97083888 Presentasi Kasus Stroke Final

8/18/2019 97083888 Presentasi Kasus Stroke Final

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Presentasi KasusPresentasi Kasus

Diajukan oleh : dr. Noegroho HarbaniDiajukan oleh : dr. Noegroho Harbani

Moderator : dr. RM. Hermanu Poespaningrat, SpSModerator : dr. RM. Hermanu Poespaningrat, SpS

Penilai : Prof. DR. dr. Hj. Sri Sutarni , SpS K!Penilai : Prof. DR. dr. Hj. Sri Sutarni , SpS K!

dr. "ukman Hakim , SpSdr. "ukman Hakim , SpS

Klaten, #$ %pril #&&$Klaten, #$ %pril #&&$


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'dentitas

Nama : (n. SPekerjaan : Pensiunan PNS

)mur : *+ tahun%gama : 'slamMR : *& +&$

%lamat : -alanharjo, lagah /angi, KlatenPendidikan : D0Masuk RS : 01 Maret #&&$


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ANAMNESIS

%llo anamnesis : diperoleh dari penderita dan istri penderita

# %pril #&&$!Keluhan utama :

Kelemahan anggota gerak kiri


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Riwayat Penyakit Sekarang

Lebih kurang 2 JamSMRS mendadakmengeluh anggota

gerak kiri terasa lemahdan berat untukdigerakkan.

Untuk jalan terjatuh,disertai nyeri kepala,bicara pelo, mulut

perot dan nyerikepala .


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Riwayat Penyakit Sekarang ( lanj..)

Kelemahan antaratangan dan kaki terjadibersamaan dengan

tingkat kelemahansama

Selama sakit penderitatidak demam,pandangan kabur,

pusing berputar,gangguan menelan,kejang, penurunankesadaran, kesemutandan gangguan ! "

!K


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ANAMNESIS

Riwayat Penyakit Dahulu

Ri2a3at hipertensi sejak tahun 1$$ tidak terkontrol

Ri2a3at merokok 4!Ri2a3at ken5ing manis 4!Ri2a3at sakit jantung 4!

Ri2a3at trauma kepala 4!Ri2a3at tumor 4!Ri2a3at stroke atau sakit serupa 4!


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ANAMNESIS (Lanj.)Riwayat Penyakit Keluarga

(idak ada keluarga 3ang menderita sakit serupa


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Evalua i i tem

Sistem serebrospinal : kelemahan anggotagerak kiri, pelo, perot, n3eri kepala bersifat akut

Sistem kardio6askuler : normalSistem Respirasi : normalSistem gastrointestinal : normal

Sistem muskuloskeletal : normalSistem intugumentum : normalSistem urogenital : normal


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Re ume anamne i

"aki4 laki usia *+ tahun, datang dengan keluhansejak # jam sebelum masuk rumah sakit kelemahananggota gerak kiri, n3eri kepala, pelo, perot. (idakada demam, penurunan kesadaran dan kejang. (idakada ri2a3at trauma, tumor, gangguan penglihatan,sakit gigi, dan infeksi telinga. Ri2a3at hipertensisejak 1$$ tidak terkontrol.


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Diagn! i Sementara

Diagnosis klinis : kelemahan anggotagerak kiri, bi5ara pelo, dan perot disertai

n3eri kepala 3ang bersifat akut.Diagnosis topik :intraserebralhemisperium de7tra, subkortikal

Diagnosis etiologi :1. Stroke hemoragik #. Stroke non hemoragik


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Pemerik aan umum

Keadaan umum : sedang,gi8i sedang, 5ompos mentis(anda 6ital : (D 1*&91&& mmHg, N : +*79mnt,RR : #& 79mnt, t : 0*, o

Statu internu ";antung : murmur 4!, S1, S# normalParu : sonor, 6esikular, ronkhi 4!

"e6er : normal"ien : tak terabaStatus psikiatrik : kooperatif, normoaktif, orientasiorang, 2aktu dan tempat baik


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Statu neur!l!gi

Kesadaran : 5ompos mentis, S


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Koordinasi dan keseimbangan : sulit dinilai@ungsi 6egetatif : dalam batas normalSkala Stroke adjah Mada : #$

Mini Mental State Examination : #+Clock Draw Test : 0

Statu neur!l!gi


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Akstremitas- ( 000 N N

K (n - ( 000 N N

A A N 4 =

(r Rf RpA A N 4 =

lonus 494

Statu neur!l!gi


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Pemerik aan #enunjang

La$!rat!rium (%& ' % ' *)

Hb: 11,0%": 11,+%(: #*&.&&&

%A:


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EK, (%& Maret *)

Kesan : Normal sinus rh3tm HR:+ 79menit!



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-ea /0 S1an (%&Maret *)

(ampak lesi hiperdens ditalamus dekstra dan di5apsula interna dekstra

Kesan: 'ntra serebralhemoragi di talamus dankapsula interna dekstra



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Diagn! i akhir

Diagn! i klini " hemiparese sinistra 5um

parese N >'' et ?'' sinistra )MN.Diagn! i t!#ik " (alamus dan kapsula internadekstra sesuai dengan 6askularisasi arteri

lentrikulostriata 5abang arteri serebri media.Diagn! i eti!l!gi " intraserebral hemoragik


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Penatalak anaan

2mum Airway ,breathing and circulation maintenanceC# 04 "9mnt'>@D Ringer asetat 1* tetes9mnt

ateter 3armak!tera#i%nti edema : Manitol #&


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Prognosis

Death : baik Disesase : dubia ad bonamDis5omfort : dubia ad bonamDisabilit3 : dubia ad bonamDissatisfa5tion : dubia ad bonmaDestitution : dubia ad malam


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@ollo2 up &09&


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#anggal $%&'%&( )%&'%&( *%&'%&( +%&'%&(Keluhan yeri kepala -

Sulit tiduryeri kepala yeri kepala yeri kepala

Keadaanumum

/ukup,/M0'M)1

/ukup,/M0'M)1

/ukup,/M0'M)1

l/ukup,/M0'M)1

#anda 3ital #4 5 6'&%(&5 +',#5$*,'

#4 5 6$&%(&5 ++,#5$),2

#4 5 6$&%(&5 ++,#5$),)

#4 5 6$&%(&5 +',#5$).

n.craniales

7arese188"988sin UM

7arese188"988sin

UM

7arese188"988sin

UM

7arese188"988sin

UM

R.:siologis Meningkat pdekstremitas kiri

Meningkat pdekstremitas

kiri


kiri


kiri

R.patologis 7ositi; pdekstremitas kiri

7ositi; pdekstremitas

kiri


kiri


kiri

clonus % % % %

Kekuatan

F"ll"# $%

999 %%%

999 %%%

999 777

999 777

999 777

999 777

999 777

999 777


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&e!inisi Str"ke&e!inisi Str"ke

Str"ke adala' an $an !$n si"nal "tak !"kalStr"ke adala' an $an !$n si"nal "tak !"kalma$%$n l"bal (an ter)adi se*ara ak$t berasalma$%$n l"bal (an ter)adi se*ara ak$t berasaldari an $an aliran dara' "tak , Termas$k didari an $an aliran dara' "tak , Termas$k disini %erdara'an s$bara*'n"id %erdara'ansini %erdara'an s$bara*'n"id %erdara'anintraserebral dan iskemik ata$ in!ark serebri,intraserebral dan iskemik ata$ in!ark serebri,Tidak termas$k disini an $an %eredaranTidak termas$k disini an $an %eredarandara' "tak se%intas t$m"r "tak in!eksi ata$dara' "tak se%intas t$m"r "tak in!eksi ata$str"ke sek$nder karena tra$ma . 0 12 4str"ke sek$nder karena tra$ma . 0 12 4


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6 Str"ke %en(ebab kematian ke-3 di berba aine ara

6 Str"ke did%t %d sem$a "l, $m$r tt% ter$tama %d$sia t$a dan menin kat d n tamba'n(a $m$r

6 Str"ke adl n !$n si"nal "tak !"kal ma$%$nl"bal ak$t 7 89 )am akibat n &0

6 &iba i 8 :1, Perdara'an : insiden 15-3; < =ntrakranialdan s$barak'n"id

8, =skemik : insiden >;- 5 <


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!L

penderita stroke akut

penurunan kes., nyeri kepala, refleks babinski

1 dari ketiganyaada

3 atau 2 dariketiganya ada tidak adaketiganya

stroke perdarahan stroke iskemik akut(stroke infark)

penurunan kes. ada, nyeri kepaladan refleks babinski tidak ada

ataunyeri kepala ada, penurunan kes.,

dan refleks babinski tidak ada

refleks babinski ada,penurunan kes. dan

nyeri kepala tidak ada

dengan atau tanpa


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Risk Factor for StrokeRisk Factor for Stroke

on modifiableon modifiable

!ge!ge"ender "ender RasRas#erediter #erediter

$odifiable$odifiable!rterial hypertension!rterial hypertension#ypercholesterolemia#ypercholesterolemia%igarette smoking%igarette smoking

&iabetes $ellitus&iabetes $ellitus#yperhomocysteinemia#yperhomocysteinemia!lcohol abuse!lcohol abuse'ral contracepti e'ral contracepti e$enopause$enopause

hysical inacti ityhysical inacti ity'besity'besity!trial Fibrillation!trial Fibrillation#ipercoagulability#ipercoagulability


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Kelema'an an "ta erak sesisiKelema'an an "ta erak sesisiPel" / *edalPel" / *edal

Per"tPer"tKes$litan menelanKes$litan menelanVerti "Verti "

Pen$r$nan kesadaranPen$r$nan kesadaranN(eri ke%alaN(eri ke%ala


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Caban arteria *ar"tis internaCaban arteria *ar"tis internaCaban arteria ?ertebralisCaban arteria ?ertebralis

Gan $an aliran sirk$lasi dara' da%atGan $an aliran sirk$lasi dara' da%atber$%a :ber$%a :

Tr"mb$sTr"mb$sEmb"l$sEmb"l$s


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K"m%likasi Str"keK"m%likasi Str"ke

&emensia&emensia&e%resi&e%resiKe*a*atanKe*a*atanE%ile%siE%ile%siK"ntrakt$r K"ntrakt$r Pe%ti* $l*er Pe%ti* $l*er

Br"n*'"%ne$m"niaBr"n*'"%ne$m"nia&e*k$bit$s&e*k$bit$sSe%tikemiaSe%tikemiaTr"mb"sis ?enaTr"mb"sis ?ena%r"!$nda%r"!$ndaEmb"li %$lm"Emb"li %$lm"

G n keseimban anG n keseimban an*airan*airan


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31

N T0@= 0T K N T0@= 0T K


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nat"m( A Str"ke, nat"m( A Str"ke,

http://www.strokecenter.org/education/ais_images/ais045-lg.jpg


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PAR0 63 @RAIN


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/6N0R6L /EN0ER 63 @RAIN


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@un5tional %reas of the -rain

-a5k

http://d/PRESENTASI%20KASUS%20211205%20baru.ppthttp://d/PRESENTASI%20KASUS%20211205%20baru.ppt


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Mungkin sulit dipercaya bahwa di dalam otakMungkin sulit dipercaya bahwa di dalam otaktersimpan informasi mengenai segala hal yangtersimpan informasi mengenai segala hal yang

mengatur kelangsungan hidup manusiamengatur kelangsungan hidup manusia


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3

C"rti*"s%inal Tra*tC"rti*"s%inal Tra*t

$ $l$


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32

"m$n*$l$s"m$n*$l$s


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'leh karena ruptur aneurisma, angioma, lesiaterosklerotik


