Kuliah Strok Prof.aa Fk Umi

7/25/2019 Kuliah Strok Prof.aa Fk Umi

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STROKESTROKE

(CEREBROVASCULAR(CEREBROVASCULARATTACK)ATTACK)

CEREBROVASCULARCEREBROVASCULAR

DISEASESDISEASES

AMIRUDDIN ALIAHAMIRUDDIN ALIAH

DEPT.OF NEUROLOGY, DIVISION OFDEPT.OF NEUROLOGY, DIVISION OF

STROKE and NEUROVASCULARSTROKE and NEUROVASCULARDISEASESDISEASES

FAC.OF MEDICINE, HASANUDDIN UNIVERSITYFAC.OF MEDICINE, HASANUDDIN UNIVERSITY

STROKESTROKECVA = CEREBROVASCULARCVA = CEREBROVASCULAR

ATTACKSATTACKS

CVD = CEREBROVASCULARCVD = CEREBROVASCULAR

DISEASEDISEASE

STROKE SUDAH LAMA DIKENALSTROKE SUDAH LAMA DIKENAL

• < HIPPOCRATES ( S.M )< HIPPOCRATES ( S.M )

• SORANUS ( ! " #$! M )SORANUS ( ! " #$! M )

FAKTORFAKTOR

S%&' *a+ n &-'n/0d +/n-

. < HIPPOCRATES (B.C.)

. SORANUS (!1#$! A.C.)

DEFINITION

STROKE 2 -3/n/-a3 4an/5+%a%/'n '5STROKE 2 -3/n/-a3 4an/5+%a%/'n '5&a/n d6+57n-%/'n&a/n d6+57n-%/'n

5'-a33683'a336,a99a&+ and d:3'9+5'-a33683'a336,a99a&+ and d:3'9+

a-7%36 and 9&'&++/:36, 3a+%+ ; =a-7%36 and 9&'&++/:36, 3a+%+ ; =

*'7&+ '& nd+ >/%* da%*, -a7+d 6*'7&+ '& nd+ >/%* da%*, -a7+d 6

n'%*/n '%*& %*an :a+-73a& '&//nn'%*/n '%*& %*an :a+-73a& '&//n

STROK (GPDO)STROK (GPDO) 2 MANIF.KLINIK da&/ GGN FUNGSI SEREBRAL2 MANIF.KLINIK da&/ GGN FUNGSI SEREBRAL

(OTAK) FOKAL 8 GLOBAL, TIMBUL MENDADAK 8 CEPAT,(OTAK) FOKAL 8 GLOBAL, TIMBUL MENDADAK 8 CEPAT,

BERLSG ; = ?AM, ATAUBERLSG ; = ?AM, ATAU MAUT, TANPA PENYEBAB1MAUT, TANPA PENYEBAB1

PENYEBAB LAIN SELAIN GGN VASKULAR (4/+. T&a74aPENYEBAB LAIN SELAIN GGN VASKULAR (4/+. T&a74a+&&a3, /n5+/ @ 9+/'n)+&&a3, /n5+/ @ 9+/'n)

EPIDEMIOLOGYEPIDEMIOLOGY

PREVALENSI PREVALENSI Ind'n+/a (; %*) 2 ,$ 8 #. PDDK Ind'n+/a (; %*) 2 ,$ 8 #. PDDK ( +7&:/ KES.RT.#!=, YOGYA )( +7&:/ KES.RT.#!=, YOGYA ) UPG = PEND.P.SARAF YG DIRAAT 2 UPG = PEND.P.SARAF YG DIRAAT 2

STROKE ( RSU DADI, # " # )STROKE ( RSU DADI, # " # )

EROPA PEND.BARU8#. PDDK8THN EROPA PEND.BARU8#. PDDK8THN AMERIKA (USA) " $ RIBU AMERIKA (USA) " $ RIBU †/THN ok STRO†/THN ok STRO

PREVALENCE

• INDONESIA (; YRS) .$ 8 #. 9'973. (YOGYA ,#!= )

• Maa++a& = '5 /n9a%/n%+ a& STROKE (RSUD #1

• EUROPE NE PA 8 # POP8YEAR

• USA " $ DIED8YR -a7+d6 +%&'

EPIDEMIOLOGY (-'n%/n7d)EPIDEMIOLOGY (-'n%/n7d)

ANGKA KECACATAN No. 1 (TERTINGGI) ANGKA KECACATAN No. 1 (TERTINGGI)

dari SEMUA PENYAKITdari SEMUA PENYAKIT

ANGKA KEMATIAN No. 3 (SESDH JTG & Ca), di EROPAUSA ANGKA KEMATIAN No. 3 (SESDH JTG & Ca), di EROPAUSA

No. 2. Seluruh Dunia (WHO 1999) sesdhNo. 2. Seluruh Dunia (WHO 1999) sesdh

peny.jantungpeny.jantung

INVALIDITY RATE 2 TOP RANK OF ALL DISEASES IN ADULTS

ORTALITY RATE 2 NO. OVER THE ORLD, a5%& HEART DIS.(HO,#)

2 N'.$ a5%& Ha&% D/+. And Can-& ( USA@ Ind7+%&/a3 C'7n%&/

EPIDEMIOL…EPIDEMIOL…

SEMUA UMUR SEMUA UMUR ↑↑ PD DEKADE " PD DEKADE "

MULAI TIMBULMULAI TIMBUL

• PSAPSA (P&da&a*an S7 A&a*n'/d) 2dad(P&da&a*an S7 A&a*n'/d) 2dad KE 3 –KE 3 –5 & 75 & 7

• PISPIS (P&d. In%&a S&&a3) 2 DEKADE " !(P&d. In%&a S&&a3) 2 DEKADE " !

• SISI (S%&' I+4/) 2(S%&' I+4/) 2

• TROMBOSISTROMBOSIS DEKADE 6 – 8DEKADE 6 – 8

• EMBOLIEMBOLI DEKADE 2 – 4 & 6DEKADE 2 – 4 & 6

SEKS J @ SEKS J @

(J ; $ @ = ( RSUD, # " # ))(J ; $ @ = ( RSUD, # " # ))

A-%+ a33 a+, 9a a% %* d-ad

SAH 9a a% $&d1%*,%*n %* d-adICH 9a a% %*1 !%* d-adNHS Ca&d/a- 4'3/ nd1=%*,and %*

T*&'4'+/+ %*1!%* d-ad

PHYSIOLOY O! CEREBRALPHYSIOLOY O! CEREBRAL

CIRCULATIONCIRCULATION

FISIOLOGI SIRKULASI SEREBRALFISIOLOGI SIRKULASI SEREBRAL

OTAK MEMERLUKAN DARAH SINAMBUNG(%78OOTAK MEMERLUKAN DARAH SINAMBUNG(%78O<<@GLUKOSA)@GLUKOSA)

ALIRAN DARAH OTAK (ADO) 2 CBF (C&&a3 B3''d F3'>)ALIRAN DARAH OTAK (ADO) 2 CBF (C&&a3 B3''d F3'>)

TGT PD $ FAKTOR UTAMA TGT PD $ FAKTOR UTAMA

#. TEKANAN (DARAH) PERFUSI KE OTAK #. TEKANAN (DARAH) PERFUSI KE OTAK

. TAHANAN PD PERIFER OTAK. TAHANAN PD PERIFER OTAK

$. DRH VISKOSITAS @ DAYA KOAGULASI ,Pa O8CO ,dan 9H$. DRH VISKOSITAS @ DAYA KOAGULASI ,Pa O8CO ,dan 9H

BRAIN NEEDS CONTINUOUSLY & OPTIMAL BLOOD SUPPLY "#$ %'"("')*+O2N',-..* -/01 5 – 7 ,. % BLOOD,(01" )' % /'1##0"

CEREBRAL BLOOD !LO CB!9 DEPENDS ON :

•CEREBRALL PERFUSION PRESSURE (CPP)• CEREBRAL PERIPHERAL RESISTANCE•FACTORS OF BLOOD VISCOSITY,COAGULOBILITY, 9H, Pa O8CO '5

TEK.PERFUSI, DITENTUKAN OLEH TEK.PERFUSI, DITENTUKAN OLEH

#.#. TD SISTEMIK ?ANTUNG,DARAH,PB DRH TD SISTEMIK ?ANTUNG,DARAH,PB DRH

.. AUTOREGULASI PB ARTERIOL OTAK AUTOREGULASI PB ARTERIOL OTAK

$.$. TAHANAN PERIFER (OTAK) TAHANAN PERIFER (OTAK)

( DAYA AUTOREGULASI P.D. OTAK( DAYA AUTOREGULASI P.D. OTAK

2 KEMAMPUAN KHUSUS ARTERIOL OTAK U8 VASOKONSTR. BILA TD SISTEMIK2 KEMAMPUAN KHUSUS ARTERIOL OTAK U8 VASOKONSTR. BILA TD SISTEMIK ↑↑

