranial hemorrhage due to

heparin, the dose depends on the duration of administration of heparin in
these patients.

Class IIA level B

Patients who experienced intracranial hemorrhage or subarachnoid

hemorrhage or subdural hemorrhage, all kinds of anticoagulant and
antiplatelet therapy should be discontinued during the acute period of at
least up to 2 weeks and soon overcome the effects of warfarin with fresh
frozen plasma or prothrombin complex concentrate and vitamin K.

Class IIB level B

Page 32 of 44

The decision to restart treatment antithrombotic therapy after intracranial

hemorrhage depends on whether there is a risk of thromboembolism in the
artery or vein, depending on the risk of thromboembolic complications
later, depending on the risk of recurrent intracranial bleeding and the
overall status of the patient. In patients who have a low risk for the
occurrence of cerebral infarction (stroke without re-arterial fibrillation and
a history of previous ischemic stroke) and a high risk of amyloid
angiopathy (eg the elderly with lobar location), or a neurological condition
that is very bad, antiplatelet agents may be considered.

EMERGING THERAPY
Plasmin:
-

Multicentre Randomized Placebo Control Trial by using 3 x 500mg oral

Plasmin in 66 patients at six teaching hospitals in Indonesia obtained
results indicate that Plasmin has a positive effect on motor repair, MRS

score and Barthel index.

Use of Citicholin in acute ischemic stroke with intravenous dose of 2 x
1000mg for 3 days, followed by oral 1000mg 2x for 3 weeks (International
Citicholine on Acute Stroke: ICTUS, October 2006)

SPECIFIC THERAPY FOR ACUTE STROKE

I. The application procedure rtPA thrombolysis therapy in acute
ischemic stroke
Fibrinolytic with rtPA generally provide benefits reperfusion of lysis of thrombus
and significant improvement of cerebral cells. (3 hours at the onset of intravenous
and intraarterial administration of 6 hours)
1. Inclusion criteria
a. age> 18 years
b. clinical diagnosis of stroke with a clear neurological deficit
Page 33 of 44

c. can be clearly defined onset (<3h, AHA 2007 guidelines or <4, 5

hours, ESO 2009)
d. no evidence of intracranial bleeding from a CT Scan
e. patient or family understand and accept the benefits and risks that may
arise and there should be a written consent from the patient or family
to do rtPA therapy
2. Exclusion Criteria
a. Age> 80 years
b. Mild neurological deficits and rapidly improving or worsening severe
neurological deficit
c. Picture of intracranial hemorrhage on CT scan
d. A history of head trauma or stroke within 3 months terakhir1
e. Multilobar infarction (picture hypodense> 1/3 of the cerebral
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.

hemispheres
Seizures at the time of stroke onset
Seizures with neurological sequelae post-ictal abnormalities
History of stroke or severe head injury in the previous 3 months
Active bleeding or acute trauma (fracture) on physical examination
History of major surgery or severe trauma within the previous 2 weeks
P dstinal history of bleeding or urinary tract in 3 weeks earlier
Systolic blood pressure> 185 mmHg, diastolk> 110 mmHg
Blood glucose <50 mg / dl or> 400 mg / dl
Symptoms of subarachnoid hemorrhage
Arterial puncture in place that cannot be compressed or lumbar

puncture within 1 week before

p. Platelet count <100. 000 / mm3
q. Received heparin within 48 hours of therapy associated with increased
r.
s.
t.
u.

aPTT
The clinical features of myocardial infarction their pericarditis
Myocardial infarction within the previous 3 months
Pregnant women
Not currently taking oral anticoagulants or when you are in the

anticoagulant therapy INR let d "1. 7

3. Recommendation
a. Giving IV rtPA dose of 0. 9 mg / kg (maximum 90 mg), 10% of the
total dose given as a bolus initials, and the rest is given as an
intravenous infusion over 60 minutes, the therapy must be given within
a span of 3 hours (AHA / ASA, Class I, level of evidence A) 1atau 4, 5
h (ESO guideline 2009). The provision is in accordance with the
inclusion and exclusion criteria above.
Page 34 of 44

