Case Report

Non Hemorrhagic
Stroke
NUR RAHMAT
1708436412

Supervisor:
dr. RIKI SUKIANDRA, Sp.S

DEPARTMENT OF NEUROLOGY
MEDICAL FACULTY OF RIAU UNIVERSITY
ARIFIN ACHMAD RIAU PROVINCE GENERAL
HOSPITAL
2019
Patient’s Identity
▪ Name : Ny. SM
▪ Age : 44 years old
▪ Gender : Female
▪ Address : Payung Sekaki – Pekanbaru
▪ Religion : Moeslem
▪ Marital Status : Married
▪ Occupation : Entrepreneur
▪ Entry Hospital : May, 6th 2019
▪ Medical Record : 010147xx
 “
Feeling weakness half of the right body
side since 2 hours before admitted to
the hospital
Present Illness History
▪ 2 hours before admitted to the hospital, the patient
complained about half of his right body side from the
head to the feet feeling weakness suddenly. It happened
when she still took a rest. The patient still could walk but
by dragging his right foot. Still able to speak without any
difficulty to pronounce words and no complaints lips
stick to one side of the face and tongue deviation. She
also felt numb half of the her right body side.
Present Illness History
▪ 2 days ago before admitted to the hospital, patients complained
headache. Pain was felt throughout the head and neck which was
felt continuously. Pain did not diminish even though the patient had
taken self-purchased headache medicine. Headache was felt more
severe. Patients also complained nausea and sometimes
accompanied by vomiting. There were no complaining of seizures,
urinate and defecate problems.
Past Illness History
• Hypertension (+)

• Diabetes Mellitus (+) since 2014 without consume any

drugs of DM until now

• Seizure (-)

• History of trauma (-)

Family Disease History
• History of hypertension (+)
found from her mother

• History of DM (+) found from

her father
Socioeconomic History

History
Works as of
an Smoking
entrepren and
eur Alcoholic
(-)
Summary
Feeling
weakness half of
Patients
his right body side
complained
from the head to
Still able to speak headache. Pain
the feet
without any was felt
(hemiparese Patient have
difficulty to throughout the
dextra). Happened Diabetes Mellitus
pronounce words head and neck
suddenly when since 2014 and no
(dysarthria) and no which was felt
she still took a drugs is consumed
complaints lips continuously.
rest. Felt numb until now.
stick to one side of Complained
half of her right
the face. nausea and
body side
sometimes by
(paresthesia right
vomiting.
upper and lower
extremities).
Physical Examination (April, 15th 2019)

Generalized Condition Physical examination Neurological status

• BP : 180/100 mmHg • Neck : Normal limit • Consciousness:

• HR : 90 bpm • Thorax : Normal Composmentis
• RR : 20 x/minute limit • GCS : 15
• T : 36,8°C • Abdomen : Normal E4V5M6
• Weight : 95 kg limit • Noble Function
:Normal
• Height : 160 cm
• Neck Rigidity :
• BMI : 37,1 kg/m2
Negative
(obesity grade II)
 Cranial Nerves
CN. I (Olfactorius)
Right Left Interpretation
Sense of Smell Normal Normal Normal

CN. II (Opticus)

Right Left Interpretation

Visual Acuity > 3/60 >3/60
Visual Fields Normal Normal Normal
Not Not
Colour Recognition
tested tested
▪ CN III (Oculomotorius)

Right Left Interpretation

Ptosis - -
Pupil
Shape Round Round
Side Φ2mm Φ2mm Normal
Extraoculer movement + +
Pupillary reaction to light
Direct + +
Indirect + +
▪ CN IV ( Trochlearis)
Right Left Interpretation

Extraocular movement + + Normal

▪ CN V (Trigeminus)
Right Left Interpretation

Motoric Normal Normal

Normal
Sensory Normal Normal
Corneal reflex + +
▪ CN VI (Abduscens)
Right Left Interpretation
Eyes movement Normal Normal
Strabismus - - Normal
Deviation - -
 ▪ CN VII (Facialis)