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0pidemilogy0pidemilogy

IncidenceIncidenceUSAUSA– ICH represents 10-15 percent of all strokesICH represents 10-15 percent of all strokes

appro!imately "0#000 new cases each year$appro!imately "0#000 new cases each year$11

%%Internationally Internationally – &sian countries '' incidence of ICH (0)$&sian countries '' incidence of ICH (0)$ **

It is twice as common as subarachnoid hemorrhageIt is twice as common as subarachnoid hemorrhageand carries an e+ually poor prognosisand carries an e+ually poor prognosis ((

11 ,troke% 1 . (0/ *5*(-*5* %,troke% 1 . (0/ *5*(-*5* %** ,trokr%*00(.( /*0 1-*0 2,trokr%*00(.( /*0 1-*0 2

(( 3 4eurosurg% 1 (. " / 1 -1 1% 3 4eurosurg% 1 (. " / 1 -1 1%


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E%idemi"l" (E%idemi"l" (

Mortality Mortality A t > da(s: 78;< t > da(s: 78;< A t 1 m"nt': 79;< t 1 m"nt': 79;< A t 1 (ear: 53< t 1 (ear: 53< A C"rrelated #it' ?"l$me "! =C 73; **C"rrelated #it' ?"l$me "! =C 73; **

Functionally indipendenceFunctionally indipendence

A t 1 m"nt': 1;< t 1 m"nt': 1;< A t 4 m"nt's: 8;< t 4 m"nt's: 8;<

Cle? Clin @ed 8;;5 9:391-399Cle? Clin @ed 8;;5 9:391-399


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rimary and Secondaryrimary and Secondary%auses of *ntracerebral #emorrhage%auses of *ntracerebral #emorrhage

rimaryrimary SecondarySecondary

(%ertensi"n(%ertensi"n m(l"id an i"%at'( m(l"id an i"%at'(

ne$r(sms ne$r(sms rteri"?en"$s rteri"?en"$s

mal!"rmati"nsmal!"rmati"nsNe"%lasmsNe"%lasmsTra$maTra$ma

nti*"a $lati"n nti*"a $lati"nDse "! t'r"mb"l(ti*sDse "! t'r"mb"l(ti*s

em"rr'a i* *"n?ersi"n "!em"rr'a i* *"n?ersi"n "!is*'emi* str"keis*'emi* str"ke

8 #R!/0R0 R!L


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>?70R#0 S8=

=#>0R

!1 M!L@=RM!#8=

! 0UR?SM

=ther causes5 bleeding into tumor, hypocoagulable state,hemorrhagic in;arction, iatrogenic, and trauma

8 #R!/0R0 R!L>0M=RR>!


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Ca$ses "! Str"keCa$ses "! Str"ke


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i%ertensii%ertensi

i%ertensi

k$t

Kr"nis

Pemb,dr' ke*il S%asme Ense!al"%ati'i%ertensi!

Pemb dr' ke*il

Pemb dr' sedan

i%"'ialin"sis

@ikr"ane$risma

Tr"mb"sis

P=S

=n!arklak$nar

ter"skler"sisT= tr"mb"sisEmb"li serebri

Fakt"r resik" lain&@ 'i%erli%idemi

%e*a'


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%erebral ascular remodeling%erebral ascular remodeling#ypertrophy media + narro ing lumen#ypertrophy media + narro ing lumen

-hese changes are protecti e-hese changes are protecti e reduction all tensionreduction all tension+ shifting of autoregulation cur e to allo+ shifting of autoregulation cur e to allocompensation at higher compensation at higher /asc remodeling accompanied by endothelial/asc remodeling accompanied by endothelialdysfunctiondysfunction impaired rela0ationimpaired rela0ation poorpoorcompensation of hypoperfusioncompensation of hypoperfusion reduced collateralreduced collateralfloflo higher susceptibility to ischemic in uryhigher susceptibility to ischemic in ury


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Perdara'an %d 'i%ertensi t)d $m$mn(a %dPerdara'an %d 'i%ertensi t)d $m$mn(a %dtem%at ( dalam dari "tak s%t an liatem%at ( dalam dari "tak s%t an liabasalis dan t'alam$s krn %emb,dara' %dbasalis dan t'alam$s krn %emb,dara' %d

daera' tsb tert$t$% dari tekanan ( tin idaera' tsb tert$t$% dari tekanan ( tin idari t'e *ir*le "! #illis,dari t'e *ir*le "! #illis,Perdar'an ini lebi' sedikit %dPerdar'an ini lebi' sedikit %d%"ns serebel$m ata$ k"rtek s$%er!isial%"ns serebel$m ata$ k"rtek s$%er!isial


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St$di %at"l" i men$n)$kkan 'i%er%lasia %dSt$di %at"l" i men$n)$kkan 'i%er%lasia %ddindin arteri media s' t)d reaksi %r"li!erasi seldindin arteri media s' t)d reaksi %r"li!erasi sel"t"t %"l"s %d a#al 'i%ertensi,"t"t %"l"s %d a#al 'i%ertensi,

al ini akan membent$k arteri"skler"sisal ini akan membent$k arteri"skler"sis'i%er%lastik,'i%er%lastik,Kem$n kinan sel "t"t %"l"s mati dan di antiKem$n kinan sel "t"t %"l"s mati dan di anti

)arin an k"la en ( memb$at dd %emb dara' )arin an k"la en ( memb$at dd %emb dara'ra%$' dan bertan $n )a#ab %ada keb"*"ranra%$' dan bertan $n )a#ab %ada keb"*"ranlebi' lan)$t,lebi' lan)$t,


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Pada 'i%ertensi kr"nik did$ a ba'#aPada 'i%ertensi kr"nik did$ a ba'#a!ibrin"id ne*r"sis mr% %rek$rs"r %dara'an,!ibrin"id ne*r"sis mr% %rek$rs"r %dara'an,


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Cerebral am(l"id an i"%at'( CCerebral am(l"id an i"%at'( C

C mr% 'asil dari %en$m%$kan %e%tidaC mr% 'asil dari %en$m%$kan %e%tidaamil"id beta ( tdk lar$t %d dd arteriamil"id beta ( tdk lar$t %d dd arteri

arteri"la dan ka%iler dari le%t"menin ealarteri"la dan ka%iler dari le%t"menin ealdan k"rtek,dan k"rtek,Pen antian sel "t"t %"l"s %d dd arteriPen antian sel "t"t %"l"s %d dd arteri"le' %enin katan amil"id beta seirin d"le' %enin katan amil"id beta seirin d

$sia memb$at da(a lent$r arteri bk$ran ,$sia memb$at da(a lent$r arteri bk$ran ,


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Pdara'an ( di'$b d C b'$b dPdara'an ( di'$b d C b'$b dinteraksi dari !akt"r resik" lain (ait$interaksi dari !akt"r resik" lain (ait$'i%ertensi,'i%ertensi,


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K"m%likasi ?ask$l"%atik s%esi!ik t)dK"m%likasi ?ask$l"%atik s%esi!ik t)dbiasan(a %d C d %dara'an,biasan(a %d C d %dara'an,K"m%likasin(a antara lain d"$ble barrelK"m%likasin(a antara lain d"$ble barrela%%earan*e ne*r"sisa%%earan*e ne*r"sis!ibrin"id mi*r"ane$risma sten"tik!ibrin"id mi*r"ane$risma sten"tikl$men mikr"'em"ra ik dan *"rti*all$men mikr"'em"ra ik dan *"rti*al

in!ar*ti"n,in!ar*ti"n,


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R$%t$r ane$r(sma : 4-18 %er 1;;;;;/t'R$%t$r ane$r(sma : 4-18 %er 1;;;;;/t'.anita : %ria 3:8.anita : %ria 3:8Dm$r : serin 9;-4; t' )aran anakDm$r : serin 9;-4; t' )aran anak

7 9; t' #anita 7 %ria7 9; t' #anita 7 %ria 9; t' %ria 7 #anita 9; t' %ria 7 #anita

Pen(ebab : *"n enital de!e*t T,mediaPen(ebab : *"n enital de!e*t T,mediaat'er"s*ler"tik/'i%ertensi emb"li in!eksi tra$ma dllat'er"s*ler"tik/'i%ertensi emb"li in!eksi tra$ma dllTem%at : 8;-85< ,*erebri mediaTem%at : 8;-85< ,*erebri media

1;< sirk$lasi %"steri"r 1;< sirk$lasi %"steri"r 35-9;< ,*erebri anteri"r 35-9;< ,*erebri anteri"r 3;< ,*ar"tid interna3;< ,*ar"tid interna


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ne$risma adala' keadaan dimana %emb ne$risma adala' keadaan dimana %embdara' m)d mbesar s*r abn"rmal ata$dara' m)d mbesar s*r abn"rmal ata$men emban s%t bal"n ( men"n)"lmen emban s%t bal"n ( men"n)"l

kel$ar,kel$ar,Serin t)d %d arteri dibasis "tak *ir*$l$sSerin t)d %d arteri dibasis "tak *ir*$l$s#illisi dan di a"rta,#illisi dan di a"rta,

@en(ebabkan r$%t$r dan kematian@en(ebabkan r$%t$r dan kematian


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Penin katan tekanan 'i%ertensi sistemikPenin katan tekanan 'i%ertensi sistemikdan menin katn(a $k$ran ane$rismadan menin katn(a $k$ran ane$rismamemi*$ tekanan %d dd danmemi*$ tekanan %d dd dan

menin katkan resik" r$%t$r menin katkan resik" r$%t$r


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@ekanisme ane$risma@ekanisme ane$risma

&e radasi %r"te"litik dari dd )ar ikat a"rta&e radasi %r"te"litik dari dd )ar ikat a"rta=n!lamasi dan res%"n im$n=n!lamasi dan res%"n im$n

Stress bi"kimia#i %d ddStress bi"kimia#i %d dd@"lek$ler enetik@"lek$ler enetik


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ne$risma terbent$k s*r %erla'an selama ne$risma terbent$k s*r %erla'an selamabbr% ta'$n dan serin tan%a e)alabbr% ta'$n dan serin tan%a e)ala

ika ane$risma men emban s*r *e%atika ane$risma men emban s*r *e%atmaka t)d r$%t$r /r"bekan ata$ keb"*"ranmaka t)d r$%t$r /r"bekan ata$ keb"*"randara' dise%an)an dd %emb dara' Hdara' dise%an)an dd %emb dara' Hd%t m$n*$l tiba-tibad%t m$n*$l tiba-tiba


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Ge)ala :Ge)ala :R$%t$r 2;< : NK + m$nta' KK + %en$r$nanR$%t$r 2;< : NK + m$nta' KK + %en$r$nankesadaran !"*al si n ke)ankesadaran !"*al si n ke)an

C"m%ressi"n >< : ?is$al de!e*tC"m%ressi"n >< : ?is$al de!e*t'i%"%it$itarism %arese an "ta erak'i%"%it$itarism %arese an "ta erak"%talm"%le i !a*ial %ain"%talm"%le i !a*ial %ain=n*idental !indin 3


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K"m%likasi :K"m%likasi :=ntra*ranial : rebleedin *erebral in!ar*ti"n=ntra*ranial : rebleedin *erebral in!ar*ti"n

idr"*e%'al$s eH%andin 'emat"midr"*e%'al$s eH%andin 'emat"mke)anke)anEHtra*ranial : m("*ard in!ar* *ardia*EHtra*ranial : m("*ard in!ar* *ardia*arr(tmia edema %$lm" stress $l*er arr(tmia edema %$lm" stress $l*er


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Ca$se : an"mali ?as*$lar intra*ranialCa$se : an"mali ?as*$lar intra*ranial V@ : ne$r(sma 1:5,3 DS V@ : ne$r(sma 1:5,3 DSGe)ala : 'aem"rr'a e e%ile%s( 'eada*'eGe)ala : 'aem"rr'a e e%ile%s( 'eada*'ene$r"l" i*al de!i*it *ranial br$it mass e!!e*tne$r"l" i*al de!i*it *ranial br$it mass e!!e*tPen$n)an : CT s*an @R= n i" ra%'(Pen$n)an : CT s*an @R= n i" ra%'(=ndikasi inter?ensi :=ndikasi inter?ensi :

EH%endin 'aemat"maEH%endin 'aemat"maRisik" %erdara'anRisik" %erdara'an&e!isit ne$r"l" i* %r" resi! &e!isit ne$r"l" i* %r" resi!


