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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!
Pemerik aan #enunjang
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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
Pemerik aan #enunjang
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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
Meningkat pdekstremitas
kiri
Meningkat pdekstremitas
kiri
R.patologis 7ositi; pdekstremitas kiri
7ositi; pdekstremitas
kiri
7ositi; pdekstremitas
kiri
7ositi; pdekstremitas
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
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P T0F=S=0 0G=P T0F=S=0 0G=
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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
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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
$men?asa dara'
/asospasme
7
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@ediate area are ins$!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$rmasa %lak
b b! b i 4 b dS i d
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!terotrombosis4 -rombus!terotrombosis4 -rombus Superimposed Superimposed pada lak !terosklerotikpada lak !terosklerotik
da%ted !r"m Falk E et al, Cir*$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
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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
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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
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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$
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,a jah Ma a Str!ke Alg!rithm
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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
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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:;;)
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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:;;)
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( ) ( 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
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FFA production Glucose production
Hyperinsulinemia
DyslipidemiaT2D
SNS activityAbnormal Na +
handlin
HTN
Atherosclerosis
P t" i % d &@P t" i % d &@
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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
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F"*al Ne$r"l" i*al =m%airment %r"minent andF"*al Ne$r"l" i*al =m%airment %r"minent and
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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
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1;>
enatalaksanaanenatalaksanaan
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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;
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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
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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
%5ute stroke 5are4 eneral management%5ute stroke 5are4 eneral management
"amsudin, #&&
% k 4 l
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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
%5ute stroke 5are4 eneral management%5ute stroke 5are4 eneral management
"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
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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
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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
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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
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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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!F!S*!!F!S*!
F S=F S=
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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$sakan di area b"rder "ne %arietalistem%"ralis "le' arteri serebri media dantem%"ralis "le' arteri serebri media dan
arteri serebri %"steri"r arteri serebri %"steri"r
!asia n"mik !asia n"mik
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14>
Nama lain: a!asia n"minal a!asia amnestisNama lain: a!asia n"minal a!asia amnestis
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Broca’s Aphasia
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• Damage to Broca’s area alone is not enough to produceBroca’s aphasia
• Usually involves Broca’s area + surrounding areasincluding M1 & insula.
Wernicke’s Aphasia
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• Damage to Wernicke’s area alone is not enough toproduce Wernicke’s aphasia
• Usually involves Wernicke’s area + surrounding areasincluding MTG & angular gyrus.
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Transcortical Sensory Aphasia
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• Variable lesion patterns, mostly posterior to Wernicke’sarea
• Deficit tends to be transient evolving into anomic aphasia
Common area?
Transcortical Motor Aphasia
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• Damage often anterior and/or superior to Broca’s area
Global Aphasia
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• Tend to be large “peri-Sylvian” lesions• But smaller lesions can also cause global aphasia
-0. ! #!S*!-0. ! #!S*!Pira*etam 'ad a %"tential e!!e*t "n *" niti?ePira*etam 'ad a %"tential e!!e*t "n *" niti?e!$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
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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$etabolisme abnormal it. 1 A 12
!nemia dan neuropati akibat defisiensi dan$etabolisme abnormal it. 1 A 12
!nemia dan neuropati akibat defisiensi dan$etabolisme abnormal it. 1 A 12
!nemia dan neuropati akibat defisiensi dan$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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&
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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
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