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manifestasi klinis stroke
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MANIFESTASI KLINIK STROKE
CLINICAL DISORDERS
A. ASYMPTOMATIC
B. FOCAL BRAIN DYSFUNCTION 1. TRANSIENT ISCHEMIC ATTACK 2. S T R O K E
C. VASCULAR DEMENTIA
D. HYPERTENSIVE ENCEPHALOPATY
TRANSIENT ISCHEMIC ATTACK
1. CAROTID SYSTEM
2. VERTEBROBASILAR SYSTEM
3. BOTH
4. UNCERTAIN LOCATION
5. POSSIBLE TIA
S T R O K E
A. TEMPORAL PROFILE 1. IMPROVING STROKE 2. WORSENING STROKE 3. STABLE STROKE
B. TYPE OF STROKE 1. BRAIN INFARCTION 2. BRAIN HEMORRHAGE 3. SUBARACHNOIDAL HEMORRHAGE (SAH) 4. INTRACEREBRAL HEMORRHAGE FROM AVM
BRAIN INFARCTION
A. MECHANISM 1. THROMBOTIC 2. EMBOLIC 3. HEMODYNAMIC
B. CLINICAL CATEGORIES 1. ATHEROTHROMBOTIC 2. CARDIOEMBOLIC 3. LACUNAR 4. OTHER (ANGIOPATHY, ARTERITIS, DLL)
BRAIN INFARCTION (LANJ.)
C. SYMPTOMS AND SIGNS BY SITE (DISTRIBUTION)
1. CAROTID ARTERY SYSTEM a. INTERNAL CAROTID ARTERY b. MIDDLE CEREBRAL ARTERY c. ANTERIOR CEREBRAL ARTERY
2. VERTEBROBASILER SYSTEM a. VERTEBRAL ARTERY b. BASILER ARTERY c. POSTERIOR CEREBRAL ARTERY
CLINICAL ASSESSMENT
A. HISTORY B. PHYSICAL EXAMINATION
1. GENERAL 2. NEUROLOGIC 3. VASCULAR :
a. Palpation b. Auscultation
4. OPHTHALMOSCOPY
BRAIN INFARCTION
• GENERALLY HAVE ONE OR MORE RISK FACTORS
• HEADACHE AND VOMITING ARE UNUSUAL AT THE
ONSET
• DEFICITS MAY CONTINUE TO WORSENING
• USUALLY FOCAL DEFICIT WITH CAROTID DISTRIBUTION
BRAIN INFARCTION
MECHANISMS OF ISCHEMIC INFARCTION
1. THROMBOTIC– a thrombus is superimposed on an atherosclerotic
plaque– precipitated by an abnormality of blood clotting
2. EMBOLIC– due to occlusion of an artery by an embolus– inadequate collateral blood flow
3. HEMODINAMIC– stenosis or occlusion of the proximal artery– collateral compensatory blood flow inadequate – global cerebral perfusion is decreased (decreased
cardiac output)
CLINICAL CATEGORIES
1. ATHEROTHROMBOTIC
• PADA VASKULER ATEROSKLEROTIK ARTERI EKSTRAKRANIAL DAN INTRAKRANIAL UTAMA
• PATOMEKANISME TERJADI INFARK OTAK :– PLAK MEMBESAR DAN OKLUSI VASKULER,
SERINGNYA DISERTAI (SUPERIMPOSED) TROMBOSIS
– EMBOLIK, DARI LEPASNYA TROMBUS ATAU FRAGMEN PLAK (ARTERY TO ARTERY EMBOLUS)
• RIWAYAT TIA (+) DAN BRUIT SERVIKAL (+)
CLINICAL CATEGORIES (LANJ)
2. CARDIOEMBOLIC
• DEFISIT FOKAL, DAPAT WORSENING STROKE• DIAGNOSA ATAS DASAR DITEMUKAN SUMBER EMBOLI KARDIAL
DAN TRANSKARDIAL : KARDIAL
# FIBRILASI ATRIAL ATAU ATRIAL FLUTTER# INFARK MIOKARD# GAGAL JANTUNG KONGESTIF# KELAINAN KATUP MITRAL DAN AORTIK
TRANSKARDIAL (PARADOXICAL EMBOLIC)# RIGHT TO LEFT CARDIAC SHUNT# SUMBER EMBOLI : TROMBUS VENA PERIFER
• INFARK OTAK MULTIPEL ATAU INFARK SISTEMIK
CLINICAL CATEGORIES (LANJ)
2. CARDIOEMBOLIC
• MANIFESTASI KLINIK ISOLATED :#ISOLATED HEMIANPSOA HOMONIM#ISOLATED APHASIA
• KOMPLIKASI : INFARK BERDARAH• INFARK PADA DAERAH KORTIKAL, DISTRIBUSI CABANG
ARTERI SEREBRI MEDIA
CLINICAL CATEGORIES (LANJ)
3. LACUNAR• LESI PADA PENETRATING ARTERIES• PADA PERCABANGAN BELOKAN 90O :
#ARTERI LENTIKULOSTRIATA#ARTERI BATANG OTAK
• ARTERI PENETRANS MISKIN SISTEM KOLATERAL• OBSTRUKSI VASKULER OK :
#ARTERIAL DISEASE (ANGIOPATHY)#TROMBUS# EMBOLI
CLINICAL CATEGORIES (LANJ)
3. LACUNAR• DIAGNOSIS KLINIK BERDASARKAN :
BRAIN IMAGING (LESI < 1,5 CM) SINDROMA KLINIK (LOKASI ANATOMIK) :
– PURE MOTOR HEMIPARESIS– PURE SENSORY STROKE– ATAXIC HEMIPARESIS– DYSARTHRIA CLUMSY HAND SYNDROME
• SINDROMA DAPAT DENGAN IMAGING NORMAL• SINDROMA DAPAT JUGA KARENA PIS KECIL ATAU
