RS Tebet, 15 Juni 2013

Dr. Tumpal. A. Siagian,

Sp.S

INTRODUCTION
One of the 5 fundamental rituals of

Islam is fasting during the month of

ramadhan.
Muslims neither eat nor drink
anything during the month,between
dawn and sunset.

URGENSI
Stroke?
Penyebab kecacatan dan kematian

yg tinggi
Untuk memberikan solusi bagi orang
yang sedang stroke
Sebagai pencegahan yang belum
kena stroke
Puasa atau shaum,dapat pahala
ganda yaitu ukhrawi dan duniawi

Prone Person to Atherosclerosis with Clinical Events: CVD, CAD, PAD

Early diagnostic is the best
Good QoL

HUMAN EVOLUTION:
SOCIO-HEALTH-PHARMACO ECONOMIC
NATIONAL HEALTH SYSTEM

Etiology
Psychis, ( stress )

Physic ,( heart disease,vascular

disease )

Behaviour (perilaku ),life style

10% of All Deaths in Developed

Countries Are Due to Stroke
Tuberculosi Malaria
s

Diarrhea
disease
Perinatal
causes
Chronic obstructive
pulmonary disease
HIV/AIDS
Respiratory tract
infection

4%
5%

3% 3%

2%

Other
27%

5%
7%
Injury
9%

Strok
e
10%

Cancer
12%

Coronary
heart
disease
13%

HIV/AIDS = human immunodeficiency virus/acquired immunodeficiency syndrome.

Adapted with permission from MacKay J, Mensah GA. The Atlas of Heart Disease and
Stroke. Available at:
http://www.who.int/cardiovascular_diseases/en/cvd_atlas_16_death_from_stroke.pdf

Incidence
Other
5%

Cryptogenic
30%

Cardiogenic
embolism
20%

Haemorrhagic stroke
15%

Atherosclerotic
cerebrovascular
disease
20%
Small vessel
disease
lacunes
25%

Ischaemic stroke
85%

Albers et al. Chest 2004; 126 (3 Suppl): 438S512S.

Incidence of Ischemic Stroke vs

Hemorrhagic Stroke and mortality
The majority of strokes are ischemic
Hemorrhagic stroke

12%
88%

30-day mortality (%)

Ischemic stroke

36%-37%

40
30
20

8%-12%
10
0

INCIDENCE

MORTALITY

American Heart Association Heart Disease and Stroke Statistics2005 Update.

Chronic disability: Major burden of stro

Most strokes are not fatal
Aftermath of stroke includes:
Neurologic disability
Dementia
Depression
Epilepsy
Falls/fractures
Up to 30% of survivors
are permanently disabled
Rothwell PM. Lancet. 2001;357:1612-1616.
American Heart Association. 2002 Heart and Stroke Statistical Update. 2001.

LIMA PERTANDA GEJALA STROK

Tiba-tiba satu atau lebih :

1.

Lemah atau semutan atau baal separuh badan

2.

Sulit bicara atau tidak mengerti pembicaraan orang lain

3.

Gangguan penglihatan (buta satu mata atau dua mata)

4.

Nyeri kepala berat atau nyeri kepala yg tidak seperti biasa dirasakan.

5.

Pusing atau vertigo

Perdarahan otak

HOW TO DIAGNOSE?
History
Carotid bruit
Duplex

Sonography
Arteriography
MSCT
MRA

Type 2 Diabetes Prevalence

is Projected to Reach
300 Million by 2025
About 155 million adults worldwide diagnosed with diabetes in 2000

83 million women and 72 million men

Between 1995 and 2025, the prevalence of diabetes in adults will
increase by 35% and the number of people with diabetes will
increase by 122%

USA
2000: 15M
2025: 21.9M
AMERICAS
(Ex-US)
2000: 20M
2025: 42M

EUROPE

ASIA

2000: 30.8M

2000: 71.8M

2025: 38.5M
AFRICA

2025: 165.7M

JAPAN
2000: 6.9M
2025: 8.5M

2000: 9.2M

OCEANIA

2025: 21.5M

2000: 0.8M
2025: 1.5M

Adapted from King H et al Diabetes Care 1998;21:1414-143

Two-Thirds of People with Diabetes

Die
of Cardiovascular Disease
Among diabetics,

macrovascular
complications,
(incl. CHD, stroke and
peripheral vascular disease),
are the leading
causes of morbidity and mortality.
Causes of mortality in people with
diabetes

67%

Adapted from Alexander CM, Antonello S Pract Diabet 2002;21:21-28.

