Stroke- Smtr 4

8/18/2019 Stroke- Smtr 4

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I Wayan Tunjung, dr. Sp.S

BAGIAN NEUROLOGI

RSU KOTA MATARAM


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CEREBROVASCULAR DISEASECEREBROVASCULAR DISEASE(CVD)(CVD)

ACUTE CVDACUTE CVD

- ACUTE STROKE- ACUTE STROKE

CHRONIC CVDCHRONIC CVD

VASCULAR DEMENTIAVASCULAR DEMENTIA

- MULTI INFARCT DEMENTIA- MULTI INFARCT DEMENTIA

- BINSWANGER’S DISEASE- BINSWANGER’S DISEASE


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A Global public Health Problem.

Generic name of Brain attack.

Death rate are rising in some countries.

A Community Health Problem and at timesstroke cases are of acute medicalemergency problem needs early &accurate diagnosis prompt treatment.


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Stroke aa!a" #$at$ e%&t 'e$ro!o&k%oka! ata$ e'*a& $$+ ata$ $$

,a' ter*a& #eara e'aak ata$ e.at

a!a /e/era.a et&k ata$ *a kare'aa'$a' %$'#& otak ,a' e/a/ka'

o!e" a'$a' .ereara' ara" otak

,a' /er!a'#$' !e/&" ar& 01 *a ata$/erak"&r e'a' keat&a'2


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MOTOR ACTIVIT3 SENSOR3 ACTIVIT3


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Origins of Gra! "ss#s fro$Origins of Gra! "ss#s fro$!% Aor!i& Ar&%!% Aor!i& Ar&%


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'ir of Wi##is'ir of Wi##is


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- Me'er&a 45 6 ara" ,a' &.o.a ar& *a't$'

- Me'$'aka' 47-086 80 ,a'&.er!$ka' /aa' #e!$r$"',a

- Me'$'aka' 586 !$ko#a ,a' /eraaa!a #&rk$!a#&


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CBF = =

= =

=

ekanan perfusi

ahanan serebro!askuler

P "A # $%

C$

ekanan darah sistemik # ' mmHgC$

ekanan darah sistemik

C$

( A B P

C$

CAAA)*

CB+ , ' "'-/% ml per 0 gram 1aringan otak per menit

"total flo2* 3-4 ml per menit%.5 6epertiganya melalui arteri karotis interna kanan.

6epertiganya melalui arteri karotis interna kiri. 6epertiganya melalui sistem !ertebro-basilaris.5 7aktu sirkulasi darah dalam otak* # ' detik.

C$* 08/ mmHg per ml per 0 gram 1aringan otak per menit.

C(9:* ;8; ml 9: per 0 1aringan otak per menit "/ ml 9: per menit

untuk seluruh otak%. C( G


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AKTOR- AKTOR YANG MEMPENGARUHI

CEREBRAL BLOOD LOW (CB ):

+aktor ekstrinsik*

ekanan darah sistemik.

>emampuan 1antung untuk memompa darah.

>ualitas dinding pembuluh darah sistem karotis dan

!ertebro-basilaris.

>ualitas darah yang menentukan !iskositasnya. +aktor intrinsik*

Autoregulasi arteri serebral.

Proses-proses biokimia2i serebral regional yangmempengaruhi lumen arteri serebral.

ekanan intrakranial.


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AKTOR- AKTOR YANG MEMPENGARUHI

CEREBRAL VASCULAR RESISTANT (CVR):

Tonus dinding pembuluh darah.

Viskositas darah. Tekanan intrakranial


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I're#ae o% ere/ra! eta/o!I're#ae o% ere/ra! eta/o!

T#$!ar .COT#$!ar .CO 00 e'$r$'e'$r$'

E9trae!!$!ar .H e'&'katE9trae!!$!ar .H e'&'kat

VASOCONSTRICTIONVASOCONSTRICTION

T#$!ar .COT#$!ar .CO 00 e'&'kate'&'kat

E9trae!!$!ar .H e'$r$'E9trae!!$!ar .H e'$r$'

Ce##at&o' o% :a#o o'#tr&t&o'Ce##at&o' o% :a#o o'#tr&t&o'

Dere#ae o% ere/ra! eta/o!Dere#ae o% ere/ra! eta/o!

T#$!ar .COT#$!ar .CO 00 e'&'kate'&'kat

E9trae!!$!ar .H e'$r$'E9trae!!$!ar .H e'$r$'

VASODILATIONVASODILATION

T#$!ar .COT#$!ar .CO 00 e'$r$'e'$r$'

E9trae!!$!ar .H e'&'katE9trae!!$!ar .H e'&'kat

Ce##at&o' o% :a#o o'#tr&t&o'Ce##at&o' o% :a#o o'#tr&t&o'


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INTA'T BRAIN TISSUE

NORMAL STATE

(E'REASE IN )ROTEIN

S*NT+ESIS

SELE'TI"E GENEE)RESSION

LA'TI' A'I(OSIS

'*TOTOI' E(EMA

ENERG* (E-I'IT

GLUTAMATEE'ITOI'IT*

ANOI'(E)OLARIATION

'

:

0

;

/

3

4

CBF+ !;488 /ra&' t#$e;&'$teCBF+ !;488 /ra&' t#$e;&'$te

'

:

0

;

/

3

/ # 4min

; # /hours

; # 3days

I S C H E M I C C O R E

4

SEVERESEVERE

MODERATEMODERATE

MILDMILD

OLIGEMIAOLIGEMIA

I S C

H E M I A

I S C

H E M I A

TIME FROM STROKE ONSETTIME FROM STROKE ONSETUNTIL IRREVERSIBLE DAMAGEUNTIL IRREVERSIBLE DAMAGEOCCURSOCCURS

CBF+ !;488 /ra&' t#$e;&'$teCBF+ !;488 /ra&' t#$e;&'$te

A


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raditional concept

Alternati!e concept


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STROKESTROKEPenyebab kematian no 3 setelah penyakit jantung

dan keganasan.

+ 2!". penduduk !tahun.

Penyebab utama #a#at menahun.

$% & '%( adalah stroke non hemoragik )+ %3(adalah stroke trombotik* dan + 3"( strokeembolik.

,ngka kematian stroke trombotik + 3-(* danstroke embolik + $(.

"% & 3%( adalah stroke hemoragik )

+ " & 2( perdarahan!hematom intraserebral*dan + % & "%( perdarahan subaraknoid.

,ngka kematian stroke hemoragik pada jaman praCT - & /%( dan pada jaman CT 2 & 3(.


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69>?69>?