Right Left Interpretation

Tic (-) (-)
Motoric
1. Frowning Normal Normal
2. Raised eye brow Normal Normal
3. Close eyes Normal Normal
4. Corners of the mouth Extracted (-)
5. Nasolabial fold
Deeper (-)
Sense of Taste Parese central type of left N.VII
Normal Normal
Chvostek Sign
(-) (-)
▪ CN VIII (Accousticus)
Right Left Interpretation
Hearing sense Normal Normal Normal

▪ CN IX (Glossopharyngeus)
Right Left Interpretation

Normal Normal
Pharyngeal Arch
Flavour sense
Normal Normal Normal

Gag Reflex
+ +
▪ CN X (Vagus)

Right Left Interpretation

Pharyngeal Arch Normal Normal
Normal
Dysfonia - -

▪ CN XI (accessorius)
Right Left Interpretation
Motoric Normal Normal
Trofi Normal Normal Normal
▪ CN XII (Hypoglossus)
Right Left Interpretation
Motoric Normal Deviation
Parese N.XII Sinistra
Trofi Eutrophy Eutrophy
Tremor - -
Disartria - -
 Motoric
Right Left Interpretation
Upper Extremity
Strength
Distal 5
3
Medial 5 3
Proksimal 5 3
Tonus Normal Normal Hemiparese sinistra
Trofi Eutrophy Eutrophy
Involunteer movement - (-)
(-)
Clonus
-
Lower Extremity
Strenght
Distal 5 3
Medial 5 3
3
Proksimal 5
Tonus Normal Normal
Trofi Eutrophy Eutrophy
Involunteer movement - (-)
Clonus - (-)
Sensory
Right Left Interpretation
Touch (+) (+) Normal
Pain (+) (+) Normal
Temperature Not applied Not applied -

Propioseptif
 Vibration Not applied Not applied -
 Position (+) (+) Normal
 Two point discrimination (+) (+) Normal

 Stereognosis (+) (+) Normal

 Graphestesia (+) (+) Normal

Reflex
Right Left Interpretation
Physiologic
Biseps (+) (+)
Physiologic reflex is
Triseps (+) (+)
Positive Normal
Patella (+) (+)
Achilles (+) (+)
Patologic
(-) (-)
Babinski
(-) (-) Patologic reflex (-)
Chaddock
(-) (-)
Hoffman Tromer
(-) (-)
Openheim
(-) (-)
Schaefer

Primitive Reflex
(-) (-) No primitive reflex
Palmomental
(-) (-)
Snout
 Coordination
Right Left Interpretation
Point to point movement (+) Not tested Non interpretable

Walk heel to toe (+) Not tested Non interpretable

Gait Not tested Not tested Non interpretable
Tandem Not tested Not tested Non interpretable
Romberg Not tested Not tested Non interpretable
 Autonomy System

• Urinate : Normal
• Defecation : Normal
 Other Examination

• Laseque :Not limited

• Kernig :Not limited
• Patrick : -/-
• Kontrapatrick : -/-
• Valsava test : -
Working Diagnose
Clinical diagnose • Symptomatic Epilepsy

Topical diagnose • Intracranial (Carotid system)

Etiological diagnose • Post Haemmorrhage Stroke

• Idiopathic Epilepsy
Differential diagnose • Post craniotomy surgery

Secondary Diagnose • Hypertension Grade II

GAJAH MADA STROKE ALGORITHM

GAJAH MADA STROKE ALGORYTHM (ASGM)

Loss of conciousness (+) Headache (+) Babinski reflex (-)

Hemorrhage stroke

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Suggestion Examination

Lab Study Imaging study

• Blood routine • Chest X-Ray
• Head CT-Scan (non contras)
• Blood Glucose Profile • Electroencephalogram (EEG)
• Electrolyte
• Cholesterol profile
 Management
Non pharmacologic therapy
• Bed rest
• Airway Management
• Nasal Canule O2 2-4 l/minute
• Observe seizure