b. Giving rtPA recommended as soon as possible, ie within a span of 3

hours (AHA / ASA class I level of evidence A) or 4, 5 h (ESO 2009)
c. Besides bleeding complications, other side effects that may occur,
which may cause angioedema partial airway obstruction, should be
considered. (AHA / ASA, Class I, level of evidence C)
d. Patients with hypertension whose blood pressure can be lowered with a
safe antihypertensive drugs, blood pressure should be kept stable
before the start of rtPA. (AHA / ASA, Class IIA, level of evidence B)
e. Patients with seizures at the time of stroke onset may be given rtPA
therapy for neurological disorders that arise secondary to stroke and
post-ictal buan a phenomenon and not a seizure because epileps. (AHA
/ ASA, Class IIA, level of evidence C) 1
f. Intraarterial thrombolysis is an alternative therapy in selected patients
with severe stroke, onset <6 hours and is caused by blockage of an
artery cerebri media are not eligible for intravenous thrombolysis.
(AHA / ASA, Class I, level of evidence B) 1.
g. Intraarterial thrombolysis therapy should be done at the stroke service
centers have facilities

cerebral angiography and intervention

experienced experts. (AHA / ASA, Class I, level of evidence C)

h. Intraarterial thrombolysis is possible for patients who have
contraindications to the use of intravenous thrombolysis, such as a
history of recent surgery. (AHA / ASA, Class IIA, level of evidence C)
i. Availability intraarterial thrombolysis not replace intravenous rtPA
administration in patients who meet the above criteria (AHA / ASA,
Class III, level of evidence C)
j. Trombektomi mechanics using tools such trombektomi Merci,
Penumbra System, Solitaire FR, and Trevo alone or in combination
with thrombolytic agents may be useful for certain patients
recanalization IIa, level of evidence B)

II. NIH recommendation on Response Time Patients will be given rtPA

in the Emergency Room
Golden Hour for the plan of rtPA (<60 minutes)

Page 35 of 44

1. The patient arrives at the emergency room with a diagnosis of stroke

2. Evaluation and examination of the patient by the triage (including history,
laboratory requests and assess NIHSS) time d "10 minutes
3. Discussed by the stroke team (including a decision made provision rtPA)
time d "15 minutes
4. Do a CT scan of the head, the time <25 minutes
5. The results of a CT scan of the head and the laboratory, time <45 minutes
6. Provision of rtPA (when patients met the inclusion criteria), the time <60
minutes

III. The use of intravenous rtPA protocols

1. rtPA infusion of 0. 9 mg / kg (maximum 90 mg) in 60 minutes with 10% of
the dose given as a bolus in 1 minute
2. Enter the patient to the ICU or stroke unit for monitoring
3. Perform a neurological assessment every 15 minutes during the infusion
and every 30 minutes thereafter for the next 6 hours, then every hour until
24 hours after treatment.
4. If there is a severe headache, acute hypertension, nausea, or vomiting, stop
the infusion (when the medium is inserted rtPA) and do a CT scan
immediately
5. Measure blood pressure every 15 minutes during the first 2 hours and
every 30 minutes during the next 6 hours, and then every hour up to 24
hours after treatment
6. Increase the frequency of blood pressure measurement when the systolic
blood pressure > 180 mmHg or when diastolic> 105 mmHg; gave
antihypertensive medications to maintain blood pressure at this level or
below the level (see protocol management of hypertension in acute
ischemic stroke)
7. Delay installation nasogastric tube, urinary catheter, or catheter
intraarterial pressure
8. Perform Ct scan to follow up within 24 hours prior anticoagulation or
antiplatelet