BRAIN ISCHEMIA (786)BRAIN ISCHEMIA (786) BRAIN HEMORRAHGE (086)BRAIN HEMORRAHGE (086)

THROMBOSISTHROMBOSIS(6)

EMBOLISMEMBOLISM(1>6)(1>6)

INTRACEREBRALINTRACEREBRAL(76)(76)

SUBARACHNOIDSUBARACHNOID(486)(486)

SUBDURAL+SUBDURAL+E?TRADURALE?TRADURAL

(06)(06)

LARGELARGE

ARTERIESARTERIES

(4>6)(4>6)

=ENETRATING=ENETRATING

ARTERIESARTERIES

(LACUNAR)(LACUNAR)

(4>6)(4>6)

CARDIOGENICCARDIOGENIC

(0>6)(0>6)

ARTER3 TOARTER3 TO

ARTER3ARTER3

(086)(086)

AORTICAORTIC

DEBRISDEBRIS

(UNKNOWN)(UNKNOWN)

NON-NON-

ANEUR3SMALANEUR3SMAL

(


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)RE"ALENSI STROKE (I)RE"ALENSI STROKE (IUSA /USA /

2 per " pada usia 0% & %0 th

$ per " pada usia $% & -0 th 1ematian

0 & $(./% per " pada usia -% & '0 th

".A. 6tallon dkk8 03:%


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(ALAM 0 BULAN )AS'A(ALAM 0 BULAN )AS'A

STROKE /STROKE /2-( apat bekerja kembali tanpake#a#atan.

20( enderita #a#at ringan.23( enderita #a#at sedang.

""( enderita #a#at berat.

$( enderita #a#at berat danmemerlukan pera4atan khusus.

").+. Gordon dkk8 0


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Nona!a# 1 )rina!a#

'%i#d 1 2u3ni#

Adu#!

Edr#y

Nona!a# 1 prina!a# I"+.

)ri3n!ri&u#ar #u&o$a#a&a.

+rdi!ary, gn!i&s

'ongni!a#Inf&!ions, in4a$$a!ions, au!oi$$un.

'oagu#a!ions

'ardio53as&u#ar'%$i&a#s, nar&o!i&s, drugs.

La&unar

+ypr!nsi3 in!ra&r6ra#

%$orr%agA!%ro!ro$6o!i& 1 $6o#i&.

STROKESTROKE

A.A.B.). )uartha8 :3


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4242 Atero#k!ero#Atero#k!ero#

0202 Keraa'a';:a#k$!&tKeraa'a';:a#k$!&t

@ L$.$# er&teato#$# e&'at$#2@ L$.$# er&teato#$# e&'at$#2

@ Arter&t reato&2@ Arter&t reato&2

@ M&9e r,o!o/$!&'e&a2@ M&9e r,o!o/$!&'e&a2

@ .o!&arter&t 'o$#a@ .o!&arter&t 'o$#a

@ Arter&t te.ora!@ Arter&t te.ora!

@ Arter&t Taka,a#$2@ Arter&t Taka,a#$2

@ Dr$ 'erot&&' a'&t@ Dr$ 'erot&&' a'&t

( A%eta&'+ %e'&! .ro.a'o!a&'+( A%eta&'+ %e'&! .ro.a'o!a&'+

et&!%e'&at+ a!ko"o!+ koka&'+ "ero&'+ LSD+et&!%e'&at+ a!ko"o!+ koka&'+ "ero&'+ LSD+

MAO &'"&/&tor)MAO &'"&/&tor)

@ I'%ek#& !$e#+ TB+ HIV+ Me'&'&t+@ I'%ek#& !$e#+ TB+ HIV+ Me'&'&t+

#e.#+ !!2#e.#+ !!2


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I2 T&ak a.at &o&%&ka#& arker2 42 U#&a

02 e' ke!a&'


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STROKEISKEMIK

STROKE+EMORAGIK

5sia tambah tua. 6ipertensi.

Penyakit jantungiskemik. Fibrilasi atrium . iabetes melitus. Penyakit 7askuler

peri8er. 6ematokrit tinggi. 1olesterol tinggi 1olesterol rendah. Fibrinogen tinggi. erokok. ,lkohol. 1egemukan.

++++

+++++++++

++++:+++

++++

+++++


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H3=ERTENSIONH3=ERTENSION

INCREASED CEREBRALINCREASED CEREBRAL

ARTERIAL WALL TENSIONARTERIAL WALL TENSIONINCREASED VASCULARINCREASED VASCULAR

=ERMEABILIT3=ERMEABILIT3

FIBROMUSCULAR THICKENING OF CEREBRAL ARTERIESFIBROMUSCULAR THICKENING OF CEREBRAL ARTERIES

WITH NARROWING OF SMALL VESSELSWITH NARROWING OF SMALL VESSELS

H3=ERTENSIVE NICROVASCULAR DISEASEH3=ERTENSIVE NICROVASCULAR DISEASE

(SMALL VESSEL DISEASE)(SMALL VESSEL DISEASE)

CEREBRALCEREBRAL

ISCHEMIAISCHEMIA

ISCHEMICISCHEMIC

ATTACKSATTACKS

MICROTHROMBIMICROTHROMBI

MICROINFARCTSMICROINFARCTS

INTRACEREBRALINTRACEREBRAL

MICROANEURISMSMICROANEURISMS

RU=TURERU=TURE

THROMBOTIC STROKETHROMBOTIC STROKE

(SMALL STROKE)(SMALL STROKE)

INTRACEREBRALINTRACEREBRAL

HEMORRHAGEHEMORRHAGE

HEMORRHAGICHEMORRHAGIC

STROKESTROKE

H3=ERTENSIVE STROKEH3=ERTENSIVE STROKE

ATHEROGENIC STIMULUSATHEROGENIC STIMULUS

H3=ERLI=IDEMIA+ DIABETESH3=ERLI=IDEMIA+ DIABETES

H3=ERTENSIVE AND ATHEROSCLEROSTIC VASCULAR DISEASEH3=ERTENSIVE AND ATHEROSCLEROSTIC VASCULAR DISEASE

(LARGE AND SMALL VESSEL DISEASE)(LARGE AND SMALL VESSEL DISEASE)

CEREBRALCEREBRAL

THROMBOSISTHROMBOSIS

CEREBRALCEREBRAL

INFARCTIONINFARCTION

ATHEROTHROMBOTICATHEROTHROMBOTIC

STROKESTROKE

H3=ERTENSIVE ATHEROTHROMBOTIC STROKEH3=ERTENSIVE ATHEROTHROMBOTIC STROKE

CEREBRALCEREBRAL

ISCHEMIAISCHEMIA

TENSIENCT CEREBRALTENSIENCT CEREBRAL

ISCHEMIC ATTACKSISCHEMIC ATTACKS

7. Hollander8 03/.7. Hollander8 03/.


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". P;erebelum "(

Pons "(

2. P;


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Gangguan prdaran dara%o!a7.

