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Definisi Stroke
Modifiable
Hypercholesterolemia
Cigarette smoking
Non modifiable Arterial hypertension
Age Diabetes Mellitus
Gender Hyperhomocysteinemi
Ras a
Herediter Alcohol abuse
Oral contraceptive
Menopause
Physical inactivity
Obesity
Atrial Fibrillation
Hipercoagulability
Risk Factors for First Ischemic Stroke
Modifiable, value established:
Hypertension
Cardiac disease
Atrial Fibrillation
Infective endocarditis
Mitral stenosis
Recent large myocardial infarction
Cigarette smoking
Sickle cell disease
Transient ischemic attacks
Asymptomatic carotid stenosis
Nonmodifiable Potentially
Age
modifiable
Diabetes mellitus
Gender
Hereditary/famili Hyperhomocysteine
al factors mia
Race/ethnicity
Leftventricular
Geographic hypertrophy
location
Less well-documented risk factors Potentially
modifiable
Elevated blood cholesterol and lipids
Cardiac disease
Cardiomyopathy
Segmental wall motion abnormalities
Nonbacterial endocarditis
Mitral annular calcification
Mitral valve prolapse
Valve strands
Fibrin formation and fibrinolysis
Fibrinogen
Anticardiolipin antibodies
Genetic and acquired causesSubclinical diseases
Intimal-medial thickness
Aortic atheroma, Ankle-brachial blood pressure ratio,
Infarct like lesions on MRI, Socioeconomic features, Non
modifiable : Season and climate
Less well-documented risk factors
Potentially modifiable (cont.)
Spontaneous echocardiographic contrast
Aortic stenosis
Patent foramen ovale
Atrial septal aneurysm
Use of oral contraceptives
Consumption of alcohol
Use of illicit drugs
Physical inactivity
Obesity
Elevated hematocrit
Dietary factors
Hyperinsulinemia and insulin resistance
Acute triggers (stress)
Migraine
Hypercoagulability and inflammation
Gorelick, 2002
Insidensi:
Infark : Insidensi 80% - mortalitas 40%
50% - Thrombotic atherosclerosis
Large-vessel 30% (carotid, middle cerebral)
Small vessel 20% (lacunar stroke)
30% Embolic (heart dis / atherosclerosis)
Young, rapid, extensive.
Incidency : 70-85%
Classification :
1. TIA (transient ischemic attack) : < 24 hours
2. RIND (Reversible Ischemic Neurological
Deficits) normal between 24 48 hours.
Prolonge-RIND normal in max. 3 4 days.
3. Stroke in evolution : worsen stroke ( > 48 hours)
4. Stroke complete : permanent neurologic deficit
Definition of Ischemic Stroke
Almost 80% of strokes
are from an emboli or a
thrombus
Embolic & Thrombotic
strokes are ISCHEMIC
< 15% of strokes are
from hemorrhage, with
an even smaller
percentage caused by
hypoperfusion
2 process in ischemic stroke:
1. Vascular : Aterosclerotic process
2. Biochemistry change /cellular
chemist
Aterosclerotic is a normal response to arterial endotel
injury
Aterosclerotic plaque forming, start in young
Clinical manifestation : acute and tent to occur one
time because sudden plaque rupture
- Demensia - Contralateral limb weakness
- Ggn mood - Contralateral sensory loss
- Ggn perilaku - Disfasia
- Inkontinensia - Disleksia, disgrafia, diskalkulia
- disfungsi olfaktorius - Disorientasi spasial
- Disfungsi opticus
Hemianopsia
Homonim
Kontralateral
- Ggn bahasa
- Ggn memori Nistagmus
- Ggn mood Disartria
- Ggn perilaku Ataksia
- Ggn saraf kranial
- Ggn fx vital Tremor
inkoordinasi
(Wilkinson, 1997)
Komplikasi Stroke
Demensia Bronchopneumonia
Depresi Deckubitus
Kecacatan Septikemia
Epilepsi Trombosis vena
Kontraktur profunda
Peptic ulcer Emboli pulmo
Ggn keseimbangan
cairan
KONDISI STROKE ISKEMIK AKUT STROKE HEMORAGIK
(necrosis)
Dr.J.Husada 11-2003
Faktor Risiko Aterosklerosis
Proses aterosklerosis terjadi atau dipercepat dg adanya
faktor risiko yg mempengaruhi sel endotel, shg terjadi
disfungsi endotel
Teori lama :
Hipertensi, DM, perokok, kolesterol, oksidan, obesitas,
olah raga kurang,dll
Teori lama :
Mediate area are insuficiently supplied with blood, and they die
Cholesterol
Atheromatous Core
(size/consistency)
Diabetes
Mellitus Fibrinogen
Ketebalan /
konsistensi
Homocysteine
Inflamasi Impaired
Fibrinolysis
Plaque
Rupture
Fuster V, et al. N Engl J Med. 1992;326:310-318.