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-V @al!"rmati"n -V @al!"rmati"n

dala' kelainan k"n enital dimana arteri dala' kelainan k"n enital dimana arteridan ?ena lan s$n di'$b "le' sat$ ata$dan ?ena lan s$n di'$b "le' sat$ ata$lebi' !ist$la '$b lan s$n ini tan%alebi' !ist$la '$b lan s$n ini tan%a%erantaraan ka%iler,%erantaraan ka%iler,

a%isan arteri tdk m%( *$k$% la% m$sk$ler a%isan arteri tdk m%( *$k$% la% m$sk$ler Vena serin dilatasi akibat tekanan aliranVena serin dilatasi akibat tekanan alirandara' ( tin i mll !ist$la,dara' ( tin i mll !ist$la,


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@ V mr% s$mber str"ke %dara'an dan@ V mr% s$mber str"ke %dara'an dan$m$mn(a %d $sia m$da$m$mn(a %d $sia m$daTera%i in?asi! meli%$ti emb"lisasiTera%i in?asi! meli%$ti emb"lisasiend"?ask$ler reseksi beda' dan radiasiend"?ask$ler reseksi beda' dan radiasi!"kal!"kal


72/223

P T0F=S=0 0G=P T0F=S=0 0G=


73/223

erdarahan

Penin katanT=K

*nfluks %a

ekrosiseuron

=skemia

l"bal

Pele%asan a en?as"k"nstrikt"r E!ek t"ksikdara'

*nfluks %a

Vas"s%sme

=skemia F"kal

Ser"t"nin Pr"sta landin dara'

roses /asospasme ada erdarahanroses /asospasme ada erdarahan


74/223

roses /asospasme ada erdarahanroses /asospasme ada erdarahan

elepasan at asokonstriktor dan komponen darah

*nfluks %a Sel "t"t %"l"s %emb$l$' dara'

1asospasme

kuat

=skemik + de!isit ne$r"l" ik

$men?asa dara'

/asospasme

7


75/223

@ediate area are ins$!i*ientl( s$%%lied #it' bl""d and t'e( die

7roses!terosklerosis

&im$lai l$ka sel end"tel - %erm$kaan tidak m$l$s la i A %r"d$ksi m"lek$ladesi =C @ A %enin katan N0 - ter)adi ketidak seimban an

&e%"larisasi - n t"n$s ?ask$ler - akti?asi m"n"sit men)adi makr"!a( men ambil & - !"am *ellF"am Cell sel b$sa mer$%akan k"m%"nen %entin %embent$k str$kt$rmasa %lak

b b! b i 4 b dS i d


76/223

!terotrombosis4 -rombus!terotrombosis4 -rombus Superimposed Superimposed pada lak !terosklerotikpada lak !terosklerotik

da%ted !r"m Falk E et al, Cir*$lati"n, 1225 28:45>-4>1,

Cerebral 9mbolism :ormation


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& small clot may break o6 from a larger thrombus and be carriedto other places in the bloodstream% 7hen the embolus reaches anartery too narrow to pass through and becomes lodged# blood 8owdistal to the fragment ceases# resulting in infarction of distal braintissue due to lack of nutrients and o!ygen%&s a cause of stroke# embolism accounts for appro!imately (*) ofcases%


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A6 l ti f th th 5l ti5 l EA6olution of the atheros5leroti5 plaEue


79/223

A6olution of the atheros5leroti5 plaEueA6olution of the atheros5leroti5 plaEue

&. A11umulati!n != li#!#r!tein in intima&. A11umulati!n != li#!#r!tein in intima . 6


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" **b5***a *nhibitors" **b5***a *nhibitors

1. latelet !dhesion

2. latelet !cti ation

latelet

" *b

la6ue rupture !cti ated latelet

" **b5***a 3. latelet !gregation

!S!,%lopidogrel

!S!,%lopidogrel

S a*et(lsali*(*li* a*id,Cann"n and Bra$n#ald Heart Disease. 8;;1,

-0!2

Fibrinogen

R!le != #latelet at tr!m$! i


81/223


82/223


83/223


84/223


85/223

F 8; : akti!itas listrik 'ilan 1; : Gan $an '"me"stasisK"nse% %en$mbra

7ebutuhan7ebutuhan "" lukosalukosa ++ '' ksigen

ksigen


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gg

CBF:CBF: 5; ml / 1;; r )ar 5; ml / 1;; r )ar "tak %ermenit,"tak %ermenit,0ksi en:0ksi en: 4 ml / 1;; r )ar 4 ml / 1;; r )ar "tak %er menit"tak %er menit$nt$k s$bstansia risea$nt$k s$bstansia risea dandan 8 ml / 1;; r )ar 8 ml / 1;; r )ar "tak %er menit $nt$k s$bstansia alba,"tak %er menit $nt$k s$bstansia alba,Keb$t$'an "ksi enKeb$t$'an "ksi en :: 12-83 ml / 1;; r )ar12-83 ml / 1;; r )ar"tak %er menit,"tak %er menit,Keb$t$'an l$k"saKeb$t$'an l$k"sa :: 9,59,5 -- > m / 1;; r )ar > m / 1;; r )ar "tak %er menit,"tak %er menit,0tak0tak :: 8;< dari sel$r$'8;< dari sel$r$' output output )ant$n (ait$ )ant$n (ait$sekitar ;; ml / menitsekitar ;; ml / menit


87/223

roses *skemiroses *skemi

Sumbatan!liran darah Pen$r$nan CBF

=skemia

TP ↓ mer$ba'%ermeabilitas membran

*nfluks %aberlebihan

Ker$sakan

membran

ekrosis

neuron

Cellular In;ury


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Cellular In;ury


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Cerebral =s*'aemia Re%er!$si"n

Ne$r"n de%"larisati"n

Ne$r"nal deat'

% Na+ Cl-

ad'esi"n

Gl$tamate release VGCC "%en

*ntracellular %aP 8

*ti?ati"nmit"*'"ndria N0S

0r anelledama e

0Hidati?estress

Tiss$eres%"nse

*(t"kines

m"le*$les

e$k"*(tead'esi"n

in!lammati"n

1$

!gents stroke iskemik 41, N@& I @P re*e%t"r anta "nists @ +8, Ca 3, N0S in'ibit"rs9, nti-"Hidants5, d'esi"n m"le*$le antib"diesVGCC: V"lta e ated *al*i$m *'annelsP 8 : F"s!"li%ase 8

*$

($

9

5$


90/223

,a jah Ma a Str!ke Alg!rithm


91/223

Patient a mitte with u en !n et != tr!ke

De1rea ing 1!n 1i!u ne 45 hea a1he 45 @a$in kiB re=le< 4

De1rea ing 1!n 1i!u ne 45 hea a1he 45 @a$in kiB re=le< '

De1rea ing 1!n 1i!u ne 45 hea a1he '5 @a$in kiB re=le< '

De1rea ing 1!n 1i!u ne 45 hea a1he '5 @a$in kiB re=le< 4

De1rea ing 1!n 1i!u ne '5 hea a1he 45 @a$in kiB re=le< 4

De1rea ing 1!n 1i!u ne '5 hea a1he 45 @a$in kiB re=le< '

De1rea ing 1!n 1i!u ne '5 hea a1he '5 @a$in kiB re=le< 4

De1rea ing 1!n 1i!u ne '5 hea a1he '5 @a$in kiB re=le< '

with

N!

N!

N!

N!

N!

N!

N!

ye

ye

ye

ye

ye

ye

ye

ye

-S

-S

-S

-S

-S

-S

AIS

AIS

Monroe- Kellie PrincipleMonroe- Kellie Principle -rain -lood


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Monroe Kellie PrincipleMonroe Kellie Principle

opied from: Rogers 1$$*! (e7tbook of Pediatri5

S@ Mass-one

DIS0IN 2IS IN 3EA02RES EM6RR A I/ S0R6KE 8SDIS0IN 2IS IN 3EA02RES EM6RR A I/ S0R6KE 8S


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DIS0IN,2IS-IN, 3EA02RES -EM6RR-A,I/ S0R6KE 8SDIS0IN,2IS-IN, 3EA02RES -EM6RR-A,I/ S0R6KE 8SIS/-EMI/ S0R6KEIS/-EMI/ S0R6KE ::

3EA02RES S2,,ES0IN, -EM6RR-A,I/ S.3EA02RES S2,,ES0IN, -EM6RR-A,I/ S. ::G early an #r!l!nge l! != 1!n 1i!u neearly an #r!l!nge l! != 1!n 1i!u neG #r!minent hea a1he5 nau ea an v!miting#r!minent hea a1he5 nau ea an v!mitingG retinal hem!rrhageretinal hem!rrhageG nu1hal rigi itynu1hal rigi ityG =!1al ign ! n!t =it the anat!mi1 #attern != a ingle=!1al ign ! n!t =it the anat!mi1 #attern != a ingle

$l!! ve el$l!! ve el

3EA02RES S2,,ES0IN, IS/-EMI/ S0R6KE "3EA02RES S2,,ES0IN, IS/-EMI/ S0R6KE "G te#wi e eteri!rati!n !r #r!gre ive w!r eningte#wi e eteri!rati!n !r #r!gre ive w!r eningG wa


94/223

@ @@ @

%8* *%!8 S*" S 'F * -R!%9R9 R!8 #9$'RR#!"9%8* *%!8 S*" S 'F * -R!%9R9 R!8 #9$'RR#!"9 (1)(1) (%aplan 1:;;)(%aplan 1:;;)


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%8 %!8 S S F -R!%9R9 R!8 #9$ RR#! 9%8 %!8 S S F R!%9R9 R!8 #9$ RR#! 9 (1)(1) (%aplan 1:;;)(%aplan 1:;;)

Le i!n Pu#il ;eye m!vement M!t!r >

en !rye=i1it

6ther

/au atenu1leu

S!metime i# ilaterally1!n tri1te ; 1!njugate

eviati!n t! i e != le i!n

/!ntralateralhemi#are i 5 !=tentran ient

-ea a1he5 1!n=u i!n

Putamen( mall)

N!rmal;1!njugate eviati!n t!i e != le i!n

/!ntralateralhemi#are i >hemi en !ry l!

A#ha ia (i= le i!n !nle=t i e)

Putamen(large)

Cith herniati!n5 #u#il ilate!n i e != le i!n;1!njugate

eviati!n t! i e != le i!n

/!ntralateralhemi#are i >hemi en !ry l!

De1rea e1!n 1i!u ne

0halamu /!n tri1te #!!rly rea1tive t!light $ilaterally;li retra1te .Eye !wn an in. /ann!tl!!k u#.

Slight 1!ntralateralhemi#are i $utgreater hemi en !ryl!