Gangguan fungsi o!a7.

(8si! nuro#ogi7fo7a#9$njadi u$u$9u$u$a7u!.

Br#angsung : ;< ja$ a!au6ra7%ir dngan 7$a!ian.



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Cerebro!"#$%!r &'"e!"e" or#erebr!%

!"#$%!r &'"or&er" (CVD) !re er"

$"e& *or &'"e!"e" +,'#, &!!e ,e

br!'. '""$e "e#o.&!r/ o

!b.or!%'/ o* ,e #erebr!% e""e%"0

I. e.er!%1 ,'" &'"e!"e '. !%"o #!%%e&

#erebr!% !2o2%e3/1 #erebro!"#$%!r

!##'&e. or #erebr!% "ro4e0


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E=ILE=S3E=ILE=S3 CEREBRAL STROKECEREBRAL STROKE

E=ILE=S3 AFTER STROKEE=ILE=S3 AFTER STROKE ISCHEMIA INFARCTISCHEMIA INFARCT HEMORRHAGEHEMORRHAGE

STROKE AFTER E=ILE=S3STROKE AFTER E=ILE=S3 VASCULARVASCULAR

MALFORMATIONSMALFORMATIONS

ANGIOMAANGIOMA


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P!r'!% "e'5$re" !.& "e#o.&!r/ e.er!%'5e&

#o.$%"'o." !re o" #oo.0 Co2%e3 2!r'!%

"e'5$re" !re r!re (L0 Gr! e !%0 6778)0

T,e or!%'/ r!e o* S!$" E2'%e2'#$" !*er

"ro4e +!" er/ ,', (91;)

(Ar"o"4! AA e !%0 )


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M!./ #%'.'#!% "$&'e" !4e ! &'"'.#'o. be+ee.

e!r%/ !.& %!e 2o" "ro4e "e'5$re" b!"e& o.

&'**ere.#e" '. ,e'r 2re"$e& 2!,o2,/"'o%o/0

? E!r%/ - o."e "e'5$re" !re ,o$, o re"$%

*ro #e%$%!r b'o#,e'#!%

D/"*$.#'o. %e!&'. o e%e#r'#!%%/

'rr'!b%e '""$e (H0@0 L$,!..1

677>)

? L!e - o."e "e'5$re" !re ,o$, o be #!$"e&

b/ %'o"'" !.& ,e &ee%o2e. o* !

e.'.o#erebr!% #'#!r'3 (B0 @e..e1 677)


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CLINICAL S3NDROMECLINICAL S3NDROME

ETIOLOG3ETIOLOG3

MOR=HOLOG3MOR=HOLOG3

STROKESTROKE

FOCAL ISCHEMIAFOCAL ISCHEMIA

NO STRUCTURALNO STRUCTURAL

LESIONLESION

ISCHEMIC INSULTISCHEMIC INSULT

STRUCTURALSTRUCTURAL

LESIONLESION

ISCHEMIC INFARCTISCHEMIC INFARCT

INTRA CEREBRALINTRA CEREBRAL


SUBARACHNOIDSUBARACHNOID


SUBDURALSUBDURAL


SINUS THROMBOSISSINUS THROMBOSIS

OTHEROTHER

EMBOLICEMBOLIC

THROMBOTICTHROMBOTIC

HEMOD3NAMICHEMOD3NAMIC

IMMUNOLOGIC;INFLAMMMATOR3IMMUNOLOGIC;INFLAMMMATOR3


=ATHOGENESIS=ATHOGENESIS


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I. STROKE ISKEMIK9NON5+EMORAGIK.

=. R3rsi6# is&%$i&

a!!a&79s!ro7 >i!% fu##r&o3ry/

5 RIN( ?R3rsi6#

Is&%$i&Nuro#ogi&a#

(8&i!@

;. S!ro7 in3o#u!ion9progrssing

s!ro7.

. 'o$p#!d s!ro7.

II. STROKE +EMORAGIK.

'ATATAN/

TIA a!au $inor9$ini s!ro7saa! ini !r$asu7 fa7!or risi7o

s!ro7.

42 =art&a! A'ter&or

C&r$!at&o' I'%art&o'

(=ACI) VARIABLE02 Tota! A'ter&or C&r$!at&o'

I'%art&o'

(TACI) =OOR

02 La$'ar I'%art&o'

(LACI) GOOD

12 =o#ter&or C&r$!at&o'

I'%art&o'(=OCI) VARIABLE



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T9, eAsit neurologik 8okal akut yang timbulkarena iskemia otak sepintas dan menghilanglagi tanpa sisa dengan #epat dalam 4aktutidak lebih dari 20 jam.


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Perdarahan!hemetoma intraserebral

eAsit neurologik 8okal yang sangat akut sampaibilateral dengan kaku deselebri* sedang

akti8!melakukan akti7itas* didahului atau disertaimuntah dan nyeri kepala hebat* 4ajah merah*kesadaran menurun sampai koma* na8as berat!ngorokdan meniup:niup pada satu sisi* sering disertai kejang8okal:umum*kaku kuduk* brodikardia*sembab papil*

perdarahan retina )perdarahan subhialoid* danhipertensi!ri4ayat hipertensi.

Perdarahan suboraknoid

Perdarahan subaraknoid primer paling seringdihubungkan dengan pe#ahnya aneurisma )mis

aneurisma sirkulus illisi dan sebagian ke#il karenamal8ormasi arterio:7enosa.


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5nilateral heada#he

isartria

,8asia* bilamana mengenai hemis8erdominan

,mourosis 8ugaks )transient mono#ularblindness ipsilateral menetap.

6emiparesis!paralisis kontralateral.

6emiparestesia!anestesia kontralateral.

Bra#hio:Fa#ial or ?eg deA#it kontralateral.

e7iatin #onjugue ke arah lesi* dll.

6istem karotis.


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istagmus.

iplopia.

angguan penglihatan!pergerakan bola mata

Vomitus.

Parestesia sirkumoral

Vertigo.

Tinitus.,mnesia.

isartria.

is8agia.

rop atta#ks )drop spells.6emihipestesia!anestesia alternans.

6emiparesis!paralisis alternans.

,taksia serebeler ipsilateral.

>indroma 6orner ipsilateral.@8talmoplegia internuklearis* dll.

6istem !ertebro-Basilaris.


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)URE MOTOR STROKE KA)SULA INTERNA,)EN(UKULUS SEREBRIBAGIAN TENGA+, BASIS)ONTIS.

)URE SENSOR* STROKE NUKLEUS "ENTRALIS)OSTERIOR TALAMUS.