Page 36 of 44

IV. Management of hypertension in Acute Ischemic Stroke will be given

rtPA
1. Systolic blood pressure> 185 mmHg or diastolic> 110 mmHg
a. Labetalol 10-20 mg IV over 1-2 minutes, may be repeated 1x; or
b. Nitropaste 1-2 inches; or
c. Infuse nicardipin 5mg / hour, titration raised 2, 5 mg / hour with an
interval of 5-15 minutes, when the blood pressure is reached,
lowered to 3 mg / h
d. If the blood pressure does not go down and stay> 185/110 mmHg,
do not give intravenous rtPA
2. Management of blood pressure during and after the use of rtPA
a. Monitor blood pressure every 15 minutes during therapy and
during the next 2 hours, then every 30 minutes for 6 hours, then
every hour for 16 hours
b. Systolic blood pressure 180-230 mmHg or diastolic 105-120
mmHg labetalol 10 mg iv for 1-2 minutes, may be repeated every
10-20 minutes, the maximum dose of 300 mg; or labetalol 10 mg
1v continued infusion of 2-8 mg / min
c. Systolic blood pressure> 230 mmHg or diastolic 121-140 mmHg
labetalol 10 mg iv for 1-2 minutes, may be repeated every 10-20
minutes, the maximum dose of 300 mg; or labetalol 10 mg iv
infusion followed 2-8 mg / min; Infuse nicardipin or 5 mg / hour,
titration until the desired effect is achieved, 2, 5 mg / h every 5
minutes, maximum 15 mg / hour. If blood pressure is not
controlled, consider sodium nitroprusside
Note; labetalol, Nitropaste, and Nitrofusit yet available in Indonesia

V. Bleeding Risk Monitor for rtPA administration

1. Category bleeding subs rtPA administration
a. Internal bleeding, including intracranial and retroperitoneal bleeding or
gastrointestinal tract, genitourinary and respiratory.

Page 37 of 44

b. Bleeding on the surface (superficial) visits especially the provision of

rtPA (eg rips venous, arterial puncture sites, the scar is still new)
2. Provision of rtPA should be discontinued if there is bleeding that is taken
seriously (eg, bleeding cannot be stopped by a local emphasis)

VII. MANAGEMENT OF INTRACEREBRAL BLEEDING

Intra-cerebral hemorrhage including emergency conditions, and have high

morbidity and high mortality so it should be diagnosed early. (Class I, Level of
Evidence A). CT and MRI is the imaging initial first choice (Class I, Level of
Evidence A), in patients who are contraindications to MRI, the CT can be
performed. (Class I, Level of Evidence A)
A. General Management
1. Correction of coagulopathy
a. To examine hemostasis, PT (INR), aPTT, and platelets in patients with
intracranial hemorrhage and any correction as soon as possible if the
abnormalities found.
Things to consider to do is
1. Vitamin C 10 mg IV, given to patients with increased INR and
administered in the same time with other therapies because the
effects will occur 6 hours later. Speed granting <1 mg / min to
minimize the risk of anaphylaxis.
2. Fresh Frozen Plasma (FFP) 2-6 units granted to correct the
deficiency of blood clotting factors if found so quickly fix INR
or aPTT. FFP therapy is to replace lost coagulation factors.
b. rFVIIa (15-90 ig / kg) can be corrected increase in INR with a
short half-life (2, 6 h) that required repeated doses.
Provision of rFVIIa in the first 3-4 hours will slow down the
progression of bleeding. 1, 2, 5 (Class IIb, Level of Evidence B) 4.
Page 38 of 44

The use of rFVIIa may be useful to prevent bleeding from the

expansive of risk for thromboembolic so that rFVIIa is not
indicated in general but in selective cases. Defibrogenasi best
corrected with cryoprecipitate.
c. The effects of heparin can be treated with protamine sulfate 10-50
mg IV within 1-3 minutes. Patients with protamine sulfate
administration

need

close

monitoring

to

see

signs

of

hypersensitivity. (Class I, Level of Evidence B)

d. Thrombocytopenia (<100 x 103 / il) should be corrected by the
administration of platelet transfusions.
2. Correction Hemorrhage Stroke Caused by Giving Anticoagulants Twentyfive percent of cases of hemorrhagic stroke (intracerebral hemorrhagic)
associated with the drug anticoagulant. The incidence ranges between 2-9
per 100 000 per year. The mortality rate reached 52% -67% compared to
patients with hemorrhagic stroke caused not by anticoagulant drugs. The
concept of emergency treatment in hemorrhagic stroke by anticoagulants
are efforts to stop bleeding quickly using drugs acting on clotting factors.
Anticoagulant drugs to stop working (reversal of anticoagulant) that is
a. Vitamin K: Vitamin K is an essential component in the liver to activate
the work of factors II, VII, IX, X. Given IV vitamin K because of the
slow kerjamenjadi effects if the drug is administered orally or
subcutaneously.
b. Fresh Frozen Plasma (FFP). Giving FFP can quickly stop the clotting
factors and quickly correcting INR. Given in conjunction with the
administration of vitamin K.
c. Prothrombin complex concentrates (PCC). There are two types of
PCC, which concentrates of factors II, IX, X and the second type
contains additional factor VII. INR monitored within 15 minutes after
the PCC is given, and the administration of vitamin K had to be paid.
PCC can be given more quickly than FPP and does not require checks