INFARK KORTIKAL
GAMBARAN KLINIK
DITENTUKAN :
LETAK LESI LUAS LESI
GAMBARAN KLINIK
ARTERI KAROTIS INTERNA
OKLUSI DI SERVIKAL GMBR KLINIK TAK KHAS BILA KOLATERAL ADEKUAT ASIMTOMATIK BILA SIMTOMATIK :
• TIA SAMPAI INFARK LUAS MEKANISME
HEMODINAMIK ARTERY-TO-ARTERY EMBOLIC ATEROTROMBOTIK (PROPAGATION TROMBUS SAMPAI A. SEREBRI
MEDIA)
GAMBARAN KLINIK
GEJALA KLINIK : MONOPARESIS S/D HEMIPARESIS DENGAN / TANPA HEMIANOPSIA DISARTRIA DAN DISFASIA AGNOSIA HEMIHIPESTESI AMAUROSIS FUGAX CERVICAL BRUIT (+) (HIGH-PITCH)
GAMBARAN KLINIK
ARTERI SEREBRI MEDIA LESI PADA BAG. PERTAMA (MI) :
GEJALA KLINIK TERGANTUNG KOLATERAL SIRKULUS WILLISI
(A.SEREBRI ANTERIOR DAN POSTERIOR) ETIOLOGI TERSERING : EMBOLIK GEJALA KLINIK BIASANYA BERAT :
HEMIPLEGIA HEMIHIPESTESIA HEMIANOPSIA HOMONIM CONTALATERAL GAZE PALSY APHASIA (HEMISFER DOMINAN)
GAMBARAN KLINIK
ARTERI SEREBRI MEDIA • LESI PADA BATANG ARTERI (ARTERIAL STEM) : GEJALA KLINIK :
¤ DEFISIT MOTORIK KARENA GIANT LACUNE ¤ TERGANTUNG KOLATERAL DIPERMUKAAN OTAK
• OKLUSI PADA CABANG ¤ PARTIAL SYNDROME (ISOLATED)
GAMBARAN KLINIK
ARTERI SEREBRI ANTERIOR
GEJALA KLINIK : HEMIPARESIS, TERUTAMA TUNGKAI HEMIHIPESTESI APRAKSIA (TERUTAMA GAIT APRAXIA) GANGGUAN FUNGSI LUHUR
GAMBARAN KLINIK
VERTEBROBASILER SYSTEM MENDARAHI :
MEDULA OBLONGATA PONTIS MESENSEFALON TALAMUS LOBUS OKSIPITALIS TEMPOROCCIPITAL JUNCTION PARIETOOCCIPOITAL JUNCTION
GAMBARAN KLINIK
ARTERI VERTEBRALIS OKLUSI A. VERTEBRALIS DAN A. CEREBELARIS INFERIOR
POSTERIOR LATERAL MEDULLARY INFARCTION GEJALA KLINIK:
• VERTIGO • MUAL / MUNTAH • DISFAGIA • ATAKSIA SEREBELARIS IPSILATERAL • IPSILATERAL HORNER’S SYNDROME • PAIN AND TEMPERATUR DISCRIMINATION :
≠ IPSILATERAL PADA WAJAH ≠ KONTRALATERAL PADA TUBUH DAN
EKSTRIMITAS
GAMBARAN KLINIK
ARTERI BASILARIS
• OKLUSI A. BASILARIS : GGN BATANG OTAK BILATERAL • OKLUSI CABANG A. BASILARIS SATU SISI BO :
LOCALIZED SYNDROME (Sindroma Batang Otak)
ALTERNATING • GEJALA UTAMA :
VERTIGO NISTAGMUS
GAMBARAN KLINIK
ARTERI SEREBRI POSTERIOR
OKLUSI SERINGKALI KARENA EMBOLI GEJALA KLINIK :
HOMONYMOUS VISUAL FIELD DEFECT : HEMIANOPSIA QUADRANOPSIA
DISLEKSIA DAN DISKALKULI (HEMISFER DOMINAN) SINDROMA LOBUS PARIETALIS (HEMISFER NON-
DOMINAN) BILATERAL :
BUTA KORTIKAL GANGGUAN TINGKAH LAKU
Effects depend on area(s) of brain affectedEffects depend on area(s) of brain affected
Effects of StrokeEffects of Stroke
Right HemisphereRight Hemisphere
= Left-sided paralysis= Spatial misperception (falling, dropping things)= Reading difficulty= Impulsiveness= Left-sided neglect= Loss of short-term memory
Effects depend on area(s) of brain affectedEffects depend on area(s) of brain affected
Effects of StrokeEffects of Stroke
Left HemisphereLeft Hemisphere
= Right-sided paralysis= Speech/language impairment= Inability to complete tasks without patient instruction= Memory loss
Effects depend on area(s) of brain affectedEffects depend on area(s) of brain affected
Effects of StrokeEffects of Stroke
Brain stemBrain stem
= Disruption of breathing= Loss of consciousness= Variable effects on blood pressure= Disruption of eye movements, swallowing, hearing, speech= Bilateral paralysis likely
Effects depend on area(s) of brain affectedEffects depend on area(s) of brain affected
Effects of StrokeEffects of Stroke
CerebellumCerebellum
= Balance= Coordination= Dizziness, nausea, vomiting= Disruption of some reflexes, especially involving head & neck
Gejala dan Tanda StrokeGejala dan Tanda Stroke
Facial Droop
Pronater Drift