SENSOR*5MOTOR STROKE NUKLEUS "ENTRALIS)OSTERIOR TALAMUS 1KRUS )OSTERIORKA)SULA INTERNA.

(*SART+RIA5'LUMS* +AN(S*N(ROME

BASIS )ONTIS,KA)SULA INTERNA.

ATAI' +EMI)ARESIS KRUS )OSTERIORKA)SULA INTERNA 1

KORONA RA(IATA,ROSTRALMENSE-ALON, BASIS)ONTIS.

Apa yang dilakukan ?


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pa yang d la u an ?- Pencegahan.- Pengobatan.


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M$punyai 7$a$puan 7o$uni7asi yang f7!if danM$punyai 7$a$puan 7o$uni7asi yang f7!if dan$nynang7an.$nynang7an.

M$punyai 7$a$puan 7#inis profsiona# yangM$punyai 7$a$puan 7#inis profsiona# yang!r7ini.!r7ini.

Mnydia7an >a7!u yang &u7up.Mnydia7an >a7!u yang &u7up.

Ana$nsis yang &pa! dan a7ura!.Ana$nsis yang &pa! dan a7ura!.

)$ri7saan 8si7 yang a7ura!.)$ri7saan 8si7 yang a7ura!.

S7or s!ro7 yang &pa! dan a7ura!.S7or s!ro7 yang &pa! dan a7ura!.

Sarana pnunjang yang !r7ini.Sarana pnunjang yang !r7ini.

(IAGNOSIS (IAGNOSIS

STROKE.STROKE.


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60 ANAMNESIS0


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)$ri7saan #a6ora!oriu$ 7#ini7 un!u7 s!ro7

)ungsi #u$6a# pada 7asus s!ro7 !r!n!u

'T9MS 'T, 'T9MS'T prfusion i$aging,'TA9MS'TA

MRI, fMRI, -LAIR i$aging, (WI, )WI, ()I, MRA,

MRS. Angiogra8 sr6ra#, (SA9(SA >i!% road $ap.

S)E'T, )ET, 'T5)ET.

EKG, E7o57ardiogra8 ?TTE, TEE@, d##



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KRITERIA PENILAIANKRITERIA PENILAIAN

I.I. Kesdaran saat seranganKesdaran saat serangan * GCS 15* GCS 15 0.0.* GCS 12 – 14* GCS 12 – 14 1.1.* GCS 9 – 11* GCS 9 – 11 2.2.* GCS 3 – * GCS 3 – 3.3.

II.II. Per!"#aan seranganPer!"#aan serangan * Pe#an $%&0 !en't(* Pe#an $%&0 !en't( 0.0.* K"rang )endada $30 – &0 !en't(* K"rang )endada $30 – &0 !en't( 1.1.* )endada $1 – 30 !en't(* )endada $1 – 30 !en't( 2.2.* Sangat !endada $+ 1 !en't(* Sangat !endada $+ 1 !en't( 3.3.

III.III. ,at" serangan,at" serangan * -ang"n t'd"r* -ang"n t'd"r 0.0.* T'd"r* T'd"r 1.1.* Ist'raat/d"d"/t'd"ran* Ist'raat/d"d"/t'd"ran 2.2.

* -eera/!e#a"an at''tas* -eera/!e#a"an at''tas 3.3.I.I. Sa!a' terad' ner' ea#aSa!a' terad' ner' ea#a * % & a!/t'da ada* % & a!/t'da ada 0.0.

* 2 – & a!* 2 – & a! 1.1.* 1 + 2 a!* 1 + 2 a! 2.2.* + 1 a!* + 1 a! 3.3.

.. Ner' ea#a saat seranganNer' ea#a saat serangan * T'da ada* T'da ada 0.0.* R'ngan – sedang* R'ngan – sedang 1.1.* 6e7at* 6e7at 2.2.* Sangat e7at* Sangat e7at 3.3.

I.I. Sa!a' terad' !"ntaSa!a' terad' !"nta * % & a!/t'da ada* % & a!/t'da ada 0.0.* 2 – & a!* 2 – & a! 1.1.

* 1 + 2 a!* 1 + 2 a! 2.2.* + 1 a!* + 1 a! 3.3.

II.II. Sa!a' terad' re8#es -a7'ns' s't'8 Sa!a' terad' re8#es -a7'ns' s't'8 * %& a!/t'da ada* %& a!/t'da ada 0.0.* 2 – & a!* 2 – & a! 1.1.* + 2 a! "n'#atera#* + 2 a! "n'#atera# 2.2.* : 2 a! 7'#atera#* : 2 a! 7'#atera# 3.3.

II.II. Teanan daraTeanan dara * )AP ; 100* )AP ; 100 0.0.* )AP % 100 – 120* )AP % 100 – 120 1.1.* )AP % 120 – 140* )AP % 120 – 140 2.2.


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Sr tta# < 0 – & $Stre 'se!'/nn e!rag'

1& – 24 $Stre e!rag'(

= – 15 $)erag"an dan er#" e!er'saan #e7' #an"t

ata" en"nang: !'sa#na CT s>an( <

= – 11 Ke!"ng'nan Stre Ise!'/nn e!rag'.

12 – 15 Ke!"ng'nan stre e!rag'

Catatan <

- Cara Pen'#a'an 'n' ana d'erg"naan ada stre a"t

)a'n 7ana sr ang d'er#e ada t'a r'ter'a en'#a'an dan "!#a r'ter'a en'#a'an:

aan !a'n !e!ert'ngg' e!"ng'nan stre e!rag'.

-'#a!an t'da se!"a r'ter'a en'#a'an $I – III( daat d'er'sa !aa sr tta# daat d''t"ng

7erdasaran "!#a r'ter'a ang daat d'er'sa <

Sr tta# ? @ "!#a sr "!#a Kr'ter'a

)a'n se!'t enent"an rentang sr tta# ang d'er#e #enga dar' se#"r" r'ter'a en'#a'an

aan !e!ert'ngg' rsentase eteatan sr stre. )'sa#na da#a! 24 aan !endeat' eteatan

dengan CT s>an ang !endeat' 100B

(A2A2 B#2 Nr2 N$art"a+ ta"$' 08882


52/108


53/108

SKORSKOR SENSITIFITASSENSITIFITAS S=ESIFISITASS=ESIFISITAS

A!!e' (We&r et a!+ 41) 8+58 8+1

S&r&ra* (H$& et a!+ 0880) 8+4 8+8

Be##o' (Maer et a!+ 47) 8+ 8+


54/108


55/108

VOLUME PERDARAHAN PADA STROKEHEMORAGIK :

(CT0 SCAN)

2 2!.!.0

% %eb!r0

'.'0

D!%! #:

1;< ? 00;5 ? . ? ! ? t1;< ? 00;5 ? . ? ! ? t


56/108


57/108


58/108


59/108


60/108


61/108


62/108


63/108

A8 B * 9perati!e photo of subarachnoid

hemorrhage.

