Assessing and Discussing Prognosis and Natural History Of

8/12/2019 Assessing and Discussing Prognosis and Natural History Of

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Assessing and Discussing Prognosis

and Natural History ofCerebrovascular Disorders

Pembimbing:

Dr. Agus Permadi, Sp.S

Disusun Oleh:

Rahmah, S.ked


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CAROTID OR VERTEBRAL ARTERYOCCLUSIVE DISEASE


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Asymptomatic Carotid Artery Disease

Carotid bruit occurs in 4 % to 5% of the population

aged 45 to 80 years. It is merely a reflection of

turbulance in the artery and relatively poor predictor

of underlying internal carotid stenosis inasymptomatic patients.

Patients with asymptomatic carotid bruits are at

greater risk than the general population for all forms

of atherosclerotic vascular disease.

The risk of myocardial infarction is also increased and

it is the leading cause of death.


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Symptomatic Carotid Artery Disease

Symptomatic carotid artery disease includes

symptoms related to transient or persistent

monocular visual loss, hemisperic transient

ischemic attack (TIA), and ischemic stroke

Patients who present with TIA or minor stroke related to

severe carotid stenotic lesions are at risk of stroke at the rate

of 13%/year for 2 years after onset of symptoms.


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Vertebrobasilar System Occlusive

DiseaseAlthough atherosclerotic occlusive

disease of the vertebral arteries is less

common than it is in the carotid system,

the development of disease in both is

associated with the same or similar riskfactors.

In the small studies available, the risk of brain stem stroke is

less than 1% to 2%/year, but it is higher if associated with

basilar stenosis. The risk of any stroke or myocardial

infarction is much higher than that in the general

population because of co-ocurring anterior circulation

atheromatous occlusive disease and coronary artery

disease.


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TRANSIENT ISCHEMIC ATTACK


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About one-third of patients with transient ischemic attack (TIA) have a

stroke within 5 years of the first attack. More than 20% of these stroke

occur within 1 month of the initial attack, and about 50% occur within 1

year, irrespective of the territory involved (carotid or vertebrobasilar

system).

The cause of death after carotid or vertebrobasilar TIA are similar(Approximately 45% cardiac and 30% hemorrhagic or ischemic stroke).

Survival is nearly 90% at 1 year after the first TIA and approximately 70%

at 5 years, 50% at 8 years, and 40% at 10 years.

The probability of stroke after TIA strongly correlates with the patients

age at onset, women who are older than 70 years have a worse survival

rate than do men who are older than age 70, but women younger than

70 years have a better survival rate than that of their male counter

parts.


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REVERSIBLE ISCHEMIC NEUROLOGICDEFICIT


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A neurologic deficit caused by focal cerebral ischemia that persists for morethan 24 hours but clears in less than 3 weeks is a cerebral infarction

subtype called a reversible ischemic neurologic deficit (RIND).

Survival rates in patients with RIND are similar to those of patients with

transient ischemic attack (TIA) and better than those of patients with major

cerebral infarction (ischemic stroke). The most common cause of death iscoronary artery disease, followed by cerebral infarction, cancer, and

respiratory disease.


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CEREBRAL INFARCTION


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After a person had cerebral infarction, the 30 days case fatality rate is

about 20%. Survival after the first cerebral infarction is about 65% at

1 year, approximately 50% at 5 years, 30% at 8 years, and about 25%

at 10 years.

The most common causes of death after cerebral infarction are

transtentorial herniation, pneumonia, cardiac disorders, pulmonary

embolus, and septicemia. Patients presenting with altered sensorium

and hemiplagia frequently die of herniation. Death from herniation

occurs more commonly on day 1 or 2 after the onset of infarct than

on any other days and considerably less frequently after day 7.

In general, about 60% to 70% of patients have early fuctional

disability after a stroke. Severe neurologic deficits with no returnof motor function within 1 month, marked cognitive perceptual

dysfunction, apraxia, or impairment in construction ability, and

urinary incontinence 2 weeks after a stroke are indicators of a poor

functional prognosis and identify patients who are likely to need

long term care.


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INTRACEREBRAL HEMORRHAGE


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For persons with intracerebral hemorrhage, survival rate ranges from

40% to 70%, immediate functional prognosis with intracerebralhemorrhage is usually better than that with cerebral infarction because

of differences in the amount of brain tissue dammage. The overall

mortality rate is about 15% to 30%, approximately 50% of survivors have

full functional recovery

For persons with Putaminal hemorrhage, the mortality

rate is about 40%, although the range of clinical

presentations is marked and typically depends on the

volume of hemorrhage. Radiologic imagingcharacteristics predictive of a poor prognosis include

large hemorrhage size and intraventricular extension.


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For patients with thalamic hemorrhage, the

functional status is usually poor, directly

depending on the size of the lesion hemorrhage

more than 3 cm in diameter are almost always

fatal.

In brain stem hemorrhage, death

usually occurs within a few hours, but,

occasionally, patients with a small

hemorrhagic lesion may survive.


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SUBARACHNOID HEMORRHAGE


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If the patient is seen at 24 hours after subarachnoid hemorrhage, the

mortality rate at 30 days is decreased to approximately 35%, at 48

hours to about 30%, at 1 week to about 25%, and at 2 weeks to 10%.

Approximately 10% patients die before they receive medical attention.

One of the major causes of mortality after the initial subarachnoid

hemorrhage is rebleeding. The rebleeding rate is approximately 2%/ day

during the first 10 days.


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THANK YOU

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Assessing and Discussing Prognosis and Natural History Of