@ MELEBAR (VASODILATASI) BILA TDS@ MELEBAR (VASODILATASI) BILA TDS ↓↓))

CPP CEREBRAL PER!USION PRESSURE9(;0"(<" /* :

1. SYSTEMIC BP ( MABP24an a&%&/a3 3''d 9&++7&)*a&% , 3''d @ :a+-.-'nd/%/'n

MABP 2 #8$( # SBP DBP )2. CEREBRAL VASCULAR AUTOREGULATION

(AUTOREGULATION) = The neurohuor!" #n$uen%e on &r!#n !r'er#o"e

#!e'er!!#n*' CPP %h!ne* #n orer 'o !#n'!#ne CB+

,. CEREB.PERIP-ERAL RESISTANCE

. DARAH . DARAH VISKOSITAS VISKOSITAS

KOAGULOBILITAS KOAGULOBILITAS

KDR 8 TEK.PARSIAL GAS KDR 8 TEK.PARSIAL GAS

1 P1 PAA COCO<< ↑↑ 8 P8 PAAOO<<↓↓ 8PH8PH ↓↓ V.DILATASIV.DILATASI

1 P1 PAA COCO<< ↓↓ 8 PAO8 PAO<< ↑↑8 PH8 PH ↑↑ VASOKONSTVASOKONST

BLOOD FACTORS

•VISCOSITY %* ;:/+-'+/%6, %* < :3'-/%6 1; %* <

•COAGULOBILITY %* 4'& -'a73a31; +3'>& 1;

•BLOOD ACIDIY %* ; a-/d 1; VASODILATION

• %* <a-/d VASOCONSTRICTION

ANATOMY OF CEREBRAL CIRCULATIONANATOMY OF CEREBRAL CIRCULATION

• ANTERIOR CIRCULATION SYSTEMANTERIOR CIRCULATION SYSTEM

(CAROTID SYSTEM)(CAROTID SYSTEM)

• POSTERIOR CIRCLATION SYSTEMPOSTERIOR CIRCLATION SYSTEM

(VERTEBRO1BASILAR SYSTEM)(VERTEBRO1BASILAR SYSTEM)

P'%n%/a3 S%&' R/+ Fa-%'&P'%n%/a3 S%&' R/+ Fa-%'&

N'n4'd/a3 and M'd/a3N'n4'd/a3 and M'd/a3

N(M>-/N(M>-/."."

M>-/."M>-/."

AGE AGE H69&%n+/'nH69&%n+/'nGener Gener Ha&% d/+a+Ha&% d/+a+

R!%eR!%e andand'hn#%#' 'hn#%#'

A%&/a3 F/&/3a%/'nA%&/a3 F/&/3a%/'n

-ere#' -ere#' D/a%+ 433/%7+D/a%+ 433/%7+

H69&-*'3+%&'34/aH69&-*'3+%&'34/aA+649%'4a%/- -a&'%/d +%n'+/+A+649%'4a%/- -a&'%/d +%n'+/+

S4'/nS4'/n

Ha:6 a3'*'3 /n%aHa:6 a3'*'3 /n%a

P*6+/-a3 /na-%/:/%6P*6+/-a3 /na-%/:/%6

R-n% TIA '& +%&', %-R-n% TIA '& +%&', %-

RISK !ACTORS !OR STROKERISK !ACTORS !OR STROKE NHS &NHS &

HS9HS9

• Fa%'& &/+/'2 Fa%'& 6an da9a% 447da*an '&an 4ndFa%'& &/+/'2 Fa%'& 6an da9a% 447da*an '&an 4nd

; &n%an %*d9 GPDO ; &n%an %*d9 GPDO

1.1. Hipertensi (>>)Hipertensi (>>)2. Peny. Jantung2. Peny. Jantung

3. Diabetes Mellitus3. Diabetes Mellitus

=. D/+3/9/d4/a=. D/+3/9/d4/a

. U+/a %7a. U+/a %7a

. Pn6. PD %9/ (a&%&/'+3&'+/+,a&%&/%/+, d33). Pn6. PD %9/ (a&%&/'+3&'+/+,a&%&/%/+, d33)

. H4a%'&/% T/n/ ( 9d 9& H4 &nda* ). H4a%'&/% T/n/ ( 9d 9& H4 &nda* )

RISK !ACTOR = !-<1'#9 ?@<@ ."- ' ,-" (" "-#"' 1 @-" -#"-#"

RISK !ACTORS %' N(@-",''@-)< S1'"NHS9 :1.Hypertension2. Heart Diseases3. Diabetes Mellitus4 D*#.$",-

5 A)"6 P"'$@"'-. V-#<#"-#"#7 H)@ H",-1<'1 ,-(9 .? H, ( ?,-(9

!AKTOR RISIKO STROKE!AKTOR RISIKO STROKE

!! MerokokMerokok

. O+/%a+. O+/%a+

#.#. Obat Obat " K'n%&a+9+/ (T789d" K'n%&a+9+/ (T789d 9&'' @9&'' @ HT)HT)

1 Ad/%/5 H&'/n, K'a/n, A49*%a4/n1 Ad/%/5 H&'/n, K'a/n, A49*%a4/n

1 An%/'a73an *9a&/n, d+1 An%/'a73an *9a&/n, d+

##. Oa% H'&4'na3 4/+.+%&'n( 9/3 KB )##. Oa% H'&4'na3 4/+.+%&'n( 9/3 KB )

#.#. Peny. DarahPeny. Darah (D/+&a+/a d&*) (D/+&a+/a d&*)

#. An4/a B&a% $. K'a73'9a%/#. An4/a B&a% $. K'a73'9a%/

. P'3/+/%4/a. P'3/+/%4/a =. L74/a,9n6.d&* 3a/nn6a=. L74/a,9n6.d&* 3a/nn6a#$. H/9&7&/-4/a#$. H/9&7&/-4/a

#=.#=. A! R#/!!' STRO0 A! R#/!!' STRO0 8TIA8TIA

RISK !ACTOR !OR STROKE(continue)! !. C/a&%% +4'/n. O+/%6#.Md/-/na3 C'n%&a-9%/:+(+9.>'4an+4'/nHTn) add/-%/: d&7+ *&'/n, -'-a/n,a49*%a4/n,%-

an%/-'a73an% *9a&/n, *9a&/n'/d, %- *'&4'na3 +%&'n,

+%&'.d&/:a%/:+##.B3''d d6+-&a+/a+ an4/a(+:&), -'a73'9a%*6,9'3/+/%*4/a,

374/a, '%*& 3''d d/+a++#.H69&7&/-4/a

#$.H/+%'&6 '5 S%&'8 TIA

#. #. "neuris#a "neuris#a (( Aneur#*! 0r#'oen# Aneur#*! 0r#'oen# ))

Mal$or#asi Mal$or#asi A1V (MAV 2 AVM) @A1V (MAV 2 AVM) @

"ngio#atosa "ngio#atosa He#o%liaHe#o%lia

&euke#ia&euke#ia

'ro#bositopenia'ro#bositopenia

Hiperho#osisteine#iaHiperho#osisteine#ia

#.#. Tuor O'! Tuor O'!

#.#. A#"o#o*#* Sere&ro3!*u"!r A#"o#o*#* Sere&ro3!*u"!r

#!. Dan 3a/n13a/n#!. Dan 3a/n13a/n

R/+ 5a-%'&+ 5'&S%&'(-on'#%nue) #. An7&6+4+

A&%&/'1:n'7+4a35'&4a%/'n(AVM) H4'9*63/a L74/a T*&'4'-6%'9n/a

H69&*'4'-6+%/n4/a#. B&a/n8In%&a-&an/a3 %74'7&+#. C&&':a+-73a& a463'/d'+/+#!. E%-.