A#ha ia (i= le i!n !nle=t i e)

%8* *%!8 S*" S 'F * -R!%9R9 R!8 #9$'RR#!"9%8* *%!8 S*" S 'F * -R!%9R9 R!8 #9$'RR#!"9 (2)(2) (%aplan 1:;;)(%aplan 1:;;)


96/223

( ) ( p )

Le i!n Pu#il ;eye m!vement M!t!r > en !rye=i1it

6ther

611i#ital l!$arwhite matter

N!rmal Mil 5 tran ienthemi#are i

/!ntralateralhemian!# ia

P!n /!n tri1te rea1tive t!light;n! h!ri !ntalm!vement . 8erti1alm!vement #re erve

ua ri#legia /!ma

/ere$ellum /!n tri1ti!n !n i e !=

le i!n; light eviati!nt! !##! ite i e.M!vement t! i e !=le i!n im#aire !r : th 1ranial nerve #al y

I# ilateral lim$ ata


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Pat" enesis %ada 'i%ertensiPat" enesis %ada 'i%ertensi

Pemb$l$' dara' %H 'i%ertensi m$da'Pemb$l$' dara' %H 'i%ertensi m$da'terl$katerl$ka terbent$k tr"mb$s dari de%"sitterbent$k tr"mb$s dari de%"sitlemak sel dara' dan k"m%"nen dara'lemak sel dara' dan k"m%"nen dara'lainlain aliran dara' ken*analiran dara' ken*an tr"mb$s terle%astr"mb$s terle%as

men($mbat l$men,men($mbat l$men,


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Insulin Resistance


99/223

FFA production Glucose production

Hyperinsulinemia

DyslipidemiaT2D

SNS activityAbnormal Na +

handlin

HTN

Atherosclerosis

P t" i % d &@P t" i % d &@


100/223

Pat" enesis %ada &@Pat" enesis %ada &@

Pemb$l$' dara' %HPemb$l$' dara' %H&@&@ ater"skler"tikater"skler"tik men an $ a$t"re $lasimen an $ a$t"re $lasi?ask$ler ?ask$ler Pasien &@Pasien &@ a$t"re $lasi men$r$n sam%ai 1;-a$t"re $lasi men$r$n sam%ai 1;-15**/1;; /mnt15**/1;; /mnt %en$mbra%en$mbraPen$r$nan a$t"re $lasi 1;**/1;; /mntPen$r$nan a$t"re $lasi 1;**/1;; /mnt %enin katan Ca ekstrasel dan K%enin katan Ca ekstrasel dan Kintraselintrasel mer$sak retik$l$mmer$sak retik$l$mend"%lasmikend"%lasmik mit"k"ndria ter an $mit"k"ndria ter an $ asid"sisasid"sisdan kematian seldan kematian sel


101/223

F"*al Ne$r"l" i*al =m%airment %r"minent andF"*al Ne$r"l" i*al =m%airment %r"minent and


102/223

1;8

s$ est l"*ati"n "! 'em"rr'a e J1s$ est l"*ati"n "! 'em"rr'a e J1utamenutamen

C"ntralateral 'emi%aresisC"ntralateral 'emi%aresisC"ntralateral sens"r( l"ssC"ntralateral sens"r( l"ssC"ntralateral *"n)$ ateC"ntralateral *"n)$ ate

a e %aresisa e %aresis"m"n(m"$s 'emian"%ia"m"n(m"$s 'emian"%ia

%'asia d"minant "r %'asia d"minant "rne le*t n"n d"minantne le*t n"n d"minant

-halamus-halamusC"ntralateral 'emi%aresisC"ntralateral 'emi%aresisC"ntralateral sens"r( l"ssC"ntralateral sens"r( l"ssC"ntralateral "r i%silateralC"ntralateral "r i%silateral

*"n)$ ate a e %aresis*"n)$ ate a e %aresis&"#n#ard de?iati"n "!&"#n#ard de?iati"n "!e(ese(esSmall sle is' %$%ilsSmall sle is' %$%ils

%'asia d"minant %'asia d"minant

:ocal 4eurological Impairment


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1;3

Cerebral hemisphereCerebral hemispherelobar white matterlobar white matter

ContralateralContralateral

hemiparesis or sensoryhemiparesis or sensorylosslossContralateral con;ugateContralateral con;ugatega=e paresisga=e paresis ContralateralContralateralhomonymous hemianopiahomonymous hemianopia&bulia&bulia&phasia dominant$ or&phasia dominant$ orneglect non dominant$neglect non dominant$

>rain stem ussually ponds$>rain stem ussually ponds$

?uadriparesis or?uadriparesis orhemiparesishemiparesis@nilateral or bilateral@nilateral or bilateralweaknessweaknessAocked-in syndromesAocked-in syndromesComaComa>ilateral hori=ontal ga=e>ilateral hori=ontal ga=e

paresisparesisBcular bobbingBcular bobbing

inpoint pupilsinpoint pupilsHyperthermia andHyperthermia andhyperDentilationhyperDentilation

prominent and suggest location of

hemorrhage$ E*

:ocal 4eurological Impairment


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1;9

%erebellum%erebellum

Tr$n*al "r ait ataHiaTr$n*al "r ait ataHia=%silateral=%silateral

imb ataHiaimb ataHiaFa*ial #eakness and sens"r( l"ssFa*ial #eakness and sens"r( l"ssC"n)$ ate a e %als(C"n)$ ate a e %als(

bd$*ent ner?e %als( bd$*ent ner?e %als(Ske# de?iati"nSke# de?iati"nSmall rea*ti?e %$%ilsSmall rea*ti?e %$%ils

ater de?el"%men "! *"ma and bilateral #eaknessater de?el"%men "! *"ma and bilateral #eaknesssens"r( l"ss %"ssiblesens"r( l"ss %"ssible

prominent and suggest location of

hemorrhage$ E(

"*ati"ns"*ati"ns


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1;5

"*ati"ns*ati ns

T'e m"st *"mm"n l"*ati"ns !"r '(%ertensi?eT'e m"st *"mm"n l"*ati"ns !"r '(%ertensi?e'em"rr'a e are:'em"rr'a e are:

P$tamenP$tamenT'alam$sT'alam$s

"bar #'ite matter "! t'e *erebral 'emis%'eres"bar #'ite matter "! t'e *erebral 'emis%'eresBrain stem %"ns in %arti*$larBrain stem %"ns in %arti*$larCerebell$mCerebell$m

T'ese l"*ati"ns re!le*t t'e ?as*$lar teerrit"ries "! s'"rtT'ese l"*ati"ns re!le*t t'e ?as*$lar teerrit"ries "! s'"rt%enetratin bran*'es arteri"les arisin !r"m t'e ma)"r%enetratin bran*'es arteri"les arisin !r"m t'e ma)"rintra*ranial arteries,intra*ranial arteries,

8 #R!/0R0 R!L >0M=RR>!


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1;4


107/223

1;>

enatalaksanaanenatalaksanaan


108/223

1;

asil "%timal tera%i Str"ke %erdara'anasil "%timal tera%i Str"ke %erdara'an

sam%ai 24 )amsam%ai 24 )am setela' "nsetsetela' "nsetP$n*ak ?as"s%asme antara 'ari ke 5-1;P$n*ak ?as"s%asme antara 'ari ke 5-1;


109/223

1;2

@ana ement@ana ementIn emergency RoomIn emergency Room A BC r$les BC r$les A BP *"ntin$"$s m"nit"rinBP *"ntin$"$s m"nit"rin

A C"ntin$"$s ECG m"nit"rinC"ntin$"$s ECG m"nit"rin A 08 %$lse "H(metr(08 %$lse "H(metr( A 8 =V lines n"rma saline "nl(8 =V lines n"rma saline "nl( A Bl""d CBC S@ C RBS PTT =NRBl""d CBC S@ C RBS PTT =NR

A Sa?e 4 ml "! bl""dSa?e 4 ml "! bl""d A Fa*ilitate trans!er t" t'e "%eratin r""m "r =CDFa*ilitate trans!er t" t'e "%eratin r""m "r =CD


110/223

11;

%5ute stroke 5are4 eneral management%5ute stroke 5are4 eneral management

(he mainsta3 of a5ute treatment %,-, !(he mainsta3 of a5ute treatment %,-, !(reatment and stabilisation of general 5ondition(reatment and stabilisation of general 5onditionSpe5ifi5 therap3Spe5ifi5 therap3

Re5analisation of a 6essel o55lusionRe5analisation of a 6essel o55lusion Pre6enti6e of me5anism leading to neuronal deathPre6enti6e of me5anism leading to neuronal death

in the is5hhemi5 brainin the is5hhemi5 brain

Aarl3 se5ondar3 pre6entionAarl3 se5ondar3 pre6entionAarl3 rehabilitationAarl3 rehabilitationProph3la7is and treatment of 5ompli5ationsProph3la7is and treatment of 5ompli5ations

"amsudin, #&&

k l


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111

-lood pressure-lood pressure (here are adeEuatel3 si8ed randomi8ed , 5ontrolled(here are adeEuatel3 si8ed randomi8ed , 5ontrolled

stud3 guiding -P mangementstud3 guiding -P mangement

Ale6ated -P sistoli5I#&&mmHg or diastoli5Ale6ated -P sistoli5I#&&mmHg or diastoli5I11&mmHg& ma3 tolerated in the a5ute phaseI11&mmHg& ma3 tolerated in the a5ute phase

%6oid and treat h3potension or drasti5 redu5tion -P%6oid and treat h3potension or drasti5 redu5tion -P

-P ma3 be lo2ered if 5ardia5 5ondition reEuire it-P ma3 be lo2ered if 5ardia5 5ondition reEuire it


"amsudin, #&&

% k 4 l


112/223

118

-lood pressure -P!-lood pressure -P!'ndi5ations for immediate %H therap3 in a5ute'ndi5ations for immediate %H therap3 in a5utestrokestroke

'ntra5erebral haemorrhage'ntra5erebral haemorrhage ardi5 failureardi5 failure %5ute 5oronar3 s3ndrome%5ute 5oronar3 s3ndrome

%orti5 disse5tion%orti5 disse5tion H3pertensi6e en5hephalophat3H3pertensi6e en5hephalophat3


"amsudin, #&&

PEN T KS N N =PERTENS= P &PEN T KS N N =PERTENS= P &STR0KE KDTSTR0KE KDT


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113

STR0KE KDTSTR0KE KDT

,FGB 9 & @F

,istolik ' **0 mmHg


114/223

in *$te Str"kein *$te Str ke

nti'(%ertensi?e treatment s'"$ld a#ait nti'(%ertensi?e treatment s'"$ld a#aitt'e s%"ntane"$s de*line in BP #it'in 1t'e s%"ntane"$s de*line in BP #it'in 1 stst t" 1;t" 1; t't' da(s , =! in*reased BP %ersist a!terda(s , =! in*reased BP %ersist a!ter>-1; da(s start treatment,>-1; da(s start treatment,Patients alread( "n anti'(%ertensi?ePatients alread( "n anti'(%ertensi?emedi*ati"n %ri"r t" str"ke dr$ s s'"$ldmedi*ati"n %ri"r t" str"ke dr$ s s'"$ldbe 'eld "r red$*ed !"r >-1; da(s eH*e%tbe 'eld "r red$*ed !"r >-1; da(s eH*e%t

B-bl"*kers s'"$ld be rad$all( "?er 5-4B-bl"*kers s'"$ld be rad$all( "?er 5-4da(sda(s

>lood ressure > $ Managementl i & k


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Treat =!:Treat =!:1,1, BP is 7 88;/19; "r @ P 713; mmBP is 7 88;/19; "r @ P 713; mm8,8, @ali nant "r '(%ertensi?e en*e%'al"%at'(@ali nant "r '(%ertensi?e en*e%'al"%at'(3,3, *$te @= *$te @=9,9, "rti* disse*ti"n is s$s%e*ted "rti* disse*ti"n is s$s%e*ted5,5, BP is 71 ;/1;; and %atient is !"r t'r"mb"l(ti*BP is 71 ;/1;; and %atient is !"r t'r"mb"l(ti*

t'era%(t'era%(

4,4, 89 '"$rs !"ll"#in t'r"mb"l(ti* t'era%(89 '"$rs !"ll"#in t'r"mb"l(ti* t'era%(71 5/11;71 5/11;

rotocol in &cute ,troke

>lood ressure > $ Managementrotocol in &cute troke


116/223

T'e F"ll"#in medi*ati"ns *an be $sed i! needed:T'e F"ll"#in medi*ati"ns *an be $sed i! needed:

Esm"l"l b"l$s 5;; $ /k =VEsm"l"l b"l$s 5;; $ /k =VEsm"l"l in!$si"n 5;-15; $ /k /min =V B"d( #ei 't H 4; m "!Esm"l"l in!$si"n 5;-15; $ /k /min =V B"d( #ei 't H 4; m "!esm"l"l dil$ted in 1;; ml "! saline in a rate "! 5-15 ml/'"$resm"l"l dil$ted in 1;; ml "! saline in a rate "! 5-15 ml/'"$r

abetal"l in!$si"n 15-35 $ /k /ml =V B"d( #ei 't H 4 m "!abetal"l in!$si"n 15-35 $ /k /ml =V B"d( #ei 't H 4 m "!labetal"l dil$ted in 1;; ml "! saline in a rate "! 15-35 ml/'"$rlabetal"l dil$ted in 1;; ml "! saline in a rate "! 15-35 ml/'"$r

abetal"l 1;;-8;; m bid-tid, P0abetal"l 1;;-8;; m bid-tid, P0 nala%rilat 1 85-5 m =V 4 '"$rl( nala%rilat 1 85-5 m =V 4 '"$rl(

asiH 8;-9; m i? tid-LidasiH 8;-9; m i? tid-LidNi*ardi%in 5 m /'"$r =VNi*ardi%in 5 m /'"$r =VCl"nidine 15;-3;; m i? b"l$s maHim$m "! >5; m %er da(Cl"nidine 15;-3;; m i? b"l$s maHim$m "! >5; m %er da(

S"di$m nitr"%r$sside ; 85-; 5 m /k /minS"di$m nitr"%r$sside ; 85-; 5 m /k /min ?"id t'e $se "! *al*i$m *'annel bl"*kers and ?"id t'e $se "! *al*i$m *'annel bl"*kers ands"di$m nitr"%$sside as %"ssibles"di$m nitr"%$sside as %"ssible

rotocol in &cute ,troke


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Lowering of blood pressureLowering of blood pressure

In acute ischemic stroke ,there is one of:In acute ischemic stroke ,there is one of:

Systolic pressure > 220 mmHgSystolic pressure > 220 mmHgDiastolic pressure > 120 mmHgDiastolic pressure > 120 mmHgMAP > 130-140 mm HgMAP > 130-140 mm Hg

with acute infark miocard /heart with acute infark miocar failure or acute kidney failure /failure or acute kidney failure /aorta toracalisaorta toracalis


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11

Cushing reexHaematom as a secondary ICP

oxyhemoglobin and bilirubin , causing theintracranial hypertensi and blocking the lcsabsorbtion

Hight catecolamin value


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/iticholine/iticholine


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18;

Mechanism AneuronalBMechanism AneuronalB– Increase choline formationnd alter degradationIncrease choline formationnd alter degradationphosphatydilcholinephosphatydilcholine

– Increase glucose uptake# asetilkholine#Increase glucose uptake# asetilkholine#

preDention lipid radicalpreDention lipid radical– Increase glutationIncrease glutation– :– Increase B* consumtionIncrease B* consumtion–

C=T=C 0 =NE


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,truktur Citicholin &dibhatla#*00*$

&mbilan oleh otak t;d paling awal (0 mnt stl pemberian# kadarpuncak stl 2 ;am pemberian per oral%7kt paruh pemberian scr INadalah *0-(0 mnt%

@ptake citicholin eksogen yg diberikan scr IN pada keadaaniskemi# hal ini krn permeabilitas kapiler otak %


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Citi*'"line

idr"lisaC(tidine

C'"linediabs"rbsi

0tak

Sintesa

PCCT

Citi*'"line

1-8 & G

P'"s%'atidil k"lin

P'"s%'atidilserin

P'"s%'atidiletan"lamin

P'"s%"li%id

setilasi

*et(l*'"lin

Betaine d" @e

@et'i"nin

S- den"s(l- -'"m"*(stein"m"*(steinC(steinGl$tati"n

Vask$larisasi"kal

nti"ksidan

@E@BR

N

REP

=R

PCCT : C(tidine tri%'"s%'at A %'"s%'"*'"line A *(tid(l(l trans!erase

1-8 & G : 1-8 &iasil Gliser"l


123/223


124/223

185

enggunaan iracetam + %iticoline ada Stroke + -raumaenggunaan iracetam + %iticoline ada Stroke + -rauma

erdarahan < Stroke 5 -rauma )erdarahan < Stroke 5 -rauma )

&apat segera diberikan&apat segera diberikanalaupun diagnosa belumalaupun diagnosa belum elas elas&apat mencegah dan&apat mencegah danmerelaksasi timbulnyamerelaksasi timbulnya

asospasmeasospasme!man dan dapat diberikan pada!man dan dapat diberikan padapenderita yang akan dioperasipenderita yang akan dioperasitanpa meningkatkan risikotanpa meningkatkan risikoperdarahan ulangperdarahan ulang

8skemik % 8n;ark A Stroke%/edera =tak sekunderB

4apat segera diberikan padapenderita trauma kepaladerajat sedang sampai berat4apat mencegah danmengatasi de:sit neurologikiskemik4apat menyelamatkan selneuron penumbraMencegah meluasnya in;arksel neuron


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N0N SDRG=C C N&=& TESN0N SDRG=C C N&=& TES1, Small 'em"rr'a es 1; *m3 "r minimal ne$r"l" i*al de!i*its,1, Small 'em"rr'a es 1; *m3 "r minimal ne$r"l" i*al de!i*its,8, GCS s*"re8, GCS s*"re ≤≤ 9, EH*e%t !"r *erebellar 'em"rr'a e #it' brainstem9, EH*e%t !"r *erebellar 'em"rr'a e #it' brainstem

*"m%ressi"n !"r li?esa?in s$r er(,*"m%ressi"n !"r li?esa?in s$r er(,

SDRG=C C N&=& TESSDRG=C C N&=& TES1, Cerebellar 'em"rr'a e 7 3 *m #'" are ne$r"l" i*all(1, Cerebellar 'em"rr'a e 7 3 *m #'" are ne$r"l" i*all(

deteri"ratin "r #'" 'a?e brainstem *"m%ressi"n anddeteri"ratin "r #'" 'a?e brainstem *"m%ressi"n and'(dr"*e%a'al$s !r"m ?entri*$lar "bstr$*ti"n,'(dr"*e%a'al$s !r"m ?entri*$lar "bstr$*ti"n,

8, =C #it' str$*t$ral lesi"n e ane$r(sm V@ "r *a?ern"$s8, =C #it' str$*t$ral lesi"n e ane$r(sm V@ "r *a?ern"$san i"ma,an i"ma,

3, M"$n %atients #it' a m"derate "r lar e l"bar 'em"rr'a e #'"3, M"$n %atients #it' a m"derate "r lar e l"bar 'em"rr'a e #'"are *lini*all(are *lini*all( deteri"ratin ,deteri"ratin ,

Rekomendasi tindakan pembedahan pada perdarahanRekomendasi tindakan pembedahan pada perdarahanintreaserebralintreaserebral


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intreaserebral

=smail S 8;;

F* !8 R9S=8-S 'F -#9 * -9R !-*' !8 S=R"*%!8 -R*!8 * *%#F* !8 R9S=8-S 'F -#9 * -9R !-*' !8 S=R"*%!8 -R*!8 * *%#(*S-*%#)(*S-*%#)


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18

@endel"# .SC 8;;9@endel"# .SC 8;;9

1;33 %atients #it' s%"ntane"$s s$%ratent"rial =C1;33 %atients #it' s%"ntane"$s s$%ratent"rial =C1;> *enters in 8> *"$ntries,1;> *enters in 8> *"$ntries,

83, < !a?"$rable "$t*"me in earl( *"nse83, < !a?"$rable "$t*"me in earl( *"nse r r ?ati?e?ati?etreatmentO ?s 84,1< in earl( s$r er(O NS ,treatmentO ?s 84,1< in earl( s$r er(O NS ,@"rtalit( 43,> < ?s 48,4 < NS Rankin s*"re@"rtalit( 43,> < ?s 48,4 < NS Rankin s*"re8 ,1< ?s 38, < NS Bart'el 88,4< ?s 84,>


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182

@annit l@annit l

1,1, "#erin =CP :"#erin =CP : =mmediate %lasma eH%ansi"n=mmediate %lasma eH%ansi"n : red$*e: red$*et'e 'emat"*rit and bl""d ?is*"sit( im%r"?ed r'e"l" (t'e 'emat"*rit and bl""d ?is*"sit( im%r"?ed r'e"l" (#'i*' in*reases CBF and 0#'i*' in*reases CBF and 0 88 deli?er(,deli?er(, 0sm"ti* e!!e*t0sm"ti* e!!e*t ::in*reased ser$m t"ni*it( dra#s edema !l$id !r"min*reased ser$m t"ni*it( dra#s edema !l$id !r"m*erebral %aren*'(ma,*erebral %aren*'(ma,

8,8, S$%%"rts t'e mi*r"*ir*$lati"n b( im%r"?in bl""dS$%%"rts t'e mi*r"*ir*$lati"n b( im%r"?in bl""dr'e"l" (r'e"l" (

3,3, P"ssible !ree s*a?en inP"ssible !ree s*a?en inGreenber 8;;;Greenber 8;;;

&"se : ; 5 A 1 ; /k b"d( #ei 't&"se : ; 5 A 1 ; /k b"d( #ei 't dam et al, 8;;1dam et al, 8;;1=? b"l$s 1;; ml "! 8; < mannit"l "?er 15 min$tes=? b"l$s 1;; ml "! 8; < mannit"l "?er 15 min$tes indsa( etindsa( et

al, 122>al, 122>

@ana ement %en$r$nan tekanan intrakranial@ana ement %en$r$nan tekanan intrakranial


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@ana ement %en$r$nan tekanan intrakranial@ana ement %en$r$nan tekanan intrakranial


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131

PR0GN0S=SPR0GN0S=S

P"$ratian 8;;3P"$ratian 8;;3


131/223

P $ratian 8;;3P $ratian 8;;3♦♦ V"l$me "! t'e 'emat"maV"l$me "! t'e 'emat"ma 3; ** 3; **♦♦ Ne$r"l" i* stat$s GCS s*"reNe$r"l" i* stat$s GCS s*"re Q Q ♦♦ =ntra?entri*$lar eHtensi"n "! t'e *l"t=ntra?entri*$lar eHtensi"n "! t'e *l"t♦♦ (dr"*e%'al$s(dr"*e%'al$s

♦♦ S$bara*'n"id eHtensi"nS$bara*'n"id eHtensi"n♦♦ nti*"a $lati"n a ents nti*"a $lati"n a ents♦♦ Relati?e edemaRelati?e edema

&a?is .SC 8;;9&a?is .SC 8;;9=n!ratent"rial lesi"n=n!ratent"rial lesi"nC"r"nar( 'eart diseaseC"r"nar( 'eart disease

(%ert'ermia(%ert'ermia


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Rek"mendasi %en*e a'an str"keRek"mendasi %en*e a'an str"ke


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%erdara'an%erdara'an

=smail S 8;;

&e!inisi&e!inisi


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!