CHD, stroke &

peripheral vascular
disease
Other

Kadar
glukosa

Hiperglikemi
reaktif

Tekanan
darah

Atero
sklerosis

Strok
iskemik

Hipertensi
reaktif

Physical Risk Factors

Psychologic Risk Factor

Stress
Depression
Anxietas
etc

Behavioral Risk Factor

Life style
Dietary
Sports
etc

Conclusion :

Chronology of
Atherosclerotic Vascular Disease
Process
Development of
atherosclerosis and
vulnerable plaque

Acute Coronary Syndrome

Secondary Prevention

Ischemic
Heart Disease
Cerebrovascular
Disease
Peripheral Vascular
Disease

Modified from Libby P

Circ 104:365,2001

Plaques in Carotid
artery
cause stroke

Heart Center Online ,

23

Cardiovascular mortality
risk doubles with each
20/10 mmHg increment*
CV mortality risk
8

8x
6
4

4x

2
0

1x
115/75

2x
135/85

155/95

175/105

SBP/DBP (mmHg)
*Individuals aged 4069 years

Lewington et al. Lancet 2002;360:190313

Greater Risk of Death

Age-adjusted CVD
death rate per
10,000 person-years

with
Diabetes and One Risk Factor
than
without Diabetes and Three
140
Diabetes
Risk120Factors*
No diabetes
100
80
60
40
20
0

None

One only

Two only

Risk factors
*Serum cholesterol >200 mg/dl, smoking, systolic blood pressure >120 mmHg
Adapted from Stamler J et al Diabetes Care 1993;16:434-444.

All three

Atherosclerosis Is Common
in Newly Diagnosed Diabetes Mellitus
Cardiovascular diseases:

common
causes of morbidity & mortality in diabetics
>50% of newly diagnosed type 2 diabetics
show evidence of cardiovascular disease
Atherosclerosis:
major cause of death
among diabetics
75% from
coronary atherosclerosis
25%
from cerebral / peripheral vascular disease
>75% of hospitalizations of diabetics
atherosclerotic disease

Adapted from Amos AF et al Diabet Med 1997;14:S7-S85; Hill Golden S Adv Stud Med 2002;2:364-370;
Haffner SM et al N Engl J Med 1998;339:229-234; Sprafka JM et al Diabetes Care 1991;14:537543.

People with diabetes developing

complications within
9 years of diagnosis (%)

In Diabetics,
Macrovascular Complications are
2x > common
Microvascular Complications
25
20

20%

15

9%

10
5
0

n=5102

n=5102

Macrovascular complications Microvascular complications

Adapted from Turner R et al Ann Intern Med 1996;124:136-145.

STROKE: DIFFERENCES BETWEEN

PATIENTS WITH AND WITHOUT
DIABETES
Clinical

Diabetic

Non-diabetic

Ischaemic Haemorhagic

Aproximately 10 : 1

Aproximately 5 : 1

Stroke risk < 55 years

Higher

Lower

Relative risk for

male/female

Female > male

Female < male

Infratentorial infarcts

More common

Less common

Lacunar infarction

More common

Less common

Infarction volume

The same

The same

2006 Blackwell Publishing Ltd Int J Clin Pract, January 2006

RISK FACTORS FOR STROKE CASE

FATALITY

ACCELERATED ATHEROGENESIS IN
DIABETES MELLITUS

MULTI-INTERVENTIONAL PACKAGE FOR

THE PREVENTION OF STROKE WITH
DIABETES

SUMMARY OF IMPORTANT TRIAL

RELATING TO STROKE IN DIABETES

The effect of ramadan fasting on cerebral stroke: A

prospective hospital based study

Ramadan fasting has no effects on

stroke frequency,type and severity

The duratio of fasting has no effect
on either frequency or type ofstroke

Ashraf El-Mitwalli et al,(Egypt J.Neurol,Psychiat.Neurosurg;2009,46(1):51-56 )

Effects of ramadan Fasting

on stroke
Although Ramadan fasting had an

adverse effect on diabetic patients with

ischemic stroke, there was no negative
effect on stroke frequency ,and the
hyprtensive hemorrhagic stroke ratio is
lower.
To comfirm the result further prosfective
studies are needed.
Dept of Neurology,Numune Education and Research Hospital.Ankara Turkey ( Turk J.Med
Sci 33 (2003) 237-241

Medicine horn - Naga

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