C * Photo at autopsy sho2ing blood clot

at the basal cisterns.

+ig. .:. 6ubarachnoid hemorrhage due to ruptured cerebral aneurysm.


64/108


65/108

42 D&a'o# ,a' e.at a' te.at2

02 Me'$ra'& e!$a#',a !e#& ata$ ko.re#&2


66/108

=USKESMAS RUMAH SAKIT

EMERGENSI RS2 UNIT STROKE

Me'&'a! 086

S$r:&:or 786

Keaata'

R&'a' 106

Sea'


67/108

HEMORAGIKHEMORAGIKNON-HEMORAGIKNON-HEMORAGIK

KONSERVATIFKONSERVATIF O=ERATIFO=ERATIF

=IS=IS SAHSAH

EFEK MASSAEFEK MASSA

()()EFEK MASSAEFEK MASSA

(-)(-)

J 01 AMJ 01 AM 0 MINGGU 0 MINGGU

O=ERATIFO=ERATIF KONSERVATIFKONSERVATIF

O=ERATIFO=ERATIFO=ERATIFO=ERATIF

ANGIOGRAFIANGIOGRAFI

01 AM 0 MINGGU01 AM 0 MINGGU

KONSERVATIFKONSERVATIF



68/108

I. )ENGOBATAN UMUM/ DB.

II. STROKE ISKEMIK9NON +EMORAGIK.

=. Rprfusi !rapu!i7 1 0 ja$.

=.=. Tro$6o#i!i75 !)A i3 a!au in!r3nsi in!ra ar!ria#.

=.;. An!i 7oagu#an

5 +parin, LMW+, %parinoid, >arfarin.

=.. +$oro#ogi

5 +$odi#usi.5 )n!o7si8#in.

=.


69/108

- C"a!&$ "a''e! a'tao't N&o&.&'2

- G!$taate ree.tor a'tao't Reae&e+ M SO12

- G!$taate ree.tor &'"&/&tor =e',to&'+ Fo#."e',to&'2

- Ga/a ao't C"!oet"&ao!e2

- G!,&'e2

0202 Ne$ro.rotek#& #ek$'er (< ) *a 5 "ar&2

- A't&o9&a't Free ra&a! #a:e'er T&r&!aa ()+

No-S,'t"a#e B!oker E/#e!e'2- I%!aator, &'"&/&tor#

(A't&-ICAM a't&/o,) E'!&oa/2

- Stat&' E#troe'2

- Ne$rotro."& %ator# /FGF2

- Ne$roo$!ator Ne$ro.e.t&e ACTH 1 48 (Sea9)

Cere/ro!,#&'2

- Ne$rore$!ator Ga'!&o#&e# GM42

- Me/ra'e #ta/&!&&' ae't C&t&o!&'e

Nootro.&# =&raeta2


??

PP

A A

A A

@@

$$

??

HH

??

A A

PP

yy

III. STROKE +EMORAGIK

44 =ENGOBATAN UMUM=ENGOBATAN UMUM


70/108

4242 =ENGOBATAN UMUM=ENGOBATAN UMUM

4242 ABC >B24242 ABC >B2

4202 Ma'aee' teka'a' ara" ("&.erte'#&)+ IC= e'&'kat+ ke*a'+4202 Ma'aee' teka'a' ara" ("&.erte'#&)+ IC= e'&'kat+ ke*a'+

"&.erter&a+ a&ra' a' '$tr&2"&.erter&a+ a&ra' a' '$tr&2

0202 Me'ea";e'o/at& .erara"a' /er$!a'2Me'ea";e'o/at& .erara"a' /er$!a'2

0242 A't& %&/r&'o!&t&k0242 A't& %&/r&'o!&t&k - A#a tra'ek#aat2- A#a tra'ek#aat2

- EACA2- EACA2


71/108

". )ENGOBATAN KAUSA, $is/

42 A'&o.!a#t, .re:e't&% e'a';ta'.a #te't&'2

02 Carot& e'artereto, arot& arter, #te'o#


72/108

TD &'$4$r < "e%!. +!4$ 8 -


73/108

D'2!4!' TD /!. %eb', '.'0

MAP

H'2ere."' 2!&! "ro4e '"4e'4 !4$

&'b'!r4!.1 4e#$!%' "'"o%'4


74/108

Ob! !.' ,'2ere."' /!. "$&!,

&'2!4!' "ebe%$ o."e "ro4e&'er$"4!. &!. $.&! 2eber'!. ob!

!.' ,'2ere."' b!r$ "!2!' -6= ,!r'

2!"#! o."e "ro4e0Kr'er'! ob! 2'%',!. %',!

G$'&e%'.e"0


STROKE AKUTSTROKE AKUT

FLOW CHART PENATALAKSANAAN HIPERTENSIFLOW CHART PENATALAKSANAAN HIPERTENSI

PADA STROKE AKUTPADA STROKE AKUT


75/108

Sto!&k 0


76/108

Ba!as 7adar gu#a dara% a$an pada fasa7u! s!ro7 is7$i7 non #a7unar/ =5

;$gH ?op!i$a# =D $gH@. +iprg#i7$ia ra7!if $aupun !ida7 s#a$a

is7$ia o!a7 a7u! $ni$6u#7an f76r6a%aya F 7#uaran 7#inis #6i% 6uru7

!ru!a$a s!ro7 non #a7unar.



77/108

Indi7asi dan syara! p$6rianinsu#in/

5 S!ro7 %$oragi7 dan non%$oragi7 dngan I((M a!au NI((M.

5 Bu7an s!ro7 #a7unar dngan(M.



78/108

(iindi7asi7an pada s!ro7 is7$i7$6o#i7 a7u! un!u7 &ga% s!ro7u#ang.

+parin9LMW+9%parinoid Fdi#anju!7an dngan >arfarin 6i#a$$nu%i syara! dapa! sgra

di6ri7an pada TIA a!au s!ro77ardio $6o#i7 yang s$6u%s$purna =5; %ari dngan 86ri#asia!riu$.

2uga un!u7 pr3nsi ("T pada s!ro7is7$i7 dngan %$ip#gia a!au



79/108

LMW+ yang di!rus7an an!i7oagu#an ora#$$6ri 7#uaran 7#inis #6i% 6ai7 pada

!ro$6osis sinus sr6ra# ?$is/ !ro$6osissinus 7a3rnosus@.

An!i7oagu#an ora# diindi7asi7an padarisi7o !inggi $6o#i o!a7 F u#ang ?A- non

3a#3u#r, 7a!u6 jan!ung 6ua!an, !ro$6us$ura#, AMI@.