PEMBAIAN PDOPEMBAIAN PDO

KLINISKLINIS S&anan '%a +9/n%a+8SOS (T&an+/n% S&anan '%a +9/n%a+8SOS (T&an+/n%

I+-*4/- A%%a- 8 TIAQ) I+-*4/- A%%a- 8 TIAQ) S%&' S%&' I+4/ 8 SI S%&' S%&' I+4/ 8 SI

(N'n H4'&&*a/- S%&'8NHS)(N'n H4'&&*a/- S%&'8NHS)

S%&' H4'&a/ 8 SH S%&' H4'&a/ 8 SH

(H4'&&*a/- S%&' 8 HSQ)(H4'&&*a/- S%&' 8 HSQ) GPDO 3a/nn6a GPDO 3a/nn6a

ETIOPATOLOGIK ETIOPATOLOGIK

#.#. T&'4'+/+ (P.D) S&&/ T&'4'+/+ (P.D) S&&/

.. E4'3/ S&&/E4'3/ S&&/$.$. A&%&/%/+A&%&/%/+

=.=. P&d&*an P&d&*an In%&a+&&a3 (PIS)In%&a+&&a3 (PIS)

S7a&a*n'/da3 (PSA)S7a&a*n'/da3 (PSA)

!AKTOR RISIKO!AKTOR RISIKOSTROK HEMORAIK HS9STROK HEMORAIK HS9

#.#. HIPERTENSIHIPERTENSI

.. ANOMALI PB DRH ANEURISMA, AVM, d33ANOMALI PB DRH ANEURISMA, AVM, d33

$.$. AMILOIDOSIS ( SEREBROVASKULAR )AMILOIDOSIS ( SEREBROVASKULAR )

=.=. TUMOR OTAK TUMOR OTAK

.. R8 OBAT ANTIKOAGULANSIA HEPARIN, d33R8 OBAT ANTIKOAGULANSIA HEPARIN, d33

.. DISKRASIA DARAH DISKRASIA DARAH

1 KOAGULOPATI1 KOAGULOPATI 1 LEUKEMIA1 LEUKEMIA

1 HEMOFILIA1 HEMOFILIA 1 TROMBOSITO PENIA1 TROMBOSITO PENIA

77 RIAYAT STROK RIAYAT STROK

PATO!ISIOLOI ISKEMI & IN!ARKPATO!ISIOLOI ISKEMI & IN!ARK

OK PDO :OK PDO :

T I AT I A

PASOKAN DRH BERKURANG (DEFISIT)PASOKAN DRH BERKURANG (DEFISIT) ISKEMIISKEMI

GE?ALA 1 SELAMA BBRP DETIK " ?AMGE?ALA 1 SELAMA BBRP DETIK " ?AM(;;2#1 4n/%) dan TDK ; =(;;2#1 4n/%) dan TDK ; =

?AM ?AM

1 DIDUGA OK VASOSPASME1 DIDUGA OK VASOSPASME(KONSTRIKSI)(KONSTRIKSI)

@ TDK TER?ADI INFARK ?AR.OTAK @ TDK TER?ADI INFARK ?AR.OTAK

STROKE ISKEMIK SINHS9STROKE ISKEMIK SINHS9

ISKEMI OTAK YG LAMA, PARAH @ LUASISKEMI OTAK YG LAMA, PARAH @ LUAS

PERUBAHAN F.STRUKTUR OTAK YG IREVERSIBELPERUBAHAN F.STRUKTUR OTAK YG IREVERSIBEL

• PENY.PB.DARAH OTAK (PPDO) %78PENY.PB.DARAH OTAK (PPDO) %78ATEROSKLEROSIS @ ATERIOSKLEROSISATEROSKLEROSIS @ ATERIOSKLEROSIS

MENYEBABKAN MENYEBABKAN 1 LUMEN PB DRH1 LUMEN PB DRH < (STENOSIS)< (STENOSIS) INSUF.ADOINSUF.ADO

1 OKLUSI MENDADAK '8TROMBUS8ATEROM1 OKLUSI MENDADAK '8TROMBUS8ATEROM

BERDARAHBERDARAH

1 TROMBUS LEPAS1 TROMBUS LEPAS EMBOLUSEMBOLUS GGN (GGN (↓↓ ADO)ADO)1 DINDING PD1 DINDING PD LEMAHLEMAH ANEURISMA ATAUANEURISMA ATAU

ROBEKROBEK ADOADO ↓↓

• TEK.PERFUSI TEK.PERFUSI ↓↓ ADOADO ↓↓ d/%n%7an '3*, d/%n%7an '3*,

1 TD SISTEMIK 1 TD SISTEMIK

1 TAHANAN PERIFER 8 INTRAKRANIAL OTAK 1 TAHANAN PERIFER 8 INTRAKRANIAL OTAK

1 DARAH1 DARAH

J"'* J"'*

+,&.-P,.J'* !+,&.-P,.J'* !

1 CO1 CO ↓↓ ('8 FIBRILASI, BLOK ?TG, d33)('8 FIBRILASI, BLOK ?TG, d33)

1 EMBOLUS LEPAS1 EMBOLUS LEPAS ISKEMI (ARITMIAISKEMI (ARITMIA

KORDIS,KORDIS,

INFARK, d33.INFARK, d33.

AMBARAN KLINIK PDO : ISKEMIK NHS9AMBARAN KLINIK PDO : ISKEMIK NHS9

TIA GE?ALA TIA GE?ALA << = ?AM, TGT P.D. YG TERLIBAT= ?AM, TGT P.D. YG TERLIBAT

/0/0/,0/ +"O'/0/0/0/,0/ +"O'/0

"HEMIPARESISHEMIPARESIS

" HEMIANESTESIAHEMIANESTESIA

" GGN BICARA8BAHASA AFASIA (H4/+5&GGN BICARA8BAHASA AFASIA (H4/+5&

d'4/nan)d'4/nan)" AMAUROSIS FUGAKS (BUTA TIBA1TIBA)AMAUROSIS FUGAKS (BUTA TIBA1TIBA)

" DISARTRIDISARTRI

/0/0/,0/ ,',4O4"0/&"/0/0/,0/ ,',4O4"0/&"

1 DIPLOPIA8PARESIS OTOT EKSTRA "DIPLOPIA8PARESIS OTOT EKSTRA "OKULAROKULAR

1 VERTIGOVERTIGO

1 DISARTRIA, DISFAGIADISARTRIA, DISFAGIA

1 HEMIPARESIS 8 TETRAPARESISHEMIPARESIS 8 TETRAPARESIS

1 HEMIHIPESTESI 8 ANESTESI 8 d793+HEMIHIPESTESI 8 ANESTESI 8 d793+

(UNILATERAL 8 BILATERAL).(UNILATERAL 8 BILATERAL).

AMBARAN KLINIS :AMBARAN KLINIS :

TIATIA

DIAGNOSIS DIAGNOSIS a%a+ da+a& .d/+57n+/ 5'a3 '%aa%a+ da+a& .d/+57n+/ 5'a3 '%a << = a4= a4PEMERIKSAAN PEMERIKSAAN

• ANAMNESISANAMNESIS

• PEM.FISIS UMUM @ NEUROLOGIK PEM.FISIS UMUM @ NEUROLOGIK

• PEM. KHUSUS PEM. KHUSUS " OFTALMODINAMOMETRI ODOFTALMODINAMOMETRI OD ↔↔ OSOS

(4 ad.+/&73a+/ A.OFTALMIKA) -a.A.C.INT(4 ad.+/&73a+/ A.OFTALMIKA) -a.A.C.INT

PEM.DOPPLER ULTRASONIK PEM.DOPPLER ULTRASONIK

" T&an+-&an/a3 d'993& (TCD) +'n'&a9*6 T&an+-&an/a3 d'993& (TCD) +'n'&a9*6" Ca&'%/d d793 ( A. CAROTCa&'%/d d793 ( A. CAROT

" EKG 8 EKHOKARDIOGRAFIEKG 8 EKHOKARDIOGRAFI

DD (DIAG. BANDING) DD (DIAG. BANDING)

#.#. PIS YG KECILPIS YG KECIL

.. PSAPSA

$.$. EPILEPSI FOKAL OK EPILEPSI FOKAL OK 1 TUMOR OTAK 1 TUMOR OTAK

1 HEMATOMA SUBDURAL1 HEMATOMA SUBDURAL

STROKE ISKEMIK SI NHS9STROKE ISKEMIK SI NHS9

BENTUK KLINISBENTUK KLINIS

#. TIA#. TIA

. STROKE . STROKE

.#. DEFISIT NEUROLOGIK ISKEMIK SEPINTAS.#. DEFISIT NEUROLOGIK ISKEMIK SEPINTAS

REVERSIBLE ISCHEMIC NEUROLOGICALREVERSIBLE ISCHEMIC NEUROLOGICAL

DEFICITSQ (RIND). GE?ALA BERLANGSUNG ;DEFICITSQ (RIND). GE?ALA BERLANGSUNG ;

= ?AM= ?AM << # MINGGU# MINGGU

.. PRIND (PROLONGED RIND).. PRIND (PROLONGED RIND) . +8d $. +8d $44

RIND @ PRINDRIND @ PRIND DEFISIT KLINIS NEUROLDEFISIT KLINIS NEUROL

MINIMALMINIMAL

.$..$. 0'O+, PO*,0/P0'O+, PO*,0/P

(PROGRESSING STROKE) (STROKE IN(PROGRESSING STROKE) (STROKE INEVOLUTION)EVOLUTION)

a3a n7&'3'/ &3+a3a n7&'3'/ &3+ @@

&%a4a* &a%&%a4a* &a%$.$. 0'O+, +OMP&/' 0'O+, +OMP&/' (COMPLETED(COMPLETED

STROKE 8 PERMANENT STROKE)STROKE 8 PERMANENT STROKE)

STROKE DGN GE?ALA KLINIS SUDAHSTROKE DGN GE?ALA KLINIS SUDAHMENETAP.MENETAP.