Pharmacologic therapy
• IVFD RL 20 dpm
• Injection Phenytoin 3 x100 mg
• Injection Diazepam 10 mg prn iv
• Injection Citicolin 2 x 500mg iv
• Injection Ranitidin 2 x 30 mg iv
• Captopril 150 mg po
• Aspilet 2 x 80 mg po
Laboratory
Blood routine (April, 15th 2019)
▪ Hb : 11,8 g/dL
▪ Leucocyte : 5.600/mm3
▪ Trombocyte : 350.000/uL
▪ Hematocryte : 35,4%
▪ Interpretation : Mild anemia
Laboratory
Blood Glucose Profile Chemistry (April, 15th 2019)
▫ Glucose : 133 mg/dl
Electrolyte (April, 15th 2019)
▫ Na : 145 mmol/L
▫ K : 2,30 mmol/L

▪ Interpretation : hypocalemy
Laboratory
▪ Renal Function
• AST : 21 U/L
• ALT : 19 U/L
• Ureum : 19 mg/dL

Interpretation: in normal limiteed

32
Imaging Study

Interpretation :
Interpretation : Post craniotomy dextra and lession in dextra lobe
Cardiomegaly

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 HAEMMORRHAGE STROKE +
POST CRANIOTOMY +
HYPERTENSION GRADE II + MILD
ANEMIA+ HYPOKALEMIA

FINAL DIAGNOSE
 S O A P
Seizure (-) fever (- CM, GCS 15 Symptomatic Continue therapy
) left extremities BP : 170/100 mmHg Epilepsy ec Pottasium chloride
felt heavy, speech Parese N VII & XII Haemmorrhagee 3x1 tab
difficult Hemiparese sinistra Stroke Ranitidine stop
Motoric 555/333 Hypertension Topiramate 1x1
April 16th 2019 555/333 grade II+ mild Observe seizure
anemia+ Suggested to do
hypokalemia physiotheraphy
Suggested to
consul nutrisionist

Seizure (-) fever (- CM, GCS 15 Symptomatic Continue therapy

) headache (-) left BP : 170/100 mmHg Epilepsy ec Check lipid profile
extremities felt minimal parese N Haemmorrhagee Consultation with
easier, irritation on VII & XII Stroke dermatologyst
April 17th 2019
both of hand and Hemiparese sinistra Hypertension Observe seizure
the back Motoric 555/333 grade II+ mild
555/333 anemia+
hypokalemia
 S O A P

“
Seizure (-) fever (-) CM, GCS 15 Symptomatic Continue therapy
headache (-) left BP : 162/90 mmHg Epilepsy ec Candesartan 8 mg
extremities felt Parese N VII & XII Haemmorrhagee 1x1
easier, irritation on Hemiparese sinistra Stroke Observe seizure
both of hand and Motoric 555/333 Hypertension Ketoconazole tab
the back 555/333 grade II+ mild 1x200 mg
Co dermatologyst: anemia+ Ketoconazole cream
April 18th 2019 (+) : cutan hypokalemia 2x1
candidiasis

Lipid profile: total

choleterol: 149/
HDL: 19/ LDL: 92,0
TGL: 193 (>>), uric
acid 8 (>>)
Seizure (-) fever (-) CM, GCS 15 Symptomatic Continue therapy
headache (-) left BP : 160/90 mmHg Epilepsy ec
extremities felt minimal parese N VII Haemmorrhagee
easier, irritation on & XII Stroke
April 19th 2019
both of hand and Hemiparese sinistra Hypertension
the back Motoric 555/333
36 grade II+ mild
555/333 anemia+
 “
S O A P
Seizure (-) fever (- CM, GCS 15 Symptomatic Continue therapy
) left extremities BP : 154/90 mmHg Epilepsy ec
felt heavy, speech Parese N VII & XII Haemmorrhagee
difficult , irritation Hemiparese sinistra Stroke
April 20th 2019 on both of hand Motoric 555/333 Hypertension
and the back 555/333 grade II+ mild
anemia+
hypokalemia

Seizure (-) fever (- CM, GCS 15 Symptomatic Continue therapy

) headache (-) left BP : 160/100 mmHg Epilepsy ec
extremities felt minimal parese N Haemmorrhagee
easier, irritation on VII & XII Stroke
April 21th 2019
both of hand and Hemiparese sinistra Hypertension
the back Motoric 555/333 grade II+ mild
555/333 anemia+
hypokalemia