Falk E, et al. Circulation. 1995:92:657-671.
Multiple faktor risiko Aterotrombosis
Generalized Lifestyle
Disorders Smoking
Age Diet
Obesity Lack of exercise
Systemic
Conditions
Atherothrombotic Hypertension
Genetic Traits Hyperlipidemia
Gender Manifestations
Diabetes
PlA2 (MI, stroke, Hypercoagulable
vascular death) states
Homocysteinemia
Inflammation
Local Factors
Elevated CRP
Blood flow patterns
CD40 Ligand, IL-6
Shear stress
Prothrombotic factors (F I and II) Vessel diameter
Fibrinogen Arterial wall structure
% arterial stenosis
MI, myocardial infarction.
Adapted from Yusuf S, et al. Circulation. 2001;104:2746-2753.
Drouet L. Cerebrovasc Dis. 2002;13(suppl 1):1-6.
Progression of atherosclerosis
to arterial thrombosis
Plaque
Athero- Rupture/
Myocardial
Fatty Fibrous sclerotic Fissure & Infarction
Normal Streak Plaque Plaque Thrombosis
Ischemic
Stroke
Critical Leg
Ischemia
Increasing Age
Atherosclerosis and Thrombus Formation
Risk of a second vascular event
Increased risk vs general population (%)
*Sudden death defined as death documented within 1 hour and attributed to coronary heart disease (CHD)
Includes only fatal MI and other CHD death; does not include non-fatal MI
1. Adult Treatment Panel II. Circulation 1994; 89:133363. 2. Kannel WB. J Cardiovasc Risk 1994; 1: 3339.
3. Wilterdink JI, Easton JD. Arch Neurol1992; 49: 85763. 4. Criqui MH et al. N Engl J Med 1992; 326: 3816.
Major clinical manifestations
of atherothrombosis
Ischemic Transient ischemic
stroke attack
Myocardial Angina:
infarction Stable
Unstable
Peripheral arterial
disease:
Intermittent claudication
Rest Pain
Gangrene
Necrosis
Sumbatan
Aliran darah Penurunan CBF
Iskemia
Nekrosis
neuron
ATP, merubah
permeabilitas membran
Kerusakan
membran
Influks Ca+
berlebihan
Oleh karena ruptur aneurisma, angioma, lesi
aterosklerotik
Definition:
Intracerebral
hemorrhage (ICH)
results from the rupture
of an intracerebral vessel
leading to the
development of a
hematoma in the
substance of the brain.