PATOLOGI SI BISA DIDAPATI PATOLOGI SI BISA DIDAPATI

1 TROMBOSIS ARTERI OTAK TROMBOSIS ARTERI OTAK

1 ,M4O&0 (/) O'"+ ,M4O&0 (/) O'"+

1 "',/'/0 "',/'/0 4/+a3n6a 9d 4/+a3n6a 9d LUES (<<) LUES (<<)

RHEUMA RHEUMA

ARTERITIS TEMPORALIS ARTERITIS TEMPORALIS

ISKEMI OTAK ISKEMI OTAK

2 GGN2 GGN DEFISIT ADODEFISIT ADO GG FUNGSIGG FUNGSINEURON TANPA MENYISAKAN PERUBAHANNEURON TANPA MENYISAKAN PERUBAHAN

YG PERMANEN YG PERMANEN

IN!ARK OTAK IN!ARK OTAK

2 OK ISKEMI OTAK YG LAMA @ PARAH2 OK ISKEMI OTAK YG LAMA @ PARAH

PERUBAHAN FUNGSI @ STRUKTUR OTAK YGPERUBAHAN FUNGSI @ STRUKTUR OTAK YGPERMANENPERMANEN

NORMA#

O#IGEMIA

SE$ERE

MODERATE

Mai%ai%'d A*or'+*aio%-

Hi+'r C!" i% +ra /a'r

0 Go2i2

0 Pro'i% 2%'2i2

T' P'%*/ra4

I%r'a2'd O5 E6raio%

Ma /ai%ai% Nor/a CMRO5

Tr'2od o7 ''ria 7ai*r'

Tr'2od o7 io%i 7ai*r'

A%o6i d'8oari9aio%

( 0EC" K: & ;EC" Ca::)

/i%2 o*r2 da2 ''B2

Maro8a+'2

N'*ro8i2

Ca28a2'

IN!ARK OTAK IN!ARK OTAK

DAERAH 8 FOKUS INFARKDAERAH 8 FOKUS INFARK(OK HIPOKSIA 8 EDEMA SEL(OK HIPOKSIA 8 EDEMA SEL

DAERAH ISKEMI (“ISCHEMICPENUMBRA”) SEL MASIH HIDUP, TDK

BERFUNGSIDAERAH EDEMA LOKAL / HIPEREMI(SEL MASIH HIDUP & BERFUNGSI)

EFALA KLINIK SIEFALA KLINIK SI

GE?ALA KLINIK @ DIAGNOSIS DIPEROLEH DGNGE?ALA KLINIK @ DIAGNOSIS DIPEROLEH DGN

#.#. ANAMNESISANAMNESIS

.. PEM. FISIS UMUMPEM. FISIS UMUM

$.$. PEM. FISIS NEUROLOGIK @ PSIKOLPEM. FISIS NEUROLOGIK @ PSIKOL

=.=. PEM. LAB DRH RUTIN, URINE RUTIN,PEM. LAB DRH RUTIN, URINE RUTIN,

KIMIA DRH, LIKUOR (LP)KIMIA DRH, LIKUOR (LP)

KHUSUS :KHUSUS :

. PEM. DOPPLER, EKG, EKHO1KG. PEM. DOPPLER, EKG, EKHO1KG. PEM. CT1SCAN (SCAN1TOMOGRAFIK) 8 MRI. PEM. CT1SCAN (SCAN1TOMOGRAFIK) 8 MRI

. PEM. ANGIOGRAFI SEREBRAL. PEM. ANGIOGRAFI SEREBRAL

!. OFTALMODINAMOMETRI!. OFTALMODINAMOMETRI

EFALA UTAMAEFALA UTAMA

1 DEFISIT NEUROL.YG TIMBUL MENDADAKDEFISIT NEUROL.YG TIMBUL MENDADAK(AKUT 8 SUB AKUT)(AKUT 8 SUB AKUT)

EFALA TT PADA :EFALA TT PADA :• LOKASI 8 PB DRH YG TERKENALOKASI 8 PB DRH YG TERKENA

• BERAT1RINGANNYA GGN PB DRHBERAT1RINGANNYA GGN PB DRH

• PERKEMBANGAN LESI 8 STROK PERKEMBANGAN LESI 8 STROK

• PD TROMBOSIS SEREBRIPD TROMBOSIS SEREBRI

1 G. N7&'3'/ d/n/ %/473G. N7&'3'/ d/n/ %/473a7%8+7a7% d/da*737/ .P&'d&'4aa7%8+7a7% d/da*737/ .P&'d&'4a

1 % ISTIRAHAT (%d &/a%), an7n% ISTIRAHAT (%d &/a%), an7n9a/9a/

1 Ma+a ( ;; 9d. .Ma+a ( ;; 9d. .FFFF " ." .FFFF))

1 B/a+an6a +ada& (%d 4n7&7n)B/a+an6a +ada& (%d 4n7&7n)

1 U+/a ( ; T*n 1 ;;)U+/a ( ; T*n 1 ;;)

1 Sn "T'4'&a (CT1S-an) Da&a*Sn "T'4'&a (CT1S-an) Da&a**/9'dn+ ' In5a& 8 I+4/ @*/9'dn+ ' In5a& 8 I+4/ @Ed4a 3'a3 '%a.Ed4a 3'a3 '%a.

PADA EMBOLI SEREBRIPADA EMBOLI SEREBRI

• MENDADAK (TER AKUT da&/ GPDO)MENDADAK (TER AKUT da&/ GPDO)

USIA ; MUDA (DEKADE III " V)USIA ; MUDA (DEKADE III " V)

• KT AKTIF (KD1KT AKTIF (KD1 KT ISTIRAHAT)KT ISTIRAHAT)

• SADAR, ATAUSADAR, ATAU ↓↓ (BILA EMBOLI BESAR) (BILA EMBOLI BESAR)

• ADA SUMBER EMBOLIADA SUMBER EMBOLI

?ANTUNG ?ANTUNG

EFALA DR SISTEM KAROTISEFALA DR SISTEM KAROTIS

#.#.A.KAROTIS INTERNAA.KAROTIS INTERNA

1 AMAUROSIS FUGAKS1 AMAUROSIS FUGAKS

1 DISFASIA 8 AFASIA (+/+/ d'4/nan)1 DISFASIA 8 AFASIA (+/+/ d'4/nan)1 HEMIPARESIS 8 PLEGI KONTRALAT1 HEMIPARESIS 8 PLEGI KONTRALAT

LESI ( BISA1 SINDROM HORNERLESI ( BISA1 SINDROM HORNER

IPSILATERAL)IPSILATERAL)

EFALA DR SISTEM KAROTISEFALA DR SISTEM KAROTIS

. A.SEREBRI ANTERIOR. A.SEREBRI ANTERIOR1 H4/9a&+/+ 'n%&a3a%. %7na/ ; 3nan1 H4/9a&+/+ 'n%&a3a%. %7na/ ; 3nan

1 Gn 8 .4n%a3 ( 5'7+ 5&'n%a3)8F7n+/1 Gn 8 .4n%a3 ( 5'7+ 5&'n%a3)8F7n+/

37*7&37*7&1 Gn +n+'&/ an.6an 37497*1 Gn +n+'&/ an.6an 37497*

(H4/*/9+%+/ 8an+%+/)(H4/*/9+%+/ 8an+%+/)

1 In'n%/nn+/a (7&/n 8 a3:/)1 In'n%/nn+/a (7&/n 8 a3:/)1 B/+a an1an1 B/+a an1an

$. A. SEREBRI MEDIA$. A. SEREBRI MEDIA

1 DI PANGKALNYA HEMIPARESIS1 DI PANGKALNYA HEMIPARESIS3nan 2 %7na/3nan 2 %7na/

DI DISTALDI DISTAL Lnan ; %7na/.Lnan ; %7na/.

