Topics

1. Stroke Definition
2. Epidemiology
3. Stroke burdens in Indonesia
4. Type of Stroke
5. Risk factors of Stroke
6. Diagnostic Stroke without imaging
(scoring)
7. Primary stroke prevention
8. Secondary stroke prevention
9. Educate people/ increase knowledge
about Stroke and Risk factors
 Stroke Definition (2013)
 Stroke is classically characterized as a neurological deficit
attributed to an acute focal injury of the central nervous
system (CNS) by a vascular cause, including cerebral
infarction, intracerebral hemorrhage (ICH), and
subarachnoid hemorrhage (SAH)
 Definition of CNS infarction: CNS infarction is brain,
spinal cord, or retinal cell death attributable to ischemia,
based on
1. pathological, imaging, or other objective evidence of
cerebral, spinal cord, or retinal focal ischemic injury in a
defined vascular distribution; or
2. clinical evidence of cerebral, spinal cord, or retinal focal
ischemic injury based on symptoms persisting ≥24 hours or
until death, and other etiologies excluded.
 TIA definition (2013)
 Conventional clinical definitions focal neurological
symptoms or signs lasting less than 24 hours has been
defined as a TIA (1994)
 One-third of those are found to have an infarct on brain
imaging
 A transient episode of focal neurological dysfunction
without acute infarction
 The timing and type of a diagnostic workup for TIA/Stroke
is beyond the scope of this statement. Although
recommendations include all patients should have brain
imaging (CT or MRI) to distinguish between ischemic or
hemorrhagic events
Epidemiology in Indonesia
Risk factors
 Stroke Subtypes
Hemorrhagic Stroke (17%) Ischemic Stroke (83%)
Atherothrombotic
Cerebrovascular
Intracerebral Disease (20%)
Hemorrhage (59%)
Cryptogenic and
Other Known
Cause (30%)

Subarachnoid Hemorrhage (41%)

Lacunar (25%) Embolism (20%)

Small vessel disease

Albers GW, et al. Chest. 1998;114:683S-698S.

Rosamond WD, et al. Stroke. 1999;30:736-743.
Risk Factors of Stroke
 Non-modifiable Risk Factors
 Age

 Gender

 Race/ethnicity

 Prior stroke

 Heredity

Sacco RL, et al. Stroke. 1997;28:1507-1517.

 Stroke: Well-Documented and
Modifiable Risk Factors
 Asymptomatic carotid stenosis
 Hypertension
 Sickle cell disease
 Diabetes  Postmenopausal hormone
 Dyslipidemia therapy
 Diet and nutrition
 Atrial fibrillation
 Physical Inactivity
 Other cardiac conditions
 Obesity and body fat distribution
 Cigarette smoke
 Hyperhomocystein
 Strategies for Preventing Stroke and
Reducing Stroke Disability

Blood pressure
Glucose
Smoking mass population
strategy acute treatment
Lipids

First stroke Secondary

prevention

high risk strategy

Rehabilitation
Hypertension
TIA
Atrial fibrillation
other vascular disease
Primary Stroke
Prevention
 Management of Risk Factors
 Non-pharmacological intervention:
 Life style modification: cessation of
smoking, drinking, reduce salt
 Exercise, weight reduction
 Pharmacological intervention:
 DM, HTN, hyperlipidemia, cardiac
diseases,
 Hypertension
 Most important intervention for secondary prevention
of ischemic stroke –present in approximately 70% of
ischemic stroke
 Hypertension defined as SBP ≥ 140 mm HG or a DBP ≥
90 mm Hg
 Initiation of BP therapy is indicated for previously
untreated patients with ischemic stroke or TIA who,
after the first several days, have an established BP >140
mmHg systolic or >90 mmHg diastolic (Class I, LOEB)
 •Initiation of therapy for patients with pressure <140
systolic and <90 diastolic is of uncertain benefit (Class
IIb, LOE C)
 Hypertension Control
 SBP<140mmHg & DBP<90mmHG

 <130/<80 if target organ damage

 Antihypertensive medications: COMPLIANCE

 Lifestyle modification

ERASE myths that take routine

antihypertensive drugs are harmful
Categories of BP in Adults (Guideline Hypertension 2017)
BP Category SBP DBP
Normal <120 mm Hg and <80 mm Hg
Elevated 120–129 mm and <80 mm Hg
Hg
Hypertension
Stage 1 130–139 mm or 80–89 mm Hg
Hg
Stage 2 ≥140 mm Hg or ≥90 mm Hg

*Individuals with SBP and DBP in 2 categories should be

designated to the higher BP category.
BP indicates blood pressure (based on an average of ≥2
careful readings obtained on ≥2 occasions, as detailed in
DBP, diastolic blood pressure; and SBP systolic blood
pressure.
Blood Pressure Treatment Goals
(JNC 8, 2016)

 Persons 60 years or older without diabetes or

CKD
 BP < 150/90 (based on strong evidence)
 Persons less than 60 years of age, with diabetes,
and/or with CKD
 BP <140/90 (based on expert opinion)
Recommendation (JNC8)
 Dyslipidemia
4 Statin Benefit Groups
1. Individuals with clinical ASCVD, defined as the
inclusion criteria for secondary prevention statin RCTs
–Acute coronary syndromes
–History of MI
–Stable or unstable angina
–Coronary or other arterial revascularization
–Stroke or TIA
–PAD
 Dyslipidemia (2)
2. Individuals with primary elevations of LDL-C ≥
190 mg/dL

3. Individuals with diabetes aged 40-75 years with

LDL-C 70-189 mg/dL and without clinical ASCVD

4. Individuals without ASCVD or diabetes with LDL-

C 70-189 mg/dL and estimated 10-year ASCVD risk
≥ 7.5% (estimated using the Pooled Cohort
Equations)
 Stroke: Potential Mechanisms of
Benefit
- LDL Statin
reduction - plaque
stabilization:
macrophages
smooth muscle cells
immunologic response - Improved endothelial function
lipid core - Reduced hemorheologic stress
oxidized LDL - Reduced platelet aggregation
- Reduced thrombotic and
enhanced fibrinolytic state

Delanty N, Vaughan CJ. Stroke 1997;28:2315-2320.