Subarachnoid Hemorrhage: Intraventricular Hemorrhage:
Vasospasme Process on Haemorrhage
vasoconstrictor agens & blood componen release
Vasospasme
Lumen stronge
vasculer Vasospasme
Iskemia
Influks Ca+
global
Nekrosis
Iskemia Fokal
Neuron
(Zauner, 2002)
Apoptosis
Sitotoksik
Vasogenik
EDEMA SEREBRI
Interstisial
Cerebral edema
Blood Vessels in the Brain
CONTROL CENTER OF BRAIN
Anterior Cerebral
Artery
Much rarer
The classic
presentation is
proximal arm/
leg weakness
with present of
distal strength,
the so-called
man in a barrel
CEREBRI MEDIA ARTERIES
Characterized by
Middle weakness of the
contralateral face with
Cerebral Artery hemianopsia and a
preference of the eyes and
head toward the side of the
involved hemispere
Aphasia in dominant
hemisphere injury
Hemineglect
Involvement restricted to
branches of the MCA may
produces fragment of this
syndrome sparing of leg
strengh
Involves the brainstem,
cerebellum, thalamus &
occipital lobes
Present with bilateral limb
weakness or sensory
Posterior Cerebral Artery disturbances, cranial nerve
defisit, ataxia, nausea, and
vomiting or coma
occlusion of the basilar
artery trunk : Present with
hemianopia, memory
disturbance, mild
personality disturbance
Rarely; bilateral thalamus
: a state of decreased
responsiveness and apathy
without motor, sensory or
visual impairment
LENTICULOSTRIATE ARTERIES
Anatomy Stroke.
Functional Areas of the Brain
Back
Mungkin sulit dipercaya bahwa di dalam otak tersimpan
informasi mengenai segala hal yang mengatur kelangsungan
hidup manusia
Brain Stem Stroke: Common Pattern
Pure Motor - Weakness of face and limbs on one side
of the body without abnormalities of higher brain
function, sensation, or vision (MCA/ACA)
Pure Sensory - Decreased sensation of face and limbs
on one side of the body without abnormalities of
higher brain function, motor function, or
vision (PCA).
Brain Stem / Cerebellum / Post Hemisp.
Patterns.
Carotid Territory
Internal Carotid Artery
proximal MCA
proximal ACA
Vertebrobaciliar Territory
Vertebral Artery
Basilar Artery
Proximal PCA
A.Carotis interna
A.Coroidea anterior a.Komunikans posterior
Talamus dan ganglia basalis
Non Neurological:
Infection : Respiratory, Urinary, Septicaemia
Metabolic : Dehydration, Electrolyte Disturbance,
Hypoglycaemia
Drugs : Major and Minor Tranquillizers, Baclofen,
Lithium Toxicity, Antiemetics
Hypoxia : Pulmonary Embolism, Chronic Pulmonary
Disease, Pulmonary Oedema
Hypercapnoea: Chronic Pulmonary Disease
Others : Limb or Bowel Ischaemia in Patients with a
Cardiac or Aortic Arch Source of Embolism
Neurological:
Progression/completion of the stroke
Extension/early recurrence
Haemorrhagic transformation of an infarct
Development of oedema around the infarct or haemorrhage
Obstructive hydrocephalus in patients with stroke in the
posterior fossa, or after subarachnoid haemorrhage
Epileptic seizures
Delayed ischaemia (in subarachnoid haemorrhage)
Incorrect diagnosis :
Cerebral Tumour - Cerebral abscess
Encephalitis - Chronic Subdural Haematoma
Subdural empyema
A.Carotis interna
A.Cerebri anterior a.Cerebri media
Talamus dan ganglia basalis Bagian terbesar dari korteks
lateral(frontal,temporal dan
parietal)
A.basilaris
A . Cerebri posterior D/S
Sisi medial lobus temporal
Bag.belakang sisi bawah
lobus temporal
Bag.medial &bag.terbesar
dari lobus occipital
Large Vessel Stroke
Hemianopsia
Homonim
Kontralateral
- Ggn bahasa
- Ggn memori Nistagmus
- Ggn mood Disartria
- Ggn perilaku Ataksia
- Ggn saraf kranial
- Ggn fx vital Tremor
inkoordinasi
(Wilkinson, 1997)
Komplikasi Stroke
Demensia Bronchopneumonia
Depresi Deckubitus
Kecacatan Septikemia
Epilepsi Trombosis vena
Kontraktur profunda
Peptic ulcer Emboli pulmo
Ggn keseimbangan
cairan
KONDISI STROKE ISKEMIK AKUT STROKE HEMORAGIK
AVM :
Kelainan kongenital, yaitu adanya pola embrionik
pembuluh darah yang menetap (tidak berkembang),
bukan suatu neoplasma yang terdiri dari pembuluh
darah yang melebar dan kacau (anyaman pembuluh
darah) yang terbentuk dari hubungan eksternal
antara sistem arteri dan sistem vena, karena tidak
terbentuknya sistem kapiler yang
menghubungkannya
(Adam, et.al, 1997)
(Gilroy, 1992)
(Selman & Ratcheson, 1991)
Kebutuhan Glukosa & Oksigen
CBF: 50 ml / 100 gr jar otak permenit.