1 HEMIHIPESTESIA 8 H " an+%+/1 HEMIHIPESTESIA 8 H " an+%+/1 GGN FUNGSI LUHUR (*4/+5& d'4/nan)1 GGN FUNGSI LUHUR (*4/+5& d'4/nan)

AFASIA MOTORIK 8 SENSORIK d33AFASIA MOTORIK 8 SENSORIK d33

=. GGN BILATERAL=. GGN BILATERAL

1 SINDROM PSEUDOBULBAR PALSY1 SINDROM PSEUDOBULBAR PALSY

(BIASA PD VASKULAR)(BIASA PD VASKULAR)

H4/93/ d793+ H4/93/ d793+

K+73/%an %3an (DISFAGI) K+73/%an %3an (DISFAGI)

Gn 4n%a3 4'+/, 47da* 4nan/+ 8 Gn 4n%a3 4'+/, 47da* 4nan/+ 8%&%a>a (F'&-% -&6/n 8 3a7*/n)%&%a>a (F'&-% -&6/n 8 3a7*/n)

1 +&/n ' PPDO '8 a&%&/%/+ (LUES, R*74a,1 +&/n ' PPDO '8 a&%&/%/+ (LUES, R*74a,

MS)MS)

EFALA N SVERTEBROEFALA N SVERTEBRO

BASILARBASILAR

#. A.SEREBRI POSTERIOR#. A.SEREBRI POSTERIOR HEMIANOPSIA HOMONIM KONTRALAT HEMIANOPSIA HOMONIM KONTRALAT

SISI LESISISI LESI

HEMIPARESIS 8 HEMIPLEGI HEMIPARESIS 8 HEMIPLEGI

KONTRALATERALKONTRALATERAL HEM1HIPESTESIA 8 ANESTESIA HEM1HIPESTESIA 8 ANESTESIA

KONTRALATERAL 7 8 PROTOPATIS KONTRALATERAL 7 8 PROTOPATIS

(N6&/, S7*7, d33)(N6&/, S7*7, d33)

PROPRIOSEPTIF PROPRIOSEPTIF (G%a&, S/a9, d33)(G%a&, S/a9, d33)

• BILA SATU CAB.KE TALAMUS TERKENA,BILA SATU CAB.KE TALAMUS TERKENA,

MAKA TER?ADI SINDROM TALAMIKUS MAKA TER?ADI SINDROM TALAMIKUS

" NYERI TALAMIK @ ANESTESIA DOLOROSANYERI TALAMIK @ ANESTESIA DOLOROSA(PEM.OB?EKTIF(PEM.OB?EKTIFANESTESIA, TETAPIANESTESIA, TETAPI

PEM.NYERIPEM.NYERI () RASA 8RABA NYERI.() RASA 8RABA NYERI.

NYERI TALAMIKNYERI TALAMIK NYERI TERUS.NYERI TERUS.

" HEMIKHOREA HEMIPARESISHEMIKHOREA HEMIPARESIS

. A.VERTEBRALIS. A.VERTEBRALIS

TER?ADI SINDROM ALLENBERG GE?.II TER?ADI SINDROM ALLENBERG GE?.II

PERIF H9. K'n%&a3 ATAKSIAPERIF H9. K'n%&a3 ATAKSIASEREBELARSEREBELAR

SESISI PD LENGAN @ TUNGKAI.SESISI PD LENGAN @ TUNGKAI.

$. A. SEREBELI POSTERIOR INFERIOR$. A. SEREBELI POSTERIOR INFERIOR

(PICA)(PICA)

1 DPT TER?ADI SINDROM HORNERQ1 DPT TER?ADI SINDROM HORNERQ

SESISI LESISESISI LESI

1 DISFAGIA1 DISFAGIA

1 NISTAGMUS1 NISTAGMUS

1 HEMIHIPESTESIA ALTERNANS1 HEMIHIPESTESIA ALTERNANS1 SINDROM ALLENBERG1 SINDROM ALLENBERG

>. GGN 8d CA!.KECI# A.!ASI#ARIS>. GGN 8d CA!.KECI# A.!ASI#ARIS

(a.8ara/'dia%) (a.8ara/'dia%)

8ar'2i2++% 8ar'2i2++% B'*/8*a% oo + di*r*2B'*/8*a% oo + di*r*2

N%.Cra%ia + i%i%a di /idi%'( i%'a /'dia%)N%.Cra%ia + i%i%a di /idi%'( i%'a /'dia%)

d'Ba +r2 '%+a) N.IIId'Ba +r2 '%+a) N.III

N.$I IPSI #ATERA# N.$I IPSI #ATERA# N.FII N.FII

: HEMIPARESIS KONTRA#AT (UMN) : HEMIPARESIS KONTRA#AT (UMN)

SINDROM BATAN OTAK SINDROM BATAN OTAK

1. MESENSE"A#ON 1. MESENSE"A#ON

SINDROM E!ER HEMIPARESIS SINDROM E!ER HEMIPARESIS

(KONTRA#AT) A#TERNANS N.III (IPSI#AT(KONTRA#AT) A#TERNANS N.III (IPSI#AT

d+% #ESI)d+% #ESI)

5. PONS 5. PONS SINDROM "O$I##E H'/i8.Bo%raa : SINDROM "O$I##E H'/i8.Bo%raa :

+'raBa% 5 /aa (KONJUGASI) B' 2i2i '2i+'raBa% 5 /aa (KONJUGASI) B' 2i2i '2i

SINDROM MI##ARDGOE!#ER SINDROM MI##ARDGOE!#ER

'/i8ar'2i2 Bo%raa : Bo%*+a2i B' 2i2i '2i :'/i8ar'2i2 Bo%raa : Bo%*+a2i B' 2i2i '2i :++% N.$II i8' 8'ri7'r 2'2i2i '2i++% N.$II i8' 8'ri7'r 2'2i2i '2i

(IPSI#ATERA#) I$, $I, $II(IPSI#ATERA#) I$, $I, $II

DIANOSIS & DIANOSTIKDIANOSIS & DIANOSTIKSI NHS9SI NHS9

KLINIS KLINIS

2 ETIOLOIK ETIOPATOLOIK 2 ETIOLOIK ETIOPATOLOIK

3 LOKALISASI !OKUS TOPIS3 LOKALISASI !OKUS TOPIS

1 DIAGNOSIS KLINIS1 DIAGNOSIS KLINIS (!o"k#$% D#%$o'#')(!o"k#$% D#%$o'#')#*%kk$ ' '" TEMUAN KLINIS#*%kk$ ' '" TEMUAN KLINIS(ANAMN + PEMFISIK +/PEMKHUSUS)(ANAMN + PEMFISIK +/PEMKHUSUS)

SI - %*. $*0"oo%#k ok / %o2SI - %*. $*0"oo%#k ok / %o2

- k0 / '02k0- k0 / '02k0

- 3$4 okGGN 5ASKULAR, BUKAN - 3$4 okGGN 5ASKULAR, BUKAN

6 TRAUMA,6 TRAUMA,

6 INFEKSI / RDG6 INFEKSI / RDG

6 PSIKOGEN6 PSIKOGEN

- CT S7$ H#8o*$' 8 '* #$# (.9-- CT S7$ H#8o*$' 8 '* #$# (.9- .9 I) 2#' #'o*$' .9 I) 2#' #'o*$'

. DIAG. ETIOL 8 ETIOPATOLOGIK . DIAG. ETIOL 8 ETIOPATOLOGIK

DASAR D8 KLINISDASAR D8 KLINIS

Fa%'& R/+/' Fa%'& R/+/' Ha+/3 P4.K*7+7+ Ha+/3 P4.K*7+7+

( LAB DRH, L/7'&, CT18MRI)( LAB DRH, L/7'&, CT18MRI)

$. DIAG.LOKALISASI 8FOKUS 8TOPIS LESI $. DIAG.LOKALISASI 8FOKUS 8TOPIS LESI

DASAR 1 GBRN KLINISDASAR 1 GBRN KLINIS

1 HASIL PEM.KHUSUS8TAMBAHAN 1 HASIL PEM.KHUSUS8TAMBAHAN

DOPPLER, OFT.DYN DOPPLER, OFT.DYN ANGIOGRAFI ANGIOGRAFI

CT1SCAN 8 MRI CT1SCAN 8 MRI

TERAPI SI NHS9TERAPI SI NHS9

1. FASE AKUT ( 10 - 14 HARI1. FASE AKUT ( 10 - 14 HARI

dari ONSET)dari ONSET)

2. PASCA FASE AKUT2. PASCA FASE AKUT

1. FASE AKUT1. FASE AKUT

SASARAN SASARAN

11 NEUROPROTEKSI 9*$4*9k$ $*0"o$11 NEUROPROTEKSI 9*$4*9k$ $*0"o$

4% 9'#3 3#084% 9'#3 3#08

1: REFERFUSI SEREBRAL DAERAH1: REFERFUSI SEREBRAL DAERAH

ISKEMIISKEMIP*#3" 0$%'# ok " $79$ 8"o'*'P*#3" 0$%'# ok " $79$ 8"o'*'

8oo%#k (OEDEM, ISKEMI 8oo%#k (OEDEM, ISKEMI INFARK)INFARK)