Lifestyle Modifications
How to Differentiate stroke ischemic from
Hemorrhage without imaging
1. Siriraj Score
Formula:
(2.5x consciousness)+ (2xVomit)+(2xheadache)+
(0.1xDBP) - (3xatheroma) - 12
Consciousness :
alert 0, drowsy/stupor 1, semicoma/coma 2
Vomit/headache within 2 hours: yes:1, No: 0
Atheroma (diabetes, angina, Coronary/claudicatio): yes 1, No:
0
If the Score > 1: Hemorrhage
Score <-1: Ischemic
Score -1 to 1: uncertain diagnostic (need imaging)

 The sensitivity and specificity of Siriraj stroke score for

cerebral infarction was 71 and 85 respectively and for
intracerebral haemorrhage, it was 73 and 90 respectively
2. Gajah Mada Score

79% sensitivity, 86% specificity

Educate People about the
symptoms of STROKE
What should you do if pts with
TIA?
Antithrombotic Therapies to Prevent
Recurrent Ischemic Stroke

 Oral anticoagulants
 Antiplatelet agents
 Aspirin 50-325 mg/day
 Clopidogrel 75 mg/day
 Guideline Stroke Prevention 2016
Established Risk
Recommendation Category
Factor
Regular blood pressure (BP) screening;
appropriate hypertension treatment.

Prehypertension (systolic BP of 120-139 mm Hg

or diastolic BP of 80-89 mm Hg): Perform
annual BP screening and lifestyle
modifications

Hypertension Class I

Hypertension: Treat to target <140/90 mm Hg;

BP reduction is more important than choice of
agent in lowering stroke risk; individualize
therapy. Home self-monitoring of blood
pressure in hypertensive patients
Physical Healthy adults: moderate- to vigorous-intensity aerobic activity
Class I
Inactivity at least 40 minutes per day, 3-4 days per week

Lifestyle interventions
Class I
High 10-year cardiovascular risk: Initiate statin therapy

Low high-density lipoprotein cholesterol or high lipoprotein

(Lp)(a): Consider niacin, although efficacy in stroke
Dyslipide
mia prevention not established

Hypertriglyceridemia: Consider fibric acid derivatives, Class IIb

although efficacy in stroke prevention not established

If statin-intolerant, consider other lipid-lowering therapies,

although efficacy in stroke prevention not established

Reduced sodium and increased potassium intake; DASH-style

Class I
Diet and diet rich in fruits and vegetables
Nutrition
Consider Mediterranean diet supplemented with nuts Class IIa
Obesity Weight reduction in overweight and obese individuals Class I

Type 1 or type 2 diabetes: Control BP, per AHA/ACC/CDC

Advisory to target <140/90 mm Hg; Treat adults with diabetes Class I
with a statin, especially in case of additional risk factors

Diabetes
Mellitus Usefulness of aspirin for primary stroke prevention in those
with diabetes but a low 10-year risk for cardiovascular disease Class IIb
is unclear

Add-on fibrate in those with diabetes is not useful in reducing

Class III
stroke risk

Counseling plus drug therapy for smokers; maintain

Class I
abstinence in those who have never smoked
Smoking
Community-wide or statewide bans on smoking in public
Class IIa
spaces are reasonable
 Valvular AF and high stroke risk (CHA2DS2-VASc score ≥ 2):
Initiate long-term warfarin therapy; target international
normalized ratio (INR), 2.0-3.0
Class I
Nonvalvular AF, CHA2DS2-VASc score ≥2, and low risk for
hemorrhagic complications: Individualize care and consider
warfarin, dabigatran, apixaban, or rivaroxaban

AF screening in the primary care setting in those older than 65

years
Class IIa
Atrial
Nonvalvular AF and CHA2DS2-VASc score of O: reasonable to
Fibrillation omit antithrombotic therapy

Nonvalvular AF, CHA2DS2-VASc score I, and low risk for

hemorrhagic complications: No antithrombotic therapy,
anticoagulant therapy, or aspirin therapy can be considered;
selection of antithrombotic agent should be individualized on
the basis of patient risk factors
Class IIb
High-risk patients with AF who are unsuitable for
anticoagulation: Consider left atrial appendage closure, if
performed at a center with a low complication rate
 Asymptomatic carotid stenosis: statin plus daily aspirin; screen
for and manage other stroke risk factors
Class I
Carotid endarterectomy (CEA): peri- and postoperative aspirin,
unless contraindicated

Asymptomatic with >70% stenosis: consider CEA if

perioperative risk for stroke, MI, and death is low (<3%)
Class IIa
Carotid >50% stenosis: repeat duplex ultrasonography annually to assess
Artery progression, regression, and treatment response
Stenosis

Consider prophylactic stenting in highly selected patients with

asymptomatic stenosis (≥60% by angiography or ≥70% by validated
Doppler ultrasonography)
Class IIb
Asymptomatic, but high risk for CEA or carotid artery stenting
complications: effectiveness of revascularization vs medical therapy
is not well established

Screening low-risk populations for asymptomatic stenosis is not Class III

recommended
Conclusion: WHO 25 by 25