Page 39 of 44

for blood screening, and do not have the risk of overload. INR
improved rapidly after administration of PCC.
d. Recombinant factor VIIa (rfVIIa). Can be at high risk of thrombotic
process so it does not get FDA approval for reversal of anticoagulant
drugs on bleeding stroke.
3. Blood Pressure Correction. Indications administration of antihypertensive
drugs that systolic blood pressure> 200 mm Hg or MAP> 150 mmHg 2.
Blood pressure is lowered by about 15% per day, the preferred use of
antihypertensive drugs with short working (short-acting) so that the dose
can be titrated and adjusted to the blood pressure response and
neurological status of the patient. 2 medications that can be used is
nicardipine, labetalol, esmolol or sodium nitroprusside.
a. Nicardipine 5 mg / h as an initial dose, then raised 2, 5 mg / h every 5
minutes until the desired effect. Maximum dose is 15mg / h.
b. Labetalol given intermittent doses of 10-20 mg IV in 2 minutes, then
40-80 mg IV every 10 minutes to achieve the desired blood pressure.
Can be converted to an oral dose of 200-400 mg every 6-12 hours.
c. Hydralazine can be given 10-20 mg IV every 4-6 hours
d. Enaloprilat can be given 0, 625-1, 2 mg IV every 6 hours
e. Sodium nitroprusside should be avoided in case of emergency
neurology because it can increase ICP. But if it takes the blood
pressure drops immediately and other drugs are not effective, the
patient can be given sodium nitroprusside 0, 25-10 ig / kg / min. The
initial dose should be lower.
4. Management of Arterial Hypertension Emergency 2
a. If TD systole> 200 mm Hg or MAP> 150 mmHg, lower TD quickly
with IV medications and monitor TD every 5 minutes.
b. If TD systole> 180 mm Hg or MAP> 130 mmHg and there is evidence
of increased intracranial pressure, lower TD continuously or
intermittently, and maintain CPP> 80 mmHg.
c. If TD systole> 180 mm Hg or MAP> 130 mmHg and there is no
evidence of increased intracranial pressure, lower TD lightly with
continuous or intermittent.
5. Maintaining cerebral perfusion pressure (CPP)

Page 40 of 44

Patients with intracerebral hemorrhage should have blood pressure that is

controlled without excessive drop in blood pressure. Keep systole blood
pressure <160 mm Hg and CPP is kept above 60-70 mmHg.
This can be achieved by lowering the ICP to normal values with mannitol
administration or operation. In case required the administration of
vasopressors, can be given:
a. Phenylephrine 2-10 ig / kg / min
b. Dopamine 2-10 ig / kg / min or
c. Norepinephrine, starting with 0, 05-0, 2 ig / kg / min and titrated to the
desired effect.
6. Management and neuro surgical intervention
Decision-making depends on the location and size of the hematoma and
neurological status of the patient. In general, surgery is recommended in
large cerebellar hematoma with an emphasis on the brain stem or impede
the flow of CSF, as well as in patients with lobar hematoma located <1 cm
from the surface of the cortex. Patients with bleeding in the thalamus and
basal ganglia usually do not require surgical intervention. There were no
evidence of hematoma evacuation memperbaikan outcome and not
obtained data on kraniektomi dekompressi improve outcomes after
intracranial hemorrhage. 2 (Class IIb, Level of Evidence B) 4. Very early
craniotomy may be accompanied by an increased risk of recurrent
bleeding. (Class IIb, Level of Evidence B) 4. Patients with supratentorial
intracerebral hemorrhage should be treated in a stroke unit. 3 (Level of
Evidence B) 4. Intracerebral hematoma evacuation routine surgery should
not be performed. It might be useful (life saving) on SAH, cerebellar
hemorrhage accompanied by compression of the brain stem and
obstructive hydrocephalus. Although there is little evidence favorable,
surgical evacuation should be considered in patients with intracerebral
hemorrhage were superficial.