%$ .$ #$k$ & R/ o2%$ .$ #$k$ & R/ o2 4% 9*$.9#$ *k 4% 9*$.9#$ *k

P*"0'# "3 4% 9*9# 0/ 2*"0$%'#$4P*"0'# "3 4% 9*9# 0/ 2*"0$%'#$4

ok '*7" o8#9ok '*7" o8#9

Un%7 /%7Un%7 /%7

1 PENANGANAN UMUM 1 PENANGANAN UMUM

BREATHING 1BREATHING 1

B1B1 AA (AIR!A; CLEAR) .$ $' 3"0' 2*2',(AIR!A; CLEAR) .$ $' 3"0' 2*2',

"*'8 *".9#$"*'8 *".9#$B:B: BB (BLOOD) <$0$%(BLOOD) <$0$% 3"' 2#k /EKG3"' 2#k /EKG

A$*9#A$*9# Ko"*k'#Ko"*k'#

TDTD S2#k$ / O8#9k$ T*kP*"0'#S2#k$ / O8#9k$ T*kP*"0'#<$%$ R/ T*$'#<$%$ R/ T*$'# ↓↓ 8 F'* Ak0 = 8 F'* Ak0 =

B> ? BRAINB> ? BRAIN

CC (CEREBRAL FUNCTION) (CEREBRAL FUNCTION)

Ko9 - #8$0, S#'#Ko9 - #8$0, S#'#

K*.$% - #o2#K*.$% - #o2# A$# Ko$@0'$A$# Ko$@0'$

K" G0 DRH (GD) - 2# #$%%# K" G0 DRH (GD) - 2# #$%%# ↓↓k$k$ 8*$-8*$ 8*$-8*$

B$' 7#"$, E*k"o#, A'9-B'B$' 7#"$, E*k"o#, A'9-B' P$0/P$0/

Ko"*k'# 2# 8*"0Ko"*k'# 2# 8*"0

B= 2 BLADDER FUNCTIONB= 2 BLADDER FUNCTION

F7n+/ /na3 d/93/*a&a */nda&/ /n5+/,F7n+/ /na3 d/93/*a&a */nda&/ /n5+/,

a%7, n a3an+ 3%&'3/%, 9H, a/&,a%7, n a3an+ 3%&'3/%, 9H, a/&,

d+.d+.

A%a+/ &%n+/ 8 /n'n%/nn+/A%a+/ &%n+/ 8 /n'n%/nn+/ a%%&,a%%&,

an%/an%/&a3a&a3a

B 2 BOEL FUNCTIONB 2 BOEL FUNCTION

N7%&/+/ 6 -779 8 '9%/4a3, 57n+/ TGIN7%&/+/ 6 -779 8 '9%/4a3, 57n+/ TGI

a/,a/,

a%a+/ '+%/9a+/ (&%n+/ a3:/) @a%a+/ '+%/9a+/ (&%n+/ a3:/) @/n'n%/nn+//n'n%/nn+/

a3:/, d/+99+/ d/'&+/, d33.a3:/, d/+99+/ d/'&+/, d33.

: R/ O2 (MEDIKAMENTOUS): R/ O2 (MEDIKAMENTOUS) B$4k 88, k B$4k 88, k'*"%9'*"%9

:1 ANTI EDEMA (OTAK):1 ANTI EDEMA (OTAK)

- G#'*"o 1 I$0', 1 GR / KGBB / H"#- G#'*"o 1 I$0', 1 GR / KGBB / H"#

- Ko"#ko'*"o# D*k'9*'o$- Ko"#ko'*"o# D*k'9*'o$ Bo0' 1 - : 9% #@, 0 - 9% / .9Bo0' 1 - : 9% #@, 0 - 9% / .9

0/ BBRP HARI0/ BBRP HARI ↓↓ (TAPERING OFF)(TAPERING OFF)

66↓↓

TIK K*8 & BDNTIK K*8 & BDN

- >- >AA

SP 1 - 1 3"# (FAk0)SP 1 - 1 3"# (FAk0)

:: ANTI KOAGULAN (SIA) HEPARIN:: ANTI KOAGULAN (SIA) HEPARIN

:> ANTI AGREGASI (TROMBOSIT) :> ANTI AGREGASI (TROMBOSIT)

A'9 A'*# S#'# (ASA) o'#' "*$3 A'9 A'*# S#'# (ASA) o'#' "*$3

- >> 9%/3"# - >> 9%/3"# T#7o8##$ (TICLID, AGULAN) : : 9% T#7o8##$ (TICLID, AGULAN) : : 9%

: OBAT PD FASE AKUT : OBAT PD FASE AKUT 0/ P*"2#k# / <9#$0/ P*"2#k# / <9#$

“ADO” T"*$ N#73o#$“ADO” T"*$ N#73o#$

6 P*$ok'###$ (#@/"#8'6 P*$ok'###$ (#@/"#8' O")O")

6 Ko*"%#$ -M*'# (Ko*"%ok"#$)6 Ko*"%#$ -M*'# (Ko*"%ok"#$)

6 S##ko#$ - P#"7*9 (NOOTROPIL) -6 S##ko#$ - P#"7*9 (NOOTROPIL) -

A9#$o834#$ : %" 9 #@/ - 1: .9/ PELANA9#$o834#$ : %" 9 #@/ - 1: .9/ PELAN

6 T"o92o#'#$ (T"o92ok#$'*)6 T"o92o#'#$ (T"o92ok#$'*)

> REHAB & R/FISIK > REHAB & R/FISIK

>1 H#8*"@*$#'# (H5) 8 R/ OEDEMA OTAK >1 H#8*"@*$#'# (H5) 8 R/ OEDEMA OTAK

O O:: HBO (T*"8# Ok'#%*$ H48*"2"#k) 0/HBO (T*"8# Ok'#%*$ H48*"2"#k) 0/

E*9 Ok & 0/ S"ok$4E*9 Ok & 0/ S"ok$4

>: REHAB >: REHAB

F#'#o*"8# '*.k H"#-I 6 8o'#'# F#'#o*"8# '*.k H"#-I 6 8o'#'#

6 %"k$ P'#6 %"k$ P'# Ak# Ak#

B#$ !#7" (“'8**73 3*"84”) Lo%o TERAPI B#$ !#7" (“'8**73 3*"84”) Lo%o TERAPI

P'#ko*"8# & So'##''# P'#ko*"8# & So'##''# T*"8# K*". T*"8# K*".

2. FASE PASCA AKUT2. FASE PASCA AKUT

S'"$ 1 R*32P*$ =S'"$ 1 R*32P*$ =

: C*%3 S"ok U$% =: C*%3 S"ok U$% =

1 R*32 $.0k$ '* k01 R*32 $.0k$ '* k0 2*2' / 2*2' /L#3$ (R*32 F#'#k, M*$ / P'#k#k &L#3$ (R*32 F#'#k, M*$ / P'#k#k &

So'# =)So'# =): P"*@*$# 6 ASA - > 9%/3"#: P"*@*$# 6 ASA - > 9%/3"#

( 0/ A$# A%"*%'# P***)( 0/ A$# A%"*%'# P***) 6 T*"8# FR#'#ko 6 T*"8# FR#'#ko - HT- HT - Rokok - Rokok - D#* - D#* - DM - L*9k - OR - DM - L*9k - OR - <$0$% - '2- <$0$% - '2

STROK HEMORAIK SHSTROK HEMORAIK SH

HS9HS9ADA : <ENIS SH !HO I$*"$#o$ADA : <ENIS SH !HO I$*"$#o$

C''##7#o$ o D#'*'* "*@ (1)C''##7#o$ o D#'*'* "*@ (1)

1 P*""3$ I$"'*"*2" (PIS) ? ICD >11 P*""3$ I$"'*"*2" (PIS) ? ICD >1

: P*""3$ S02"k3$o# (PSA) ?: P*""3$ S02"k3$o# (PSA) ?

ICD >ICD >

PERDARAHAN INTRASEREBRAL (PIS)PERDARAHAN INTRASEREBRAL (PIS)

J DEF PIS #3 8*""3$ 8"#9*" k#2 "0'k / "o2*k$4 8*92 "3DEF PIS #3 8*""3$ 8"#9*" k#2 "0'k / "o2*k$4 8*92 "3

8"*$k#9 ok 4% 20k$ k"*$ "09 ("# 0") 8"*$k#9 ok 4% 20k$ k"*$ "09 ("# 0")

J KLINIS KLINIS Ak!Ak! (9*920"0k /k"#'#' 9(9*920"0k /k"#'#' 9 24 "a#24 "a#))

S$ak!S$ak! (2# 9*920"0k(2# 9*920"0k % & ' Hari% & ' Hari))

S$krikS$krik (2# k"#'#' '*9 '/(2# k"#'#' '*9 '/ ** ' +ari)' +ari)

J EPIDEMIOLOGI EPIDEMIOLOGI

- DEKADE - ("-" 30$)- DEKADE - ("-" 30$)

- k#-k# & P*"*980$ (KL k ? 8")- k#-k# & P*"*980$ (KL k ? 8")

- A$%k K*9#$ - (- A$%k K*9#$ - ( > 3"# ? 1 )> 3"# ? 1 )

1 MG ?: )1 MG ?: )

• PATOLOGI @ PATOFISIOLOGI PATOLOGI @ PATOFISIOLOGI

1 PIS d/ KAPSULA INTERNA1 PIS d/ KAPSULA INTERNA

(a.-. 4d/a(a.-. 4d/a a.3n%/-73'a.3n%/-73'

+%&/%a)+%&/%a)

1 d/ SEREBELUM @ BTG OTAK1 d/ SEREBELUM @ BTG OTAK

(FOSSA POST)(FOSSA POST)

1 # d/ HEMISFER d/37a& Ka9+. In%.1 # d/ HEMISFER d/37a& Ka9+. In%.