Ef7!i8!as F 7a$anan %parin I.".

un!u7 s!ro7 is7$i7 a7u! 6#u$ &u7up6u7!i F $asi% 7on!ro3rsia# F !ida7dir7o$ndasi. A.A.B.). )uartha8 :3

ISCHEMIC STROKE

EVALUATION MANAGEMENT O ISCHEMIC STROKE


80/108

ISCHEMIC STROKE

SUS=ECTED LARGE ARTER3SUS=ECTED LARGE ARTER3

THROMBOSIS;STENOSISTHROMBOSIS;STENOSISLACUNAR STROKELACUNAR STROKE SUS=ECTED CARDIOGENICSUS=ECTED CARDIOGENIC

EMBOLISMEMBOLISM

THROMBOL3TIC DRUGTHROMBOL3TIC DRUG

WITH;ORWITH;OR

ANTICOAGULANT ORANTICOAGULANT OR

ANGIO=LAST3ANGIO=LAST3

NO ANTICOAGULANT+ CONTROLNO ANTICOAGULANT+ CONTROL

H3=ERTENSION+ =LATELETH3=ERTENSION+ =LATELET

INHIBITOR INHIBITOR

THROMBOL3TIC DRUGTHROMBOL3TIC DRUG

WITH;ORWITH;OR

ANTICOAGULANTANTICOAGULANT

HIGH-GRADEHIGH-GRADE

STENOSISSTENOSIS

DEFINITIVEDEFINITIVETHERA=H3THERA=H3

NOT HIGH-GRADENOT HIGH-GRADE

STENOSISSTENOSIS

=LATELET=LATELETINHIBITORSINHIBITORS

E"o EGE"o EG

DEFINITIVEDEFINITIVE

THERA=H3THERA=H3

U!tra#o$' &t" Do..!er orU!tra#o$' &t" Do..!er or

a'&ora.",a'&ora.",


STROKESTROKE

CT SCANCT SCAN

ISCHEMIC STROKEISCHEMIC STROKE HEMORAGIC STROKEHEMORAGIC STROKE


81/108

SURGICAL SURGICAL

3ES 3ES

O=ERATING THEATREO=ERATING THEATRE

I C UI C UNONO

INSERT IC= MONITORINSERT IC= MONITOR

RECOMMENDED IC= J 08 HRECOMMENDED IC= J 08 H

MA= J 4


82/108

CT SCAN

SKOR STROKE

ABC >B2 Me.erta"a'ka' .ate'#& *a!a' 'a%a# #&rk$!a#&

aek$at2 O0 #e#$a& ke/$t$"a' (4 0 L;e'&t)2

E$:o!e& %!$& #tat$# /er&ka' &:% NaCL 8+6 r&'er

!aktat ; a#etat+ "&'ar& ek#tro#a+ .a'ta$ $r&'e o$t.$t2 =a'ta$ ta'a :&ta! #tat$# 'e$ro!o #e!aa 01 50

*a =a'ta$ %$'#& #a!$ra' er'a+ #a!$ra' ke'&'+

ke#e&/a'a' a&ra' e!ektro!&t+ $!a ara" =e'ea"a' .e'a'a'a' ke*a' ata$ eea otak Stat$# && e'a' a#$.a' '$tr& aek$at Ne$ro.rotek#& Ne$rore#tora#& re"a/&!&ta#& =e'ea"a' .e'a'a'a' ko.!&ka#& #e&'& $'k&' =e'ea"a/ .e'a'a'a' %aktor r&ko+ .e',ak&t

.e',erta+ ata$ ka$#a2

STROKE

ISKEMIK STROKE HEMORAGIK

(= I S) 3A 3A TIDAKTIDAK


EVALUASIEVALUASI

.e/er&a'.e/er&a'

t=A t=A A't&"&.erte'#& /&!a &.er!$ka'22 H&.erte'#&

SB= 008 H ata$ DB= 408 H+

& k 48 4 63A3A

TIDAKTIDAK


83/108

&t$r$'ka' 48 4>62

La/eta!o!2

N&kar&.&'2 D&!t&ae2 DB= 418 H+ &t$r$'ka' 48 4>6

N&tro.r$##&e2 A't& koa$!a' .aa ka#$# #e!ekt&% e'a'

.er#,arata' .ea'ta$a' ketat2 A't& .!ate!et ae't

A#eto#a! ora!+ o# aa! 48 + #e!a'*$t',a

5> ;"ar&

3A 3A

MANAGEMEN TEKANAN DARAHMANAGEMEN TEKANAN DARAH A't& "&.erte'#& /&!a &.er!$ka'2 SB= 47> H ata$ DB= 448 H

La/eta!o!2 N&kar&.&'2 D&!t&ae2

DB= 418 N&tro.r$##&e2

&ka teka'a' ara" t&ak e'$r$'+ *a'a'

/er&ka' t=A2

TROMBOLISISTROMBOLISIS t=A &:

=aa #troke ke&k ak$t e'a' o'#et *e!a# t&ak < *a2 Mee'$"& kr&ter&a &'k!$#& ek#k!$#&2

D&raat & ICU ; #troke $'&t2 Do# 8+ ;k &: 8 e'&t+ 486 o# #e/aa& /o!$# &'&a! 86 #a',a a!a

&'%$# 8 e'&t o# ak#&a! 8 2 D&.a'ta$ teka'a' ara"+ aa',a e*a!a .erara"a' .e/$r$ka' k!&'

t=A &'tra-arter&a! O'#et *e!a# t&ak *a2

ANTI =LATELET AGENTANTI =LATELET AGENT CT #a' t&ak aa .erara"a' a!a 01 *a #ete!a" .e/er&a' t=A2 A#eto#a! ora! o# aa! 48 + #e!a'*$t',a 5> ;"ar&

=REVENSI=REVENSI

SEKUNDERSEKUNDER


STROKE HEMORAGIK

(PERDARAHAN INTRASEREBRALPIS SPONTAN)

S O

A$te #troke $#t /e treate a# a e&a! eere',2 = &k k!& & ! / ECG


84/108

STROKE

CT SCAN

SKOR

STROKE

=eer&k#aa' k!&'+ !a/+ ECG2

ABC > B5 I't$/a#& e'otrakea! /&!a =O0 J 8 H;5+ k=a ata$ =CO0 >8

H;+< k=a+ #a'o#+ &.e'&'’ aa! 'a%a#+ ata$ a'aa'

a#.&ra#&25 E$:o!e& #tat$# /er&ka' NaCL 8+6+ r&'er !aktat;a#etat+ "&'ar&

ektro#a+ .a'ta$ $r&'e o$t.$t25 Detek#& .e/$r$ka' e%&t 'e$ro!o&k %oka!;%oka! - $$25 Detek#& ta'a tra$a ka.&t ka$#a tra$a2