Oksigen: 6 ml / 100 gr jar otak per menit untuk
substansia grisea dan 2 ml / 100 gr jar otak per menit
untuk substansia alba.
Kebutuhan oksigen: 19-23 ml / 100 gr jar otak per menit.
Kebutuhan glukosa: 4.5 - 7 mg / 100 gr jar otak per menit.
Otak: 20% dari seluruh output jantung, yaitu sekitar 800
ml / menit
A-V Malformation
Cause : anomali vascular intracranial
AVM : Aneurysma = 1:5.3 (US)
Gejala : haemorrhage, epilepsy, headache,
neurological deficit, cranial bruit,mass effect
Penunjang : CT scan, MRI,Angiography
Indikasi intervensi :
Expending haematoma
Risiko perdarahan
Defisit neurologic progresif
SAH - Anatomy
Gadjah Mada Stroke Algorithm
Patient admitted with sudden onset of stroke
with
Decreasing consciousness +, headache +, Babinskis reflex + yes HS
No
Decreasing consciousness +, headache +, Babinskis reflex - yes HS
No
Decreasing consciousness +, headache -, Babinskis reflex - yes HS
No
Decreasing consciousness +, headache -, Babinskis reflex + yes HS
No
Decreasing consciousness -, headache +, Babinskis reflex + yes HS
No
Decreasing consciousness -, headache +, Babinskis reflex - yes HS
No
Decreasing consciousness -, headache -, Babinskis reflex + yes AIS
No
Decreasing consciousness -, headache -, Babinskis reflex - yes AIS
Brain Blood
Monroe- Kellie Principle
CSF Mas
Bones
Gambaran skor
Awitan sangat mendadak 2
Perubahan bertahap 1
Perjalanan klinis berfluktuasi 2
Bingung malam hari 1
Kepribadian relatif baik 1
Adanya depresi 1
Keluhan somatik 1
Gangguan emosional 1
Riwayat hipertensi 1
Riwayat adanya stroke 2
Bukti adanya atherosklerosis 1
Adanya gejala neurologik fokal 2
Adanya tanda neurologik fokal 2
Common Stroke Patterns
Right (Non-dominant) Hemisphere Stroke
Extinction of left-sided stimuli
Left hemiparesis
Left-sided sensory loss
Left visual field defect
Poor left conjugate gaze
Spatial disorientation
Aneurysma
Ruptur aneurysma : 6-12 per 100000/th
Wanita : pria = 3:2
Umur : sering 40-60 th, jarang anak
> 40 th, wanita > pria
< 40 th, pria > wanita
Penyebab : congenital (defect T.media),
atherosclerotik/hipertensi,emboli,infeksi,trauma, dll
Tempat : 20-25% A.cerebri media
10% sirkulasi posterior
35-40% A.cerebri anterior
30% A.carotid interna
Aneurysma
Gejala :
Ruptur (90%) : NK(+),muntah,KK(+),penurunan
kesadaran,focal sign,kejang
Compression (7%) : visual defect, hipopituitarism,
parese anggota gerak, optalmoplegi, facial pain
Incidental finding (3%)
(21 67 %) (Adams, et.al, 1997)
(Listiono, 1998)
(Selman & Ratcheson, 1991)
(Toole, 1990)
Ti : - letak di frontal & temporal
- Lesi besar & melibatkan struktur kortikal (Litriono, 1998)
Sudden weakness, paralysis, or numbness of the face,
arm and the leg on one or both sides of the body
STROKE AKUT
Positif Negatif
Positif Negatif
Candesartan
O CH3 N N
N NH
HN N
COOH
(Perdossi, 2004)
Piracetam
Mechanism (neuronal)
Repair cell membran fluidity
Repair neurotransmission
Stimulation adenylate kinase
Mechanism (vascular)
Increase eritrocyte deformability
Decrease platelet hyperagregation
Repir microcirculation
(Perdossi, 2004)
METABOLISME CITICHOLIN & PERANANNYA DLM MEMPERBAIKI FUNGSI OTAK