PATOL. EKSTRAVASASI DARAHPATOL. EKSTRAVASASI DARAH

HEMATOMA OEDEMA PERILESIONALHEMATOMA OEDEMA PERILESIONAL

DISKONTINUITAS ?ARINGANDISKONTINUITAS ?ARINGAN

KOMPRESIKOMPRESI

?AR. SEKITAR PB DRH ?AR. SEKITAR PB DRH ISKEMI ?AR.YBSISKEMI ?AR.YBS

BR KLNISBR KLNIS

G*. K#$#' #920 & % 8 G*. K#$#' #920 & % 8

- ."#$%$ (*"3) ok 4% *'"0k'#- ."#$%$ (*"3) ok 4% *'"0k'#

- *"3 #'k*9#- *"3 #'k*9# 82 "3 4% *"ko98"*'# 82 "3 4% *"ko98"*'#

- ."#$%$ (*"3) ok #$ 4% *"ko98"*'#- ."#$%$ (*"3) ok #$ 4% *"ko98"*'#

6 Tk / k .*' GE< PRODROMAL, k*70# 6 Tk / k .*' GE< PRODROMAL, k*70#

6 N4*"# K*8 (H*2), M06 N4*"# K*8 (H*2), M0 M0$3 (S#$"o9M0$3 (S#$"o9

TIK 9*$#$%%#)TIK 9*$#$%%#)

6 O$'* / S*"$%$ '*"#$%k# 8 S#$% 3"#, !k06 O$'* / S*"$%$ '*"#$%k# 8 S#$% 3"#, !k0B*"k*%#$, E9o'#B*"k*%#$, E9o'#

• HEMIPARESIS 8 HEMIPLEGIHEMIPARESIS 8 HEMIPLEGI LANGSUNGLANGSUNG

TER?ADI (da&/ a>a38'n+%) TER?ADI (da&/ a>a38'n+%)

• KESADARAN BIASANYAKESADARAN BIASANYA ↓↓ KOMAKOMA

( d34 KT < #8 a4( d34 KT < #8 a4

KOMAKOMA$ d34 KT #81 a4 (KOMA)$ d34 KT #81 a4 (KOMA)

# %&ad/ ; ?a4 1 # *a&/)# %&ad/ ; ?a4 1 # *a&/)

• GE?ALA FOKAL (NEUROL) LAINGE?ALA FOKAL (NEUROL) LAIN

TERGANTUNG TERGANTUNG PB DRH OTAK YG PB DRH OTAK YG

ROBEK, YG ISKEMI, YG TERTEKAN (LIHATROBEK, YG ISKEMI, YG TERTEKAN (LIHAT

GE?.KLINIS SI) 2 NHSGE?.KLINIS SI) 2 NHS

• GE?ALA AKIBAT EDEMA OTAK KOMA,GE?ALA AKIBAT EDEMA OTAK KOMA,

BRADIPNEU8GGN. RESP, BRADIKARDI,BRADIPNEU8GGN. RESP, BRADIKARDI,

d33.d33.

DIANOSIS PISDIANOSIS PIS

ATAS ATAS

1 KLINIS A/ & P1 KLINIS A/ & P

: LAB LIKUOR: LAB LIKUOR BERDRH (ERITROSITBERDRH (ERITROSIT 1/991/99>>))

> CT-S7$$#$% (S7$-TOMOGRAFIK) HIPERDENS> CT-S7$$#$% (S7$-TOMOGRAFIK) HIPERDENS(98k 80#3) 9 ."3*9#'*", 0 9'0k(98k 80#3) 9 ."3*9#'*", 0 9'0k@*$"#k*/"0$% '0"k3$o# (8) #k*##$%# *"3 /@*$"#k*/"0$% '0"k3$o# (8) #k*##$%# *"3 /7#$7#$ 3#8o*$' (**9 ok) + 8*$o"o$%$ %"#'7#$7#$ 3#8o*$' (**9 ok) + 8*$o"o$%$ %"#'

*$%3 ( 7*"*2"#)*$%3 ( 7*"*2"#)K#$# %$ CT-S7$$#$% ( & MRI)K#$# %$ CT-S7$$#$% ( & MRI) D/ *2#3D/ *2#3*"8*"74*"8*"74 *k# 1 *k# 1

AMBARAN CT SCAN MRI PADA STROK NHS &HS9

#. SI (NHS)#. SI (NHS)

. PSA. PSA

$. ENSEFALOPATI HIPERTENSIF (HE) 2$. ENSEFALOPATI HIPERTENSIF (HE) 2EHEH

DD PIS

DD PISDD PIS

,E"ALATES,E"ALATES EHEH PISPIS

11 D*#'# 0$#okD*#'# 0$#ok

:: HT 9#%$HT 9#%$

>> L#k0o" L#k0o" CT-S7$$#$%CT-S7$$#$%

G%$ P08#G%$ P08#

(R*D#9**")(R*D#9**")

<*"$#3<*"$#3 No"9 No"9

S$%0#$o*$ ( "3(+))S$%0#$o*$ ( "3(+))2N2N

+ (8 '* $.0)+ (8 '* $.0)

DDDD SISI PSAPSA PISPIS

11 D*#'# okD*#'# ok

:: TIA/SOSTIA/SOS

'*2*09$4'*2*09$4>> ONSETONSET

N4*"# K*8 N4*"# K*8

M0$3M0$3

K*'"$K*'"$

Kk0 k00k Kk0 k00k

L#k0o" (DRH)L#k0o" (DRH)

R#$%$/2*"R#$%$/2*"

+ (2#')+ (2#')

P*$ (.9/3"#)P*$ (.9/3"#)

k*70# E92o#k*70# E92o#

*#k*#k 9*$#)9*$#)

T#k/"#$%$T#k/"#$%$

Tk (k*70# #Tk (k*70# #

BTG Ok)BTG Ok)

N/KDG N/KDG ↓↓

T#k T#k

<*"$#3 (DRH-)<*"$#3 (DRH-)(*"# 99(*"# 99>>))

R#$%$R#$%$

1 : 9*$#1 : 9*$#

S$% 3*2 (+)S$% 3*2 (+)

S*"#$%S*"#$%

B#'/B#'B#'/B#' ↓↓S*2*$" S*2*$"

B#' (+)B#' (+)

D"3 (+) (: D"3 (+) (:

1/991/99>>))

B*"B*"

<"$%<"$%

M*$#/.9M*$#/.9

H*2H*2

S*"#$%S*"#$%

B#'B#' ↓↓ Ko9Ko9

++ (B#')(B#')

S*"#$% (+)S*"#$% (+)(( 1/991/99>>))

PRO,NOSIS SERIUS DI PEN,ARUHI OLEHPRO,NOSIS SERIUS DI PEN,ARUHI OLEH

11 D*". k*'"$ Ko9D*". k*'"$ Ko9 11 †† '" '" 11 ††:: U'# U'# ↑↑ 0'#0'# ↑↑$%k$%k †† ( 3( 3 Mo"#'Mo"#' ↑↑))

>> <*$#' Lk 2$4k<*$#' Lk 2$4k † (1) P" (1 )† (1) P" (1 )

U909 T*k DRH TDU909 T*k DRH TD ↑↓↑↓ P"o% .**k P"o% .**k

R/ 92R/ 92 P"o% 20"0k P"o% 20"0k

TERAPI U/U/TERAPI U/U/ ABC d R SI (NHS) ABC d R SI (NHS)

J KHUSUS K0'KHUSUS K0' O2 k 2$4k 3"8$ O2 k 2$4k 3"8$ A' T"$*k'9 1%"/#@/ .9A' T"$*k'9 1%"/#@/ .9 > 9#$%%0> 9#$%%0

O8*"'# B# Lo7P*""3$ S08*"#7#O8*"'# B# Lo7P*""3$ S08*"#7#

J REHAB : 9% >9%REHAB : 9% >9% FT ' SIFT ' SI

PERDARAHAN SUBARAKHNOID (PSA) SAHPERDARAHAN SUBARAKHNOID (PSA) SAH

J DEF DRH TERDPT /MASUK KEDEF DRH TERDPT /MASUK KE

RSUBARAKHNOIDRSUBARAKHNOID

J PEMBAGIAN PEMBAGIAN

1 PSA PRIMER (SPONTAN) 82 "3 SA "o2*k,1 PSA PRIMER (SPONTAN) 82 "3 SA "o2*k,

"3 20k$ "# 8"*$k#9 ok (& 20k$ ok"3 20k$ "# 8"*$k#9 ok (& 20k$ ok

TRAUMA)TRAUMA)