Re'abilitasi . 0 : Tindakan bert$)$anRe'abilitasi . 0 : Tindakan bert$)$anmen $ran i dam%ak disabilitas/'andi*a% a armen $ran i dam%ak disabilitas/'andi*a% a arda%at berinte rasi d mas(arakat,da%at berinte rasi d mas(arakat,Fisi"tera%i mr% s$b instalasi re'abilitasiFisi"tera%i mr% s$b instalasi re'abilitasi tHtH"k$%asi "rt"tik %r"stetik tera%i #i*ara %sik"l" i"k$%asi "rt"tik %r"stetik tera%i #i*ara %sik"l" idan s"sial medikdan s"sial medik

T$)$anT$)$an


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$)$)

@em%erbaiki !$n si@em%erbaiki !$n sim"t"rik #i*ara k" niti! dan !$n si lainm"t"rik #i*ara k" niti! dan !$n si lain(an ter an $(an ter an $

Reada%tasi s"sial dan mental $nt$kReada%tasi s"sial dan mental $nt$kmem$li'kan '$b$n an inter%ers"nal danmem$li'kan '$b$n an inter%ers"nal danakti?itas s"sialakti?itas s"sial

&a%at melaksanakan akti?itas ke'id$%an&a%at melaksanakan akti?itas ke'id$%anse'ari-'arise'ari-'ari

lan)$tanlan)$tan


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)$)

Prinsi% re'abilitasi str"kePrinsi% re'abilitasi str"ke %enderita%enderitatidak ter ant$n %ada "ran laintidak ter ant$n %ada "ran lainKeber'asilan b$kan dari ban(akn(a )i#aKeber'asilan b$kan dari ban(akn(a )i#a

( tert"l"n t% bera%a ban(ak %enderita( tert"l"n t% bera%a ban(ak %enderitaber!H la i dimas(arakatber!H la i dimas(arakat

Re'abilitati"nRe'abilitati"n


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13

EDS= Re*"mmendati"nsEDS= Re*"mmendati"ns1, Re'abilitati"n s'"$ld be initiated earl( a!ter1, Re'abilitati"n s'"$ld be initiated earl( a!ter

str"kestr"ke e?el =e?el =

8, E?er( %atient s'"$ld 'a?e a**ess t" e?al$ati"n8, E?er( %atient s'"$ld 'a?e a**ess t" e?al$ati"n!"r re'abilitati"n!"r re'abilitati"n e?el ===e?el ===

3, Re'abilitati"n ser?i*es s'"$ld be %r"?ided b( a3, Re'abilitati"n ser?i*es s'"$ld be %r"?ided b( a

m$ltidis*i%linar( teamm$ltidis*i%linar( team e?el ===e?el ===

Rehabilitation 7rogram 5Rehabilitation 7rogram 57h i l th 57h i l th 5


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132

7hysical therapy 57hysical therapy 5

J MobiliCationMobiliCation

J DalkingDalkingJ Major motor or sensory impairment o; the limbsMajor motor or sensory impairment o; the limbsJ 7rescription o; de3ices, such as a cane or7rescription o; de3ices, such as a cane or

EalkerEalker

=ccupational #herapy 5=ccupational #herapy 5J @ine mo3ements o; the hand@ine mo3ements o; the handJ !rm ;unction!rm ;unctionJ UtiliCation o; toolsUtiliCation o; toolsJ !ssisti3e de3ices!ssisti3e de3icesJ !bility to ;unction independently!bility to ;unction independently


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19;

Speech -herapySpeech -herapy 44

6 &isorders of language&isorders of language

6 &isorders of articulation&isorders of articulation6 &isorders of s allo ing&isorders of s allo ing

Fakt"r (an ber%en ar$' %adaFakt"r (an ber%en ar$' %ada'asil ak'ir re'abilitasi'asil ak'ir re'abilitasi


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'asil ak'ir re'abilitasiasil ak ir re abilitasiPen(ebab str"kePen(ebab str"keBeratn(a str"keBeratn(a str"ke

"kasi str"ke"kasi str"keDsia %enderitaDsia %enderita

@"ti?asi %enderita ke%ribadian %rem"rbit dan m""d@"ti?asi %enderita ke%ribadian %rem"rbit dan m""dKel$ar a %enderitaKel$ar a %enderitaSistem s"si" ek"n"mi %enderita dan kel$ar aSistem s"si" ek"n"mi %enderita dan kel$ar a&e!isit ne$r"l" i (an k'$s$s&e!isit ne$r"l" i (an k'$s$s

.akt$ a#al laman(a dan intensitas %emberian tera%i.akt$ a#al laman(a dan intensitas %emberian tera%ire'abilitasire'abilitasiTim re'abilitasiTim re'abilitasi

K"m%likasi Str"keK"m%likasi Str"ke


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198

K m%likasi Str keK m%likasi Str ke

&emensia&emensia&e%resi&e%resiKe*a*atanKe*a*atan

E%ile%siE%ile%siK"ntrakt$r K"ntrakt$r Pe%ti* $l*er Pe%ti* $l*er

Br"n*'"%ne$m"niaBr"n*'"%ne$m"nia&ek$bit$s&ek$bit$sSe%tikemiaSe%tikemia

Tr"mb"sis ?enaTr"mb"sis ?ena%r"!$nda%r"!$ndaEmb"li %$lm"Emb"li %$lm"

G n keseimban anG n keseimban an*airan*airan

Risk o; Stroke RecurrenceRisk o; Stroke RecurrenceApercentage eFperiencingApercentage eFperiencing


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193

strokeBstrokeB

&fter FI&&fter FI& &fter ,troke&fter ,troke(0 days - ) (-10)(0 days - ) (-10)

1 Oear 1*-1() 10-1 )1 Oear 1*-1() 10-1 )

5 Oears * -* ) *5- 0)5 Oears * -* ) *5- 0),ource/ ,acco GA# 7olf Lorelick >% 4eurology,ource/ ,acco GA# 7olf Lorelick >% 4eurology

1 . 5( supp $/ ,15-,* %1 . 5( supp $/ ,15-,* %


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199

Sindrom !rteriSindrom !rteri

Middle Cerebral &rtery%Middle Cerebral

&rtery%


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195

Aargest branch of InternalAargest branch of InternalCarotid%Carotid%,upplies portion of frontal,upplies portion of frontallobe and lateral surface oflobe and lateral surface of

Femporal and arietal Femporal and arietal

lobes%lobes%rimary Motor and ,ensoryrimary Motor and ,ensory

areas for face# throat # handareas for face# throat # handand arm%and arm%


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194

Fhe MC& proceeds laterally into the lateral sulcus Fhe MC& proceeds laterally into the lateral sulcusand spreads to supply Dirtually the entire lateraland spreads to supply Dirtually the entire lateralsurface of the cerebral hemiphere# where most ofsurface of the cerebral hemiphere# where most ofthe precentral and postcentral gyri are located%the precentral and postcentral gyri are located%Included in this region are the motor speech ofIncluded in this region are the motor speech ofarea >roca and the sensory language area ofarea >roca and the sensory language area of7ernickle%7ernickle%MC& also supply the putamen# part of theMC& also supply the putamen# part of the

caudate nucleus# the outer globus pallidus# thecaudate nucleus# the outer globus pallidus# theposterior limb of the internal capsule and theposterior limb of the internal capsule and thecorona radiata%corona radiata%

!rtery.

M844L0 /0R0 R!L !R#0R? AM/!BM844L0 /0R0 R!L !R#0R? AM/!B


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19>

Characteri=ed by weakness of theCharacteri=ed by weakness of thecontralateral face with hemianopsia and acontralateral face with hemianopsia and apreference of the eyes and head toward thepreference of the eyes and head toward the

side of the inDolDed hemispereside of the inDolDed hemispere&phasia in dominant hemisphere in;ury&phasia in dominant hemisphere in;uryHemineglectHemineglectInDolDement restricted to branches of theInDolDement restricted to branches of theMC& may produces fragment of thisMC& may produces fragment of thissyndrome sparing of leg strenghsyndrome sparing of leg strengh

Str!ke Syn r!meStr!ke Syn r!me$Mi l 1 $ l ' 1! #l


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19

Mi le 1ere$ral artery ' 1!m#leteMi le 1ere$ral artery ' 1!m#lete

Ceakne ' u##er an l!wer e


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192

Mi le 1ere$ral artery F u#eri!r ivi i!nMi le 1ere$ral artery F u#eri!r ivi i!n

Ceakne ' u##er an l!wer e


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15;

8i ual l! ' h!m!nym!u hemian!#ia8i ual l! ' h!m!nym!u hemian!#ia(/)(/)

8i ual l! ' u##er Gua rant an!# ia8i ual l! ' u##er Gua rant an!# ia(/)(/)

/!n tru1ti!nal a#ra

!nterior /erebral !rtery!nterior /erebral !rtery


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151

yy

&nterior Cerebral &rtery


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158

Fhe &C& follow the corpus callosum Fhe &C& follow the corpus callosumsupplying the anterior four Pfths of thesupplying the anterior four Pfths of thecorpus callosum and medial aspect ofcorpus callosum and medial aspect ofthe frontal and parietal lobes%


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153

Much rarerMuch rarer Fhe classic presentation is pro!imal arm leg Fhe classic presentation is pro!imal arm legweakness with present of distal strength# theweakness with present of distal strength# theso-called Qman in a barrelRso-called Qman in a barrelR

&C& occlusions cause contralateral motor and&C& occlusions cause contralateral motor andsomatosensory dePcits# primarily of the lowersomatosensory dePcits# primarily of the lowere!tremities%e!tremities%In addition# apra!ia# mental and personalIn addition# apra!ia# mental and personal

changes# primitiD re8e!es and bowel andchanges# primitiD re8e!es and bowel andbladder incontinence often ptresentbladder incontinence often ptresent

7osterior /erebral !rtery7osterior /erebral !rtery


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159

B,F9GIBG C9G9>G&A &GF9GO C&$B,F9GIBG C9G9>G&A &GF9GO C&$


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155

InDolDes the brainstem# cerebellum# thalamusInDolDes the brainstem# cerebellum# thalamusS occipital lobesS occipital lobes

resent with bilateral limb weakness or sensoryresent with bilateral limb weakness or sensorydisturbances# cranial nerDe dePsit# ata!ia#disturbances# cranial nerDe dePsit# ata!ia#nausea# and Domiting or comanausea# and Domiting or comaocclusion of the basilar artery trunk / resentocclusion of the basilar artery trunk / resentwith hemianopia# memory disturbance# mildwith hemianopia# memory disturbance# mild

personality disturbancepersonality disturbanceGarely. bilateral thalamus / a state ofGarely. bilateral thalamus / a state ofdecreased responsiDeness and apathy withoutdecreased responsiDeness and apathy withoutmotor# sensory or Disual impairmentmotor# sensory or Disual impairment


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154

!F!S*!!F!S*!

F S=F S=


156/223

15>

F S F S

!asia adala': !asia adala': an $an kemam%$an berba'asaan $an kemam%$an berba'asa

sese"ran (an disebabkan "le'sese"ran (an disebabkan "le'

ker$sakan "tak akibat s$at$ker$sakan "tak akibat s$at$str"ke an $an %eredaran dara' di "takstr"ke an $an %eredaran dara' di "tak

&'arma%er#ira %rins 1223&'arma%er#ira %rins 1223


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Sindr"m-sindr"m !asiaSindr"m-sindr"m !asia


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152

Sindr m sindr m !asiaS d s d !as a

!asia Gl"bal !asia Gl"bal !asia Br"**a !asia Br"**a !asia Transk"rtikal m"t"ris !asia Transk"rtikal m"t"ris

!asia Transk"rtikal sens"rik !asia Transk"rtikal sens"rik !asia Transk"rtikal *am%$ran !asia Transk"rtikal *am%$ran !asia .erni*ke !asia .erni*ke

!asia K"nd$ksi !asia K"nd$ksi !asia n"mik !asia n"mik

!asia !asiaoo >enis>enis icaraicara enamaenama emahaemaha pengulanpengulan membacmembac menulismenulis


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spontanspontan anan manman gangan aa

11 Br"*aBr"*a


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!asia #erni*ke !asia #erni*ke


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148

!

