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Department of Neurology Faculty of Medicine, Syiah Kuala University Banda Aceh, March 29, 2011
ACUTE STROKE
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STROKE
The third leading cause of death The leading cause of serious, long-term disability Indonesia : Riskesdas Depkes RI, 2007 Prevalence of stroke 8,3 per 1.000 people Mortality : stroke 15,4%, hypertensive 6,8% & ischemic heart disease 5,1% Stroke Statistics,U.S. Statistics, 2010 143,579 people die each year from stroke Each year, about 795,000 people suffer a stroke About 600,000 of these are first attacks, and 185,000 are recurrent attacks
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STROKE
A major economic burden on healthcare system Incidence is expected to increase 25% by 2050 Ischemic stroke, when arteries are blocked by blood clots (emboli) or by the gradual build-up of plaque other fatty deposits. (Approximately 80% of stroke are ischemic) Hemorrhagic stroke, occur when a blood brain breaks leaking blood into the bain.
KLASIFIKASI
Patologi Anatomi
Stroke Iskemik
Stroke Hemoragik
Perjalanan Klinis
Transient Ischemic Attack Reversible Ischemic Neurological Defisit Stroke In-evolution Komplit Stroke Stroke Sirkulasi Serebral Anterior Stroke Sirkulasi Serebral Posterior
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Sirkulasi Serebral
STROKE
Hemorragic Stroke
Ischemic Stroke
Ischemic Stroke
Ischemic Stroke
ISCHEMIC STROKE
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Pathophysiology
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CBF
50.9 cc/ 100 gr otak/menit Daya cadang serebrovaskuler Kehilangan fungsi Aktifitas listrik otak terhenti Kematian sel saraf
CBF
35 40 cc 20 35 cc < 10 20 cc
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3/ 4/ 2011
EDEMA FORMATION
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Anatomy of Stroke
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Tekanan darah
Reflek patologi (babinsky) Sumber trombus/emboli CT Scan/MRI otak Pemeriksaan Penunjang
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Diagnostic Supports
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Coronal orientation: in a slice dividing the head into front and back halves. Sagittal orientation: in a slice dividing the head into left and right halves. Axial orientation: in a slice dividing the head into upper and lower halves.
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Left: diffusion-weighted MRI in acute ischemic stroke performed 35 minutes after symptom onset. Right: apparent diffusion coefficient (adc) map obtained from the same patient at the same time. 25
Diffusion-perfusion mismatch in acute ischemic stroke. The perfusion abnormality (right) is larger than the diffusion abnormality (left), indicating the ischemic penumbra, which is at risk of infarction.
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Left: Perfusion-weighted MRI of a patient who presented 1 hour after onset of stroke symptoms. Right: Mean transfer time (MTT) map of the same patient.
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CT SCAN : BRAIN
CT scan Gold Standard
Ischemia, Infarction (Size, Location) Edematous (Midline Shift)
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CEREBRAL ANGIOGRAPHY
(Cerebral Angiogram, Cerebral Arteriogram, Digital Subtraction Angiography [DSA])
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ECHOCARDIOGRAM
Examines the heart through the chest (called transthoracic echocardiogram, or TTE), and one that examines the heart through the throat (called transesophageal echocardiogram, or TEE)
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ELECTROCARDIOGRAM
(EKG, ECG)
Atrial fibrilation CAD, Ischemic heart disease Infarct myocard (acute, acute) RBB, LBB LVH, RVH T inversion; Q pathology;
ST depretson; ST elevation
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LABORATORY TEST
Blood routine, Glucose, Lipid Profile, Uric Acid Fibrinogen, Agregation of Trombocyte,INR Protein C, S; Anticardiolipin Antibody (ACA)
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Neuro-Pharmacology Intervention
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Neurocritical Care Intervention Optimization of medical treatment is key in the care of the stroke patient and we should be cautious when prognosticating early in the setting of acute stroke and be aware of the potential effect do not resuscitate status may have on patient outcome
J NeuroIntervent Surg 2011;3:34-37
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TIME IS BRAIN
Prehospital Management Hospital Management Emergency Medical Service Facilities for Emergency Stroke Care
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TIME IS BRAIN
Medical emergency, early hospital management Time depedent therapy
Acute therapy Comprehensive risk factor management (antihypertensive therapy, early rehabilitation, discharge planning)
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TROMBOLYSIS rt-PA
Intravenous Recombinant Tissue Plasminogen Activator
The engine for emergency stroke Beneficial within 3 hours of stroke onset
(NINDS 1995, PROACT II study 1999, National Stroke Foundation 2007, AHA/ASA 2007)
Anticoagulant Therapy
After the onset of stroke (emboli )(3 8 hours)
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Autoregulation of cerebral blood flow in a normal brain and in the ischemic penumbra (the tissues surrounding the ischemic core after a stroke)
In the normal brain, cerebral blood flow is kept at 50 mL/100 g per minute, despite continuous fluctuations of mean blood pressure between 70 and 120 mm Hg (continuous line). Any increase in pressure leads to vasoconstriction and any decrease to vasodilation, which prevents the risk of cerebral hyper- and hypoperfusion, respectively. Above and below the limits of cerebral blood flow autoregulation, cerebral perfusion passively follows the perfusion pressure. In the ischemic penumbra, tissue perfusion follows perfusion pressure (dashed line): any fall in blood pressure may precipitate ischemia, while an increase in blood pressure may 43 cause edema and hemorrhagic transformation. CMAJ, March 1, 2005; 172 (5)
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Anti-hypertensive Medications in the Acute Ischemic Stroke Mostly as mono-therapy was common among a history of hypertension Angiotensin-converting enzyme inhibitors (ACEI) 65 (45.6%) Diuretics 41 (34.5%) ACEI were used in combination with diuretics in 29 (23.4%) In Cochrane review found no evidence that giving calcium antagonists after an ischemic stroke saves lives or prevents disabilities.
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9. 10.
Rapid onset of action Predictable dose response Titratable to desired BP Minimal dosage adjustment Minimal adverse effects Easy conversion to oral agents Acceptable cost-to-benefit ratio Does not impair blood flow to vital organs (No sudden dips in BP; Does not decrease cardiac output) Does not increase ICP Normalizes CBF autoregulatory curve
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Hemorragic Stroke
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HEMORRAGIC STROKE
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Pemeriksaan Penunjang
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MANAGEMENT
Management Kesadaran Menurun Perdarahan Intraserebral Perdarahan Subarakhnoid Perawatan Intensive Perawatan Intensive
Tekanan Darah
Pemeriksaan NeuroDiagnostik Medikamentosa/Operatif
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BRAIN CT SCAN
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BRAIN CT SCAN
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Terimong geunaseh...
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