: PSA SEKUNDER : PSA SEKUNDER

' "3 "# 0" RSUBARAKHNOID 9#'' "3 "# 0" RSUBARAKHNOID 9#'"# 8"*$k#9 ok (PIS) 0 T09o" Ok "# 8"*$k#9 ok (PIS) 0 T09o" Ok

ETIOLOGI ETIOLOGI

#.#.ANEURISMA PECAH ( )ANEURISMA PECAH ( )

..Ma35'&4a+/ AV (MAV) 9-a* () 8Ma35'&4a+/ AV (MAV) 9-a* () 8

An/'4aAn/'4a$.$.S7nd& (PIS 8 T7 O%a) ( )S7nd& (PIS 8 T7 O%a) ( )

=.=. Ta d/. Ka7+an6a ( ) Ta d/. Ka7+an6a ( )

EPIDEMIOLOGIEPIDEMIOLOGI

J PSA ? 1 k'0' GPDOPSA ? 1 k'0' GPDO

J INSIDENS INSIDENS

- USIA *k* > - USIA *k* > (: I #920 (: I #920

8 3$) 8 3$)

-- <ENIS<ENIS KEL MA5 k#-k# 8*"*980$KEL MA5 k#-k# 8*"*980$

CLINICAL !EATURES :CLINICAL !EATURES :

J G*. P"o"o9 N4*"# k*83*2 & 9*$k ? 1G*. P"o"o9 N4*"# k*83*2 & 9*$k ? 1

J K*'"$ *"%% - "#$%$, '*2*$", 0 UP &K*'"$ *"%% - "#$%$, '*2*$", 0 UP &Do$, 2*"@"#'#Do$, 2*"@"#'#

- 2#' *#*" '8 ko9- 2#' *#*" '8 ko9

J T$ "$%'$% MENINGEAL (+) (kk0 k00k &/k*"$#%' '#%$)T$ "$%'$% MENINGEAL (+) (kk0 k00k &/k*"$#%' '#%$)

J G*. N*0"ook "#$%$, %, *'# 82"3 4% *"%% (#3 DDG*. N*0"ook "#$%$, %, *'# 82"3 4% *"%% (#3 DD PIS & SI)PIS & SI)

DIANOSIS :DIANOSIS :

11 KLINIS A & PKLINIS A & P

:: L#k0o" - 2*""3 (398#" 1)L#k0o" - 2*""3 (398#" 1) E"#E"#

:-1 "#20 /99:-1 "#20 /99>>

- 0 '$ok"o9 ('*3 8*""3$- 0 '$ok"o9 ('*3 8*""3$

.9 .9 > 3"#)> 3"#)> PEMSKEN TOMOGRAFIK H#8*"*$'> PEMSKEN TOMOGRAFIK H#8*"*$'

%$ Q Ko$"'%$ Q Ko$"' 8 *"#3 A$*0"#'9 / M@8 *"#3 A$*0"#'9 / M@

ANGIOGRAFI '*3 22"8 3"# 8'7 o$'* ANGIOGRAFI '*3 22"8 3"# 8'7 o$'*(ko$"'(ko$"' A$*0"#'9 / M@ (+))A$*0"#'9 / M@ (+))

SONOGRAFI (TCD ?T"$'7"$# Do88*") SONOGRAFI (TCD ?T"$'7"$# Do88*")

PEMERIKSAAN TCD

PRONOSIS : 1)1 $PRONOSIS : 1)1 $

J E#oo%# E#oo%#

- 8 A$*0"4'9- 8 A$*0"4'9 20"0k 20"0k

- 90#8* 20"0k 8 #$%%- 90#8* 20"0k 8 #$%%

- ok'# $*0"/M@ 7o9$ & 7*"*2"#- ok'# $*0"/M@ 7o9$ & 7*"*2"#

$$ .**k .**k '*"#$% 9'0k '*"#$% 9'0k PIS /@*$"#k*PIS /@*$"#k*

J U'# $.0U'# $.0 20"0k 20"0k

J Ko9 : .9Ko9 : .9 20"0k 20"0k

J K*.$% S8'9*, HT,PSA 0$%$K*.$% S8'9*, HT,PSA 0$%$ 8"o% .**k 8"o% .**k

TERAPI :TERAPI :

#.#. TERAPI FASE AKUT (1 +8d "$ 4/n7) 2 TERAPI FASE AKUT (1 +8d "$ 4/n7) 2

PISPIS

.. Pa+-a a7%Pa+-a a7% An/'&a #An/'&a # 78Bda*78Bda*

Sa&a5 K3/9/n L/a+/ PB D 6+Sa&a5 K3/9/n L/a+/ PB D 6+

$.$. R8 N/4'd/9/n (Pa+-a A7%) 78 Ca*R8 N/4'd/9/n (Pa+-a A7%) 78 Ca*

S9a+4S9a+4

=.=. R*a (PB DRH Pa+-a PSA)R*a (PB DRH Pa+-a PSA)

TERAPITERAPIUMUMUMUM

UMUMUMUM

B B B1 R*'8#"'# (B"*3#$%) *".9#$ .$ $8'B1 R*'8#"'# (B"*3#$%) *".9#$ .$ $8'

OO::- PAO- PAO::, PACO, PACO::

B: Boo, T*".9#$$4 '#"k0'# 0909 <TG,B: Boo, T*".9#$$4 '#"k0'# 0909 <TG,

TD, DRH (H2 ), 5#'ko'#' I$k*TD, DRH (H2 ), 5#'ko'#' I$k*

C#"$, A'9-B', K N CC#"$, A'9-B', K N C

B> B"#$ (Ok) P$'B> B"#$ (Ok) P$'

↓↓

K*.$%K*.$%

R/R/O**9 okO**9 ok R/ K*'"$R/ K*'"$

B B*", K**" B B*", K**"

5U, TU5U, TU O0 80 I$80 S%$'#O0 80 I$80 S%$'#

U"#$* = R/=-U"#$* = R/=- > 9/.9> 9/.9B Bo* (TGI) R/N0"#'# PE$*" o"B Bo* (TGI) R/N0"#'# PE$*" o"

(I$0' / So$* 920$%)(I$0' / So$* 920$%)

O2'#8'#O2'#8'# (%*#'3, '*'k )(%*#'3, '*'k ) R/R/

Po'#'# P*$ E*@'# k*8 & 230 :Po'#'# P*$ E*@'# k*8 & 230 :

KHUSUSKHUSUS

STROK ISKE/IK STROK ISKE/IK

SASARAN ATASI ISKEMIKSASARAN ATASI ISKEMIK

CBF TER<AMINCBF TER<AMINTINDAKAN 6 TD TDK DITURUNKAN =TINDAKAN 6 TD TDK DITURUNKAN =

('* k0 1-1 3"# I)('* k0 1-1 3"# I)

: 99H%): 99H%)

6 GD6 GD : 9% TDK #0"0$k$: 9% TDK #0"0$k$('* k0)('* k0)

R/ - T*"8# 0909 *".9#$R/ - T*"8# 0909 *".9#$

- O2 ANTHINE- O2 ANTHINESS

NOOTROPHIC NOOTROPHICSS

ERGOTERGOTSS CODERGOCRINE, CODERGOCRINE,

- PEN; DASAR / RISIKO- PEN; DASAR / RISIKO

R/ BEDAHR/ BEDAH

TERIMA KASIHTERIMA KASIH

TIN?AUAN UMUM

TIN?AUAN UMUMNEUROLOGI• TIN?AUAN UMUM NEUROLOGI

• BATASAN NEUROLOI

• ANATOMI SUSUNAN SARAF " PUSAT TEPI

N.MUSKULAR

• FISIOLOGI FUNGSI SUS.SARAF

. OTONOM . FUNGSI LUHUR

. SENSORIK . MOTORIK

TIN?AUAN UMUM STROKEQ

•ANATOMI VASKULAROTAK

!AAL SIRKULASI OTAK

PHYSIOLOY O! CEREBRALPHYSIOLOY O! CEREBRAL

CIRCULATIONCIRCULATION

FISIOLOGI SIRKULASI SEREBRALFISIOLOGI SIRKULASI SEREBRAL

OTAK MEMERLUKAN DARAH SINAMBUNG(%78OOTAK MEMERLUKAN DARAH SINAMBUNG(%78O<<@GLUKOSA)@GLUKOSA)

ALIRAN DARAH OTAK (ADO) 2 CBF (C&&a3 B3''d F3'>)ALIRAN DARAH OTAK (ADO) 2 CBF (C&&a3 B