Nama lain: a!asia sens"rik a!asiaNama lain: a!asia sens"rik a!asiarese%ti! a!asia ak$stisrese%ti! a!asia ak$stis

"kasi lesi: ba ian %"steri"r ir$s tem%"ral"kasi lesi: ba ian %"steri"r ir$s tem%"ral

atas 'emis!er kiriatas 'emis!er kiriKelainan %ada arteri tem%"ralis %"steri"r Kelainan %ada arteri tem%"ralis %"steri"r

!asia K"nd$ksi !asia K"nd$ksi


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143

$$

Nama lain: a!asia sentral a!asia a!erenNama lain: a!asia sentral a!asia a!erenm"t"rism"t"ris

"kasi lesi: ba ian %"steri"r !asik$l$s"kasi lesi: ba ian %"steri"r !asik$l$s

ark$at$s 'emis!er kiriark$at$s 'emis!er kiriGan $an %ada arteri %arietalis %"steri"r Gan $an %ada arteri %arietalis %"steri"r

!asia Gl"bal !asia Gl"bal


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149

"kasi lesi: daera' !r"nt" tem%"r"%arietal"kasi lesi: daera' !r"nt" tem%"r"%arietal%eris(l?is di 'emis!er kiri%eris(l?is di 'emis!er kiriSem$a as%ek ba'asa I bi*ara ter an $Sem$a as%ek ba'asa I bi*ara ter an $

S$mbatan %ada ba ian de%an arteriS$mbatan %ada ba ian de%an arteriserebri media bisa )$ a karena 'emat"mserebri media bisa )$ a karena 'emat"m(an l$as(an l$as

!asia Transk"rtikal m"t"ris !asia Transk"rtikal m"t"ris


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145

Nama lain: sindr"m is"lasi anteri"r a!asiaNama lain: sindr"m is"lasi anteri"r a!asiadinamisdinamis

"kasi lesi:!r"ntal 'emis!er kiri"kasi lesi:!r"ntal 'emis!er kiriGan $an %ada arteri "rbit"!r"nt"lateral danGan $an %ada arteri "rbit"!r"nt"lateral dan*aban terminal arteri serebri anteri"r *aban terminal arteri serebri anteri"r

!asia Transk"rtikal Sens"ris !asia Transk"rtikal Sens"ris


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144

"kasi lesi: tem%"r"%ariet" "ksi%ital kiri,"kasi lesi: tem%"r"%ariet" "ksi%ital kiri,Ker$sakan di area b"rder "ne %arietalisKer$sakan di area b"rder "ne %arietalistem%"ralis "le' arteri serebri media dantem%"ralis "le' arteri serebri media dan

arteri serebri %"steri"r arteri serebri %"steri"r

!asia n"mik !asia n"mik


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14>

Nama lain: a!asia n"minal a!asia amnestisNama lain: a!asia n"minal a!asia amnestis


167/223


168/223


169/223


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Broca’s Aphasia


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• Damage to Broca’s area alone is not enough to produceBroca’s aphasia

• Usually involves Broca’s area + surrounding areasincluding M1 & insula.

Wernicke’s Aphasia


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• Damage to Wernicke’s area alone is not enough toproduce Wernicke’s aphasia

• Usually involves Wernicke’s area + surrounding areasincluding MTG & angular gyrus.


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Transcortical Sensory Aphasia


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• Variable lesion patterns, mostly posterior to Wernicke’sarea

• Deficit tends to be transient evolving into anomic aphasia

Common area?

Transcortical Motor Aphasia


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• Damage often anterior and/or superior to Broca’s area

Global Aphasia


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• Tend to be large “peri-Sylvian” lesions• But smaller lesions can also cause global aphasia

-0. ! #!S*!-0. ! #!S*!Pira*etam 'ad a %"tential e!!e*t "n *" niti?ePira*etam 'ad a %"tential e!!e*t "n *" niti?e!$n*ti"ns!$n*ti"ns


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!$n ti ns!$n ti ns

$sed in t'e treatment "! a%'asia 9, dail($sed in t'e treatment "! a%'asia 9, dail("?er 4 t"18 #eeks b$t t'e me*'anism"?er 4 t"18 #eeks b$t t'e me*'anismremained a matter "! s%e*$lati"n,remained a matter "! s%e*$lati"n,

Pira*etam as anPira*etam as an adjuvant to speech therapy adjuvant to speech therapy improves recovery improves recovery "! ?ari"$s lan $a e !$n*ti"ns"! ?ari"$s lan $a e !$n*ti"nsand t'is e!!e*t is a**"m%anied b( a si ni!i*antand t'is e!!e*t is a**"m%anied b( a si ni!i*antin*rease "! task-related !l"# a*ti?ati"n in el"L$entin*rease "! task-related !l"# a*ti?ati"n in el"L$entareas "! t'e le!t 'emis%'ere,areas "! t'e le!t 'emis%'ere,

KesslerKessler et alet al 8;;;8;;;

S%ee*' TH and %'asiaS%ee*' TH and %'asia


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1>2

T'e e!!i*a*( "!T'e e!!i*a*( "! speech therapy speech therapy isis still controversial still controversial #it' se?eral rand"mi ed *"ntr"lled trials (ieldin n"#it' se?eral rand"mi ed *"ntr"lled trials (ieldin n"

di!!eren*e in "$t*"me bet#een treated and n"ntreateddi!!eren*e in "$t*"me bet#een treated and n"ntreated

r"$%s,r"$%s,Ferr"Ferr" et al. citet al. cit KesslerKessler et al et al , 8;;;, 8;;;

0n t'e "t'er 'and m"st a$t'"r ass$me a bene!i*ial0n t'e "t'er 'and m"st a$t'"r ass$me a bene!i*ials%e*i!i* e!!e*t "! s%ee*' t'era%( %arti*$larl( #'en it iss%e*i!i* e!!e*t "! s%ee*' t'era%( %arti*$larl( #'en it isintense and starts early intense and starts early ,,

@$ss"@$ss" et al.et al. 1222 1222

R9%'/9RC FR'$ ! #!S*!R9%'/9RC FR'$ ! #!S*!


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Two mechanismsTwo mechanisms !"r re*"?er( !r"m a%'asia!"r re*"?er( !r"m a%'asia repair of damagedrepair of damaged

language networkslanguage networks andand activation of compensatory areas.activation of compensatory areas.

Re*"?er( m$st in?"l?e re i"nsRe*"?er( m$st in?"l?e re i"ns outside the morphologically damagedoutside the morphologically damagedareaarea t'at re ain "r take "?er lan $a e !$n*ti"ns l"st in a*$te str"ke,t'at re ain "r take "?er lan $a e !$n*ti"ns l"st in a*$te str"ke,

T'eT'e restoration of left hemisphere language networksrestoration of left hemisphere language networks is ass"*iatedis ass"*iated#it' better re*"?er( and in?ersel( related t" a*ti?it( in t'e#it' better re*"?er( and in?ersel( related t" a*ti?it( in t'e compensatedcompensated

or recruited areas of the right hemisphere.or recruited areas of the right hemisphere.

Ca"Ca" et al et al , 1222 and Kessler, 1222 and Kessler et al.,et al., 8;;;8;;;

R'" 'S*SR'" 'S*S

@" "! '@" "! ' i li $i i* !$ * i"i li $i i* !$ * i"


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@"st "! t'e@"st "! t'e spontaneous recovery spontaneous recovery in lin $isti* !$n*ti"nin lin $isti* !$n*ti"n

"**$rs in t'e"**$rs in t'e first weeksfirst weeks a!ter str"ke and isa!ter str"ke and is completed bycompleted bythe end of the first year the end of the first year alt'"$ ' re%"rts eHist "! alt'"$ ' re%"rts eHist "!

im%r"?ements "**$rrin as a res$lt "!im%r"?ements "**$rrin as a res$lt "! long-term therapy long-term therapy "!"!%atients #it' *'r"ni* a%'asia%atients #it' *'r"ni* a%'asia

P$l?erm$llerP$l?erm$ller et al et al , 8;;1 ,, 8;;1 ,

Fakt"r AFakt"r Pr" n"sisFakt"r AFakt"r Pr" n"sis


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1 8

$as *edera$as *ederaetak *ederaetak *edera

Ke%ara'an a!asiaKe%ara'an a!asiaDm$r Dm$r =ntele ensi dan Pendidikan=ntele ensi dan Pendidikan

ateralisasiateralisasiKe%ribadianKe%ribadian

-!&*R-!&*R


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1 3

TES F S=TES F S=DNTDKDNTDK

&= GN0S=S&= GN0S=S=NF0R@ S==NF0R@ S=

RE B= =T S=RE B= =T S=

T$)$an T &=RT$)$an T &=R


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1 9

@emb$at dia n"sis a!asia /b$kan a!asia@emb$at dia n"sis a!asia /b$kan a!asia@emb$at dia n"sis sindr"m a!asia mana@emb$at dia n"sis sindr"m a!asia mana@emberi in!"rmasi ke%ada %asien@emberi in!"rmasi ke%ada %asienlin k$n ann(a dan "ran keti a lainlin k$n ann(a dan "ran keti a lain@en)adi titik t"lak $nt$k %enan anan@en)adi titik t"lak $nt$k %enan anan

re'abilitasire'abilitasi

Perbedaan k'asPerbedaan k'as


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1 5

!asia !asia : kes$litan %enem$an kata ?erbal I: kes$litan %enem$an kata ?erbal It$lis )elek ?is$al ba $st$lis )elek ?is$al ba $s&isartri&isartri : Kes$litan men $*a%kan kata: Kes$litan men $*a%kan kata&emensia&emensia : Kesala'an memberi: Kesala'an memberinama %erse%si ?is$al )eleknama %erse%si ?is$al )elekk td%t %erekaman n"rmal ke in atan drk td%t %erekaman n"rmal ke in atan dr

ambar tidak ada demensiaambar tidak ada demensia &'arma%er#ira Prins 1223&'arma%er#ira Prins 1223

"$ns!ield Dnit D"$ns!ield Dnit D+1;;;+1;;; B"neB"ne+1;;+1;; Calsi!i*ati"nsCalsi!i*ati"ns


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+1;;+1;; Calsi!i ati nsCalsi!i ati ns+>;+>;

em"rr'a esem"rr'a es+5;+5;Gre( matter Gre( matter +35+35.'ite matter .'ite matter

+85+85Edema/ne*r"sisEdema/ne*r"sis+1;+1;Cerebr"s%inal !l$idCerebr"s%inal !l$id+5+5;; .ater .ater

-1;-1;Fatt( str$*t$reFatt( str$*t$re-1;;-1;;-1;;;-1;;; ir ir


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!stuti!stuti4eurologist4eurologist

G,@


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F&GL9 F


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&FBM9 &4I,M9HBMB,I,F9I4

:& FBG GI,I B I4


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Hyperhomocysteinemiais a risk factor for both

ischemic strokeand

osteoporotic fracturesin elderly men and

women

7ernodjo 4ahlan,7ernodjo 4ahlan,!stutiG,!stutiG,2&&2&&

21 natiDe 3aDanese patients21 natiDe 3aDanese patientswere eligiblewere eligible7e found ** sub;ects (2 )$7e found ** sub;ects (2 )$with hyperhomocysteinemia#with hyperhomocysteinemia#


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FH9 >949:IF B: FH9 >949:IF B:M9&,@G9M94F B:M9&,@G9M94F B:

CBGG9A&FIB4 >9F7994CBGG9A&FIB4 >9F7994HBMBCO,F9I49 &4


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N Mean tHcy (mmol/L)Tugasworo 30 Stro e !"#3"$%#"%

(33& Hyper Hcy)

Meta analyses o; 2* clinicalstudies

0le3ation in risk associated Eith HM increment in t>cy

Cerebrovasc.dis. M/F1.9

(1.6-2.3)(11 s tudies)

Boushey et al, JAMA 1995

kk

Increased fracture risk is aIncreased fracture risk is arecogni=ed complicationrecogni=ed complicationfollowingfollowing strokestroke % >one loss% >one lossfollowing a hemiplegicfollowing a hemiplegic


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,troke,trokeincreases theincreases the

risk ofrisk ofsubse+uent hipsubse+uent hip

fracture by * tofracture by * to times% times%

following a hemiplegicfollowing a hemiplegic

strokestroke has been proposedhas been proposed

asas

a ma;or risk factor for post-a ma;or risk factor for post-strokestroke hip fracture# with ahip fracture# with a recent focus on therecent focus on thedeDelopment of noDeldeDelopment of noDeltherapeutic measurestherapeutic measures totopreDent bone loss andpreDent bone loss andfractures afterfractures after strokestroke % 7e% 7ebrie8ybrie8y reDiew the literaturereDiew the literatureon the epidemiology andon the epidemiology andpathophysiologypathophysiology of bone lossof bone loss

and hip fracture afterand hip fracture after strokestroke ##and then criticallyand then critically reDiewreDiewrecent studies on preDentiDerecent studies on preDentiDestrategies%strategies%

Hip fractures after stroke and their prevention

% % Myint1#*# %9%,% oole( and 9%&%7arburton 1

8ncreased8ncreasedl ! i3it l t ! ti3it

8ncreasedplasma


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=steoclast !cti3ity=steoclast !cti3ity

in the 7resence o;in the 7resence o;8ncreased8ncreased>omocysteine>omocysteine/oncentrations/oncentrations

may be anmay be an

independent riskindependent risk;actor ;or osteoporotic;actor ;or osteoporotic;ractures and;ractures andthere;ore may alsothere;ore may alsoad3ersely aIect bonead3ersely aIect bonemetabolism.metabolism.Markus Herrmann#1 Fhomas 7idmann#* Lra=ianaMarkus Herrmann#1 Fhomas 7idmann#* Lra=iana

Colaianni#( ,ilDia Colucci#(Colaianni#( ,ilDia Colucci#( &lberta Uallone#( and&lberta Uallone#( and7olfgang Herrmann1V7olfgang Herrmann1V +linical +he!istry 1, %o. 1(, (**+linical +he!istry 1, %o. 1(, (**

plasmahomocysteine A>cysB

,eDeral studies found that,eDeral studies found thatcobalamin andcobalamin and

folate status are related tofolate status are related tob i l d i M $b i l d it >M


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bone mineral density >MM1*%

In addition# low cobalamin status has been shown to reduceosteoblast actiDity %othin0 is no n, ho e&er, a/o#t osteoclast-2+ function in the presence of increased HCO or low > Ditaminconcentrations%

It has been suggested that disturbedcrosslinking of collagen

Pb il d d d Pb illi 1 d * d i i


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Pbrils and reduced Pbrillin-1 and -* depositionlead to a disturbed architecture of bone matri! inhomocystinuric

patients .

The i!"act o4 inter!olec#lar collagen cross-links in bone has been adduced# in part# from studies of lathyrism The s eet "ea Lathyr#s odorat#s co!"o#nd)a!ino"ro"ionitrile

irre&ersi/ly inhibits lysyl o!idase and blocksinitial collagen cross-link formation% Fhis e6ect could lead to

SEDIAAN


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acti3e ;orm H 3 ( e thy l - )


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Jenis 1itamin 62 dan man;aatnya

/

/o Vitamin B komplek


198/223

62

#84!K !K#8@

!K#8@

/o pB 1 , B 6 , B 12

1it kompleks

1,

2,

1*

=>

/o

BHBH

CH *

/o

4alamLi3er

>ycobal

4alam Serum

/> $/o

Memperbaikineuropatimelalui sintesis asamnukleat,

/> $

/o

europati

perifer

europatiperifer

Memperbaiki anemiamelalui sintesis heme

!nemia dan neuropati akibat defisiensi dan$etabolisme abnormal it. 1 A 12




MemperbaikiDefisiensi cobalamin

MemperbaikiDefisiensi cobalamin Kadar

Homosistein me

:aktor Gisiko gangguan,erebroDaskuler

koroner# peny% embuluh darah te Frombosis Dena

Serum /airan serebrospinal

91 2%


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&


200/223


201/223

d"$ble-blind rand"mi ed d"$ble-blind rand"mi ed*"ntr"lled st$d( "! 48*"ntr"lled st$d( "! 48*"nse*$ti?e %atients a ed 45*"nse*$ti?e %atients a ed 45(ears "r "lder #it' resid$al(ears "r "lder #it' resid$alM"s'i'ir" Sat" @&M"s'i'ir" Sat" @&

!M!. "##$%"&'()#*"- !M!. "##$%"&'()#*"- )#** )#**


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(ears r lder #it resid$al(ears r lder #it resid$al

'emi%le ia at least 1 (ear 'emi%le ia at least 1 (ear !"ll"#in !irst is*'emi* str"ke!"ll"#in !irst is*'emi* str"ke#'" #ere re*r$ited !r"m a#'" #ere re*r$ited !r"m asin le a%anese '"s%ital !r"msin le a%anese '"s%ital !r"m

%ril 1 8;;; t" @a( 31 %ril 1 8;;; t" @a( 318;;1, Patients #ere assi ned8;;1, Patients #ere assi nedt" dail( "ral treatment #it't" dail( "ral treatment #it'5m "! !"late and 15;; "!5m "! !"late and 15;; "!me*"balamin "r d"$bleme*"balamin "r d"$ble

%la*eb" 552 *"m%leted t'e%la*eb" 552 *"m%leted t'e8-(ear !"ll"#-$%,8-(ear !"ll"#-$%,

M"s'iaki "nda @&M"s'iaki "nda @&$n =#am"t" @&$n =#am"t" @&

T"m"'ir" Kan"k" P'&T"m"'ir" Kan"k" P'&Kei Sat"' @&Kei Sat"' @&

=n t'is a%anese %"%$lati"n #it' a=n t'is a%anese %"%$lati"n #it' a'i ' baseline !ra*t$re risk *"mbined'i ' baseline !ra*t$re risk *"mbined

treatment #it' !"latetreatment #it' !"lateand ?itamin B18 isand ?itamin B18 issa!e and e!!e*ti?e insa!e and e!!e*ti?e inred$*in t'e risk "! ared$*in t'e risk "! a'i% !ra*t$re in elderl('i% !ra*t$re in elderl(%atients !"ll"#in%atients !"ll"#instr"ke,str"ke,

Treatment #it' !"late andTreatment #it' !"late and


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M"s'i'ir" Sat" @& M"s'iaki "nda @&M"s'i'ir" Sat" @& M"s'iaki "nda @&$n =#am"t" @& T"m"'ir" Kan"k"$n =#am"t" @& T"m"'ir" Kan"k"P'& Kei Sat"' @&P'& Kei Sat"' @&

@ @ar*' 8 8;;5 V"l 823 N", 2@ @ar*' 8 8;;5 V"l 823 N", 2

me*"balaminme*"balamin#as e!!e*ti?e in red$*in#as e!!e*ti?e in red$*in

t'e risk "! t'e seri"$st'e risk "! t'e seri"$s

%"st str"ke *"m%li*ati"n%"st str"ke *"m%li*ati"n"! "! !ra*t$res,!ra*t$res,

0Iect o; @olate and0Iect o; @olate andMecobalamin on >ipMecobalamin on >ip@ i 7 i


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@ractures in 7atients@ractures in 7atients

Dith StrokeDith Stroke& Gandomi=ed Controlled& Gandomi=ed Controlled

Frial Frial demonstrated ademonstrated a

reduction inreduction inplasmaplasmahomocysteinehomocysteine

leDels byleDels bycombinationcombinationtherapy withtherapy with

folate and Ditaminfolate and Ditamin>1*>1*

in patients within patients with

?oshihiro Sato, M4, ?oshiaki ?oshihiro Sato, M4, ?oshiaki>onda, M4 Jun 8Eamoto, M4>onda, M4 Jun 8Eamoto, M4#omohiro Kanoko, 7h4 Kei#omohiro Kanoko, 7h4 KeiSatoh, M4Satoh, M4

J!M!, March 2, 2&& 1ol 2($, J!M!, March 2, 2&& 1ol 2($,

o. (o. (

!melioration by!melioration bymecobalamin o; subclinicalmecobalamin o; subclinicalcarpal tunnel syndromecarpal tunnel syndrome

in3ol3ing unaIected limbs inin3ol3ing unaIected limbs instroke patientsstroke patients

Fhe purpose of this study was to eDaluate the e6ects of the Fhe purpose of this study was to eDaluate the e6ects of theorally administeredorally administered mecobalaminmecobalamin # an analogue of Ditamin >1*## an analogue of Ditamin >1*#for carpal tunnel syndrome CF $ in the nonparetic side infor carpal tunnel syndrome CF $ in the nonparetic side in


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for carpal tunnel syndrome CF,$ in the nonparetic side infor carpal tunnel syndrome CF,$ in the nonparetic side in

patients followingpatients following strokestroke % In a randomi=ed open label and% In a randomi=ed open label andprospectiDe study ofprospectiDe study of strokestroke patients# 2" receiDed of 1500 mugpatients# 2" receiDed of 1500 mugmecobalaminmecobalamin daily for * years# and the remaining 2daily for * years# and the remaining 2

untreated group$ did not% &t baseline# sensory nerDe conductionuntreated group$ did not% &t baseline# sensory nerDe conductionDelocity# motor nerDe conduction Delocity# sensory nerDe actionDelocity# motor nerDe conduction Delocity# sensory nerDe actionpotentials ,4& $ at the wrist# palm-to-wrist distal sensorypotentials ,4& $ at the wrist# palm-to-wrist distal sensorylatency# palm-to-wrist ,4& # motor nerDe conduction Delocitylatency# palm-to-wrist ,4& # motor nerDe conduction Delocitycompound motor action potentials# and distal motor latency ofcompound motor action potentials# and distal motor latency ofmedian nerDe were signiPcantly more abnormal on themedian nerDe were signiPcantly more abnormal on thenonparetic side than on the hemiparetic side or in controls%nonparetic side than on the hemiparetic side or in controls%>efore the treatment *1 patients (1)$ of untreated and *0>efore the treatment *1 patients (1)$ of untreated and *0patients (0)$ of treated group met electrophysiologic criteriapatients (0)$ of treated group met electrophysiologic criteriafor CF,% ,ensory impairment of the nonparetic side had lessenedfor CF,% ,ensory impairment of the nonparetic side had lessenedin the treated group% &fter * years# all electrophysiologic indicesin the treated group% &fter * years# all electrophysiologic indicesof nonparetic side were signiPcantly improDed in the treatedof nonparetic side were signiPcantly improDed in the treatedgroup compared with those in the untreated group% Fhegroup compared with those in the untreated group% FheimproDement from baseline of electrophysiologic parameters inimproD

Documents

97083888 Presentasi Kasus Stroke Final