5 =a'ta$ ta'a :&ta! #tat$# 'e$ro!o #e!aa 01 50 *a25 =a'ta$ #tat$# &&+ a!'$tr& aka' e'"a/at .e$!&"a'2 Ne$ro .rotek#&2 =rora %&otera.& re"a/&!&ta#&2 =e'ea"a' a' .e'a'a'a' ko.!&ka#&+ %aktor r&ko+ a'

.e',ak&t;a'$a' .e',erta ata$ ka$#a2

STROKE ISKEMIK STROKE HEMORAGIK

(= I S)

TIDAK 3A


STROKE HEMORAGIK

(= I S)


85/108

MANAGEMEN TEKANAN DARAHANAGEMEN TEKANAN DARAH

HI=ERTENSI Teka'a' ara" o.t&$ &'&:&$a!2 A't& "&.erte'#& /&!a MA= 4 ;*a &2:2 &'%$#+ &t&'katka' 0+> ;*a t&a. 4> e'&t #a.a& o# ak#&a! 4> ;*a2 D&!t&ae > 18 ;k;e'&t &'%$# ko't&',$2 N&tro.r$##&e 8+0> 8+> ;k;e'&t &2:2 &'%$# t&tra#& &t&'katka' 8+> ;k;e'&t+ o# ak#&a! 48

;k;e'&t (*&ka SB= 0 ;k;'t I+: &'%$#+ &t&'katka' #a.a& > 48 ;k;'t2 Do/$ta&' > 4> ;k;'t &2:2 &'%$#+ &t&'katka' #a.a& 18 ;k;'t2

STROKE

HEMORAGIK

(= I S)


86/108

MANAGEMEN

ANAGEMEN

OPERATI

PERATI

Ko'#$! Bea" #ara%2 Ka'&at o.era#& (reo:a! o%

"eatoa)=erara"a' #ere/e!$ <

+ e'a' eter&ora#&

'e$ro!o&k+ ko.re#& Bra&'

#te "&ro#e%a!$# ak$t2=IS e'a' e%ek e#ak+

e'a' ke$'k&'a'

Goo o$toe2U#&a $a e'a'

.erara"a' !o/ar

oerate-!are’

eter&ora#& k!&'

MANAGEMEN

ANAGEMEN

CAIRAN

AIRAN

Goa! E$:o!e&a2 O.t&a! CV= =W=2 488 0088 !;"r2 Korek#& e!ektro!&t /&!a

&.er!$ka'2

MANAGEMEN

ANAGEMEN

KE@ANG

E@ANG

B&!a .er!$ a't& ko':$!#&

/&!a ke*a' ata$

e'ea" ke*a'2 Fe'&to&' !oa&' o#e 47

(4> 08) ;k


87/108

MANAGEMENANAGEMEN

SUHU BADAN

UHU BADAN

H&.erter&a Coo!&' B!a'ket2 Ie Water a#tr&

!a:ee2 =araetao!

&2:;ora!;reta!2

MANAGEMEN ICPANAGEMEN ICP

MENINGKAT

ENINGKAT

IC= 08 H > e'&t2 Goa! IC= J 08 H C== 58 H2 O#otera.&

Ma''&to! 4> 0>6 8+0> 0 ;k &2:2 &'%$#


88/108

OPERASI DEKOMPRESI J

=. Ting7a! 7sadaran/


89/108

=. Ting7a! 7sadaran/

Ksadaran $nurun ?sopor 1 7o$a@9G'S , oprasia!au !ida7 oprasi ang7a 7$a!ian !!ap !inggi ?J5= H@, 7&ua#i #if sa3ing surgry pada G'S <dngan 7o$prsi 6a!ang o!a7 dari prdara%ansr6#u$.

;. T$pa! #si/

+$a!o$ 6sar di sr6#u$ a!au su6s!ansia a#6asu67or!i7a#9#o6ar dngan p$6uru7an 7unis &pa!.. )na$pang %$a!o$/

: &$, 7%ususnya prdara%an sr6#u$.


90/108

+EMATOM

A

(I'

ATION

)u!a$n

T%a#a$us

Su6&or!C

)ons

'r6##u$

A#r!, %$a!o$a $#.

+$a!o$a 3o#u$ : $#

Sopor &o$a, : 0 $#

(p &o$a,

......

.(ro>sy 9 #!%argi&, ; 5 0$# ...

*oung, progrssi3 d8&i!s .

Ad3an&d ag ...

.......+$a!o$a : &$ dia$!r

5

5

5

5

* ecommended - * not recommended * uestionable

"(. +isher8 :0%


CLASI ICATION O SUBARACHNOID HEMORRHAGE

WORL( -E(ERATION O-NEUROLOGI'AL SURGEONSGRA(E

+UNT AN( +ESS 'LASSI-I'ATIONS'ALE


91/108

GRA(E S'ALE

W-NSGRA(E

G'S MOTOR(E-I'IT

GRA(E NEUROLOGI'AL STATUS

I

II

IIII"

"

=D

=< 1 =

=< 1 ==; 1 J

0 1

A6sn!

A6sn!

)rsn!)rsn! ora6sn!

)rsn! ora6sn!

I

II

IIII"

"

Asy$p!o$a!i&, or $ini$a#%ada&% and s#ig%!

nu&%a# rigidi!y.Modra! !o s3r%ada&%, nu&%a# rigidi!yno nuro#ogi& d8&i! C&p!&rania# nr3 pa#sy.

(ro>sy, $ini$a# nuro#ogi&d8&i!.

S!uporous, $odra!5!o5s3r %$iparsispossi6#y ar#y d&r6ra!rigidi!y and 3g!a!i3dis!ur6an&s.

(p &o$a, d&r6ra!

rigidi!y $ori6undaparan&.

SUBARACHNOID HEMORRHAGE OUTCOME OUTCOME ALGORITHM

S A HS A H


92/108

WFNSWFNS

GRADE I IIIGRADE I III

CLI= ; COILCLI= ; COIL

S A HS A H

WFNSWFNS

GRADE IV VGRADE IV V

CEREBRALCEREBRAL

VASO=ASMVASO=ASM

FUNCTIONALFUNCTIONAL

INDE=ENDENCEINDE=ENDENCE

WFNS GRADE II IIIWFNS GRADE II III

AFTER SURGER3 FORAFTER SURGER3 FOR

HEMATOMA ORHEMATOMA OR

VENTRICULOSTOM3VENTRICULOSTOM3

INDETERMINATEINDETERMINATE =OOR UTCOME=OOR UTCOME

3ES 3ES 3ES 3ES

NONO

NONO

NO ASISTANCE NEEDED+NO ASISTANCE NEEDED+

MINOR HANDICA=MINOR HANDICA=

SEVERE DISABILIT3+SEVERE DISABILIT3+

VEGETATIVE STATE+VEGETATIVE STATE+

OR DEATHOR DEATH

(E2F2N2 W&*&k#+ 088


93/108

PROGNOSTICATOR O POOR OUTCOME

D - years.

le7el o8 #on#iousness a8ter i#tus )ea#hgrade.