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B. Indications Surgery
a. Cerebellar hematoma with a diameter> 3 cm were accompanied
suppression and brain stem or hydrocephalus due to obstruction of the
ventricular should be done with as soon as possible. 2, 5 (Class I, Level of
Evidence B)
b. Bleeding with structural abnormalities such as an aneurysm or AVM.
(Class III-V, Level of Evidence C)
c. Lobar hematoma with medium-large size which is located close to the
cortex (<1 cm) 2, 5 in patients with age <45th with GCS 9-12 5,
evacuation of supratentorial ICH by standard craniotomy can be
considered. 2 (Class IIb, Level of Evidence B)
d. Evacuation of supratentorial ICH routine with standard craniotomy within
96 hours is not recommended (Class III, Level of Evidence A). Exception
in lobar hematoma 1 cm from the cortex. Management neuro intervention
in cases of bleeding stroke can be done in an effort to find the cause of the
bleeding and its management. Digital cerebral angiography examination
Substraction can be done if there is suspicion of the cause is an
arteriovenous malformation or fistula. (Class IIb, level of evidence B)
e. Provision of appropriate antiepileptic drugs should always be used for the
treatment of clinical seizures in patients with ICH. (Class I, Level of
Evidence B) 4. Giving antiepileptic prophylaxis in a short time due to ICH
can reduce the risk of seizures in patients with lobar hemorrhage5. (Class
IIb, Level of Evidence C). Consider the 24-hour EEG monitoring in
patients with coma (GCS <8), including in patients with supratentorial
intracerebral hemorrhage deep, Keppra can be given IV or fosphenytoin as
prophylaxis.
f. Prevention of recurrent ICH. Treatment of hypertension in non-acute
setting is very important to reduce the risk of recurrent ICH and ICH.
(Class I, Level of Evidence A). Smoking, heavy alcoholism and cocaine
use is a risk factor for ICH and kick the habit should be recommended for
the prevention of ICH. (Class I, Level of Evidence B)
Intracerebral Hemorrhage Management Recommendations:

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1.
2.
3.
4.
5.
6.

Correction of coagulopathy
Blood Pressure Correction
Maintaining cerebral perfusion pressure (CPP)
Surgical management
Provision of antiepileptic drugs
Prevention of recurrent ICH

(Recommendation Class I, Level Evidensi Level B)

VIII. MANAGEMENT OF SUBARACHNOID HEMORRHAGE

(PSA)
PSA is a state of emergency are often misdiagnosed.
Severe headache that appears acute / abrupt should be suspected as a sign of PSA
(Class I, Level of Evidence B). CT scan of the head should be performed in
patients suspected of PSA (Class I, Level of Evidence B). Lumbar puncture for
spinal fluid analysis serebro (CSS) is recommended when the CT scan did not
show signs of PSA (Class I, Level of Evidence B)
Cerebral angiography should be performed in patients with a PSA to see a picture
of the aneurysm (Class I, Level of Evidence B). MRA and CTA may be
considered if conventional angiography cannot be performed (Class II B, Level of
Evidence B)
1. Guidelines for the management of
a. Patients with signs of Grade I or II H & H PSA 1 (Appendix 1)
- Early identification of severe headache is a clue to efforts to reduce
-

mortality and morbidity

Bed rest with the head elevated total 30 0 in a room with a quiet and

comfortable environment, if necessary, provide O2 2-3 l / min

Be careful use of sedative
Put IV infusion at emergency room and strictly monitor neurological

disorders that arise.

b. Patients with grade III, IV or V (H & H PSA), treatment should be more
intensive

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Perform ABC management in accordance with the protocol of patients

in the emergency room.

Endotracheal intubation to prevent aspiration and ensure adequate

airway.
If there are signs of herniation of the intubation (see chapter IV, on

intra-cranial pressure control)

Avoid excessive use of sedatives because it would complicate the
assessment of neurological status

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