37
 “
S O A P
Seizure (-) fever (- CM, GCS 15 Symptomatic Patient discharge
) left extremities BP : 160/90 mmHg Epilepsy ec Consultation with
felt heavy, speech Parese N VII & XII Haemmorrhagee psychiatric (09.00)
difficult , irritation Hemiparese sinistra Stroke
on both of hand Motoric 555/333 Hypertension Therapy from
April 22th 2019 and the back 555/333 grade II+ mild psiciatric:
reduced, anxious anemia+ Fluoxetine 1x10
with his disease Consultation (+) hypokalemia mg (at night)
11.00:
Complete anxiety
disorders

38
 ▪ “
Post hospitalalization therapy
Candesartan 1 mg 1x1 tab
▪ Citicoline 500 mg 1x1 tab
▪ Fenitoin 100 mg 3x1 tab
▪ Aspilet 2x1 tab
▪ Topiramate 1x1 tab
▪ Fluoxetin 10 mg 1x1 (at night) tab
▪ Ketoconazole 1x200 mg tab
▪ Ketokonazole cream 2x1

39
EPILEPSY
A chronic brain disorder characterized by
repetitive unprovoked seizures more than two times
in more than 24 hours in less than 6 months, which result
from paroxysmal uncontrolled discharges of neurons
within the central nervous system
41
42
pathophysiology
Classification of Epilepsy ILAE 1981

44
Classification of Epilepsy ILAE 1981

45
46
 Etiology of Epilepsy

Idiopathic

Symptomatic

Cryptogenic
48
49
DIAGNOSE

MRI
PHYSICAL EEG
HISTORY EXAMINATION

50
THERAPY
IDIOPATHIC

VPA, LTG, CLB,CZP, ESM

CBZ, VPA, LTG, TPM,

FOCALL GENERALIZED

CBZ, VPA CLB, PHT, VPA, TPM, CLB, PHT, PB

PB

SYMPTOMATIC
EEG Primer 1999. h. 245-59 Harvey, 2001
53
 A man, 59 years old

History
Iinitial subjective feeling, loss of Diagnosed by Non haemmorraghe stroke
Focal Seizure, 9 times
consciousness, discognitive 7 months ago

Physical examination
Hypertension Grade II Parese central type N. VII & XII sinistra Hemiparese sinistra

Symptomatic Epilepsy
Basic of topic diagnosis

Anamnesis

Seizure Weakness on left extremities

Physical examination

Hemiparese sinistra

Intracranial (Carotid System)

 A man, 59 years old

History
No headache, loss consciousness after
Weakness on left extremities Hypertension
seizure

Physical examination
Gajah Mada Stroke Algorithm Siriraj Score -5

Post non haemmorrhage stroke

Basic differential diagnosis

Idiopathic
Epilepsy
Basic final diagnose

Anamnesis Physical Head CT

examination Scan
• Focal Seizure • Hypertension • Old infarct
• Weakness of • Hemiparese on right
left extremity sinistra frontapariet
• Occurred • Parese N.VII al lobes,
when he in atrophy
resting & XII
cerebri
• speech
diffilties
Basic treatment

• Bedrest : maintain the adequate

circulation to the brain
Non • Airway management : Maintain
Pharmacology adequate airway
• O2 2-4 l/minute : well-perfusion

59
Phamacology
•IVFD NaCl 0,9% 20 dpm is to maintain the euvolemic condition.
•Inj Phenytoin 3 x100 mg Normal Saline 20 ml iv to prevent any
seizure
•Inj Diazepam 10 mg iv prn to manage seizure
•Amlodipine 1 x 10 mg to maintain his blood pressure
•Inj citicoline 3 x 500 mg iv is as the neuroprotector
•Aspirin 2x80 mg p.o is to releave thrombocyte, platelet
aggregation and adhesion by suppressing A2-Thromboxane.
•Ranitidine Inj. 2 x 50 mg per IV as the gastricprotector.

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 THANK YOU

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