PCCT
Hidrolisa
Cytidine Otak
Citicholine
diabsorbsi Citicholine
Choline Sintesa
1-2 DAG
Asetilasi Phosphatidilserin
Vaskularisasi
Lokal Acetylcholin Phosphatidiletanolamin Phosphatidilkolin
Ado Me
Betaine M
Methionin Phospolipid E
M
S-Adenosyl-L-homocystein B
Antioksidan
Glutation Cystein Homocystein R
A
N
R
E
1-2 DAG : 1-2 Diasil Gliserol P
A
I
PCCT : Cytidine triphosphat phosphocholine cytidylyl transferase
R
Melindungi Sel Memperbaiki Fungsi
Jaringan Neuron
Piracetam
Jaringan Serebrovaskuler
Piracetam mengurangi alir masuk Kalsium yang tidak normal ke dalam neuron & sel otot polos
pembuluh darah. Oleh karena itu, Piracetam mempengaruhi sistem saraf dan sistem
serebrovaskuler, dimana Piracetam memiliki efek sitoprotektif dan fungsional
CDP-cholin, pirasetam,
nimodipin, piritinol
CDP-cholin :meningkatkan neurotransmiter
dopaminergik, mengurangi asam radikal bebas,
memperbaiki kerusakan metab lipid mitokondria di
serebral akibat hipoksia
Pirasetam : meningkatkan cholinergik dan
neurotransmiter eksitatori amin (glutamat dan aspartat)
dlm jumlah dan fungsi, mengurangi radikal bebas,
memproteksi metab neuron.
Objective Stroke Rehabilitation
Occupational Therapy :
Fine movements of the hand
Arm function
Utilization of tools
Assistive devices
Ability to function independently
Speech Therapy :
Disorders of language
Disorders of articulation
Disorders of swallowing
Factors that Influence the Successfully
of Rehabilitation
Cause of stroke
Severity of stroke
Location
Age
Self motivation
Premorbide personality and mood
Family
Social economy
Specific deficit neurology
Onset, duration and intensity
Rehabilitation team
Rehabilitation Started
Stroke rehabilitation more effective when it started in first
day in hospital and the latest of 2-3 days after
onset.(Feigenson)
Stroke patients result emboli/trombosis without
complication need to mobilization within 2-3 days, but
stroke patients result subarahnoid hemorrhage have to stable
previously during 10-14 days before mobilization.(Swenson)
Stroke patients with intracerebral hemorrhage have to lie
down during 3 weeks.(Toole JF)
Purpose of Rehabilitation
Occupational Therapy :
Fine movements of the hand
Arm function
Utilization of tools
Assistive devices
Ability to function independently
Speech Therapy :
Disorders of language
Disorders of articulation
Disorders of swallowing
Factors that Influence the Successfully
of Rehabilitation
Cause of stroke
Severity of stroke
Location
Age
Self motivation
Premorbide personality and mood
Family
Social economy
Specific deficit neurology
Onset, duration and intensity
Rehabilitation team
Rehabilitation Started
Stroke rehabilitation more effective when it started in first
day in hospital and the latest of 2-3 days after
onset.(Feigenson)
Stroke patients result emboli/trombosis without
complication need to mobilization within 2-3 days, but
stroke patients result subarahnoid hemorrhage have to stable
previously during 10-14 days before mobilization.(Swenson)
Stroke patients with intracerebral hemorrhage have to lie
down during 3 weeks.(Toole JF)
Purpose of Rehabilitation