?imb paresis )ea#h grade.

6ypergli#emia a8ter i#tus.

9C6 Blood 7olume D $ ##.

9V6 blood 7olume D 2 ##. idline shi8t o8 septum pellu#idum!pineal

gland )$ & " mm on CT s#an.

,#ute hydro#ephalus )putaminal hemorrhage"Da!erat et al8 00E +ieschi et al8 044E Phan et al8 :%


ISCHEMIC STROKE (ANTERIOR CIRCULATION):



94/108

?e7el o8 #on#iousness a8ter i#tus.

aEe palsy* gaEe pre8eren#e* pupillaryasymmetry.

6ypodensity D %( o8 arterial territory*brain s4elling* or early midline shi8t onCT s#an.

eed 8or reintubation and me#hani#al7entilation.

"7i1dicks8 6cott8 03%.

ISCHEMIC STROKE (POSTERIOR CIRCULATION):


95/108


Basilar artery o##lusion #ausing lo#ked:in syndrome or #oma.

Cerebellar in8ar#tion 4ith brain stem#ompression and hydro#ephalus.

Bilateral thalami# in8ar#ts.

")adeau8 et al8 0:%.

B!oo .re##$re

Sok&' !&.&#Stroke orta!&t,

Ma## #trate, &' .o.$!at&o' A$te treate't


96/108

F&r#t e:er #troke=r&ar, =re:e't&o' Seo'ar, =re:e't&o'

H&"-rk #trate,I' &'&:&$a!

Re"a/&!&tat&o'

Re$rre't #troke

H,.erte'#&o'

TIA

Atr&a! %&/r&!at&o'

Ot"er :a#$!ar ea#e

Stroke-re!ate a/&!&t,


97/108


98/108

PENCEGAHAN


99/108

STROKE42=roo#& ke#e"ata'

02=e'ea"a' .r&er


100/108

STROKE PREVENTION

SECONAR! PREVENTION

PRI"AR! PREVENTION

STROKE CONTROL STRATEGY


101/108

NOR"A# RISK $ACTOR STROKE%TIA

& "OI$! #I$E&ST!#E - "OI$! #I$E&ST!#E

- CONTRO# O$ RISK $ACTOR

- "OI$! #I$E&ST!#E

- CONTRO# O$ RISK $ACTOR

- ANTI T'RO"(OTIC.

- T'RO"(ECTO"!.

- AN)IOP#AST! AN

STENTIN)

PRO"OTION PRI"AR! PREVENTION SECONAR! REVENTION

MODI Y

ODI Y

CONTROL O

ONTROL O

ANTI

NTI

THROMBECTO

HROMBECTO

ANGIOPLASTY

NGIOPLASTY


102/108

LI E-STYLEI E-STYLE RISKISK

ACTORS

ACTORS

THROMBOTIHROMBOTI

C

MYY ANDND

STENTING

TENTING

*.*.ietiet

+.+. Phy,icalPhy,ical

e-eci,e.e-eci,e.

/./.Ce,,ation o0Ce,,ation o0

,1oking.,1oking.

2.2.AlcoholAlcohol

eduction.eduction.

*.*.In1odi0iable.In1odi0iable.

+.+."odi0iable."odi0iable.

*.*.Anti platelet.Anti platelet.

+.+.Anti coagulant.Anti coagulant.

*.*.Sy1pto1aticSy1pto1atic

,teno,i, 345678.,teno,i, 345678.

+.+.A,y1pto1aticA,y1pto1atic

,teno,i, 39:678.,teno,i, 39:678.

*.*. Patient ;ith highPatient ;ith high

i,k ,y1pto1atici,k ,y1pto1atic

caoted ,teno,i,caoted ,teno,i,

o inopeableo inopeable

ca,e,.ca,e,.


103/108

Gaya %idup s%a!/

Mnga!ur po#a $a7an yang s%a!.

Mng%n!i7an ro7o7.

Mng%indari $inu$ a#7o%o# dan

pnya#a% guna7an o6a!.

O#a% raga !ra!ur.

Mng%indari s!rs dan is!ira%a!yang &u7up.


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PREVENSI SEKUNDER


105/108

4242 Mo&%&ka#& a,a "&$. a' %aktor r&ko2Mo&%&ka#& a,a "&$. a' %aktor r&ko2

0202 A't& =!ate!et ae'tA't& =!ate!et ae't

A#eto#a!;ASA ta/ 5> ;"ar&+ 4 ? I2A#eto#a!;ASA ta/ 5> ;"ar&+ 4 ? I2

ASA 0> ;D&.,r&ao!e 088 a. 0 ? I2ASA 0> ;D&.,r&ao!e 088 a. 0 ? I2

C!o.&ore! 5> ta/ 4 ? I2C!o.&ore! 5> ta/ 4 ? I2

T&!o.&&'e 0>8 ta/ 0 ? I2T&!o.&&'e 0>8 ta/ 0 ? I2

A#.&r&' 5> ta/ C!o.&ore! 5> ta/ 4 ? I2A#.&r&' 5> ta/ C!o.&ore! 5> ta/ 4 ? I2


106/108

Ca'a&a' Ne$ro!o&a! Sa!e2

Sa'&'a:&a' Ne$ro!o&a! Stroke Sa!e2

E$ro.ea' Stroke Sa!e2Ra'k&' Sa!e2

Bart"e! I'e92

O$tae a%ter oa2

COMACOMA

DEADDEAD SURVIVORSURVIVOR


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DE=ENDENTDE=ENDENT

(ASSISTANCE WITH =ERSONAL NEEDS)(ASSISTANCE WITH =ERSONAL NEEDS)INDE=ENDENTINDE=ENDENT

(LOCK AFTER THEMSELVES)(LOCK AFTER THEMSELVES)

MODERATEL3MODERATEL3

DISABLEDDISABLED

GOODGOOD

RECOVER3RECOVER3VEGETATIVEVEGETATIVE

STATESTATESEVEREL3SEVEREL3

DISABLEDDISABLED

=ERSISTENT=ERSISTENT

VEGETATIVE STATEVEGETATIVE STATELOCK-INLOCK-IN

S3NDROMES3NDROMEAKINETIC MUTISMAKINETIC MUTISM


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Documents

Stroke- Smtr 4