Departement Neurology Madical Faculty of Airlangga University Dr. Soetomo General Hospital Surabaya
Simposium Emergency for Every Doctor
28 Januari 2017 Introduction :
Approximately 16 Million first-ever
Strokes + 5,7 million people /year
Second most common single cause of
death after ischemic heart disease
The largest cause of adult disability and
needing longterm health care medical burden 3 % total health care Introduction :
Incidence & Prevalence ~ age
> 55 year
75 89 % Strokes > 65 years
poor outcomes of ischemic stroke in the
elderly patients AGING RELATED CHANGES IN THE CNS
Brain weight 0,1 % / year between the
age of 20 60 year More rapid loss : cerebral cortex & hippocampus Brain volume : 0,1 - 0,2 % , 30 - 50 years 0,3 - 0,5 %, > 70 years Neuronal loss, neuronal atrophy dendritic and perikaryal atrophy NT & Reseptors Degeneration of Astrocytic & Microglial hyperactivity on CT / MRI : Leukoaraiosis ( patch on periventzicular & subcortical area : low density ) Leukoaraiosis Risk of Recurrent Stroke
Glutamate Cascade Ca influx
Brain Microvascular (BBB) capillary surface area CBF 20 % Accumulation of Glutamade and lactate Electrolyte immbalance Ischemic Neuronal Death Macmillan, Neurology Volum e 6, 2010 AGING RELATED RISK FACTOR Incidence of stroke : Morbidily & Mortality age
80 year : > < 80 year : >
AF & CHD > Cardioembolic Ischemic Stroke
1,5 % - 23,5 %
Carotid artery stenosis
Macmillan, Neurology Volum e 6, 2010 CLINICAL MANIFESTATIONS
Acute on chronic : Neuro emergency
Older Patiens : More severe deficits Recover more slowly Vascular respons to stress and injury Multiple organ dysfunction Effect of multiple medications STROKE THROMBOTIC STROKE EMBOLI STROKE INFARK STROKE INFARK TROMBOTIK EMBOLI ICH SAH IVH TRETMENT Stroke : Neuro Emergancy Acute on chronic proces Fundamental approaches to Acute Ischemic Stroke Therapy Reperfusion Neuroprotection
Primary and secondary Stroke Therapy :
Antiplatelet (Aspirin,clopidogrel, etc) Control of Risk Factors (a.HT, Dyshipidemia / Statin, etc) Interventional rtPA : (Intra Arterial rtPA and Intra Venous rtPA)
up to 3 after ischemic stroke
elder patients, old individuals predisposed to
symptomatic ICH & hemorrhagic transformation microangiophaty (cerebral amyloid angiopathy, hypertensive microangiopathy) and leukoaraiosis
Higher mortility risk and less favorable outcomes
NEUROPROTECTION
to protect neurons from ischemic reperfusion
injury
to amplify the time window for trombolytic
treatment
> 1000 drugs, only 100 by reached clinical trial
(animal human clinical trial) ANTIPLATELET DRUGS
Inhibit platelet adhesian and agregation
early mortality : 48 of sympton onset
L.D. Aspirin 22 %, clopidogrel
ANTIHYPERTENSIVE
30 40 % Stroke insidence 39 % Rate of death from Stroke (HYVET) 30 % Risk of Recurent Stroke
Sistolic BP 140 - 150 mmtlg save in older in
Diastolic BP 80 - 90 mmtlg dividual risk of cerebral hypoperfusion (orthostatic) STATIN
For control of plasma colesterol
Reduce the risk of Ischemic Stroke Mate analysis : prevention of major vascular event (22 % RR 65 y, 19 % RR 65 y) 25 % mortality stroke as an anti inflamatory, anti trombotic, plaque stabilizing and anti oxidant effects Neuro protective effect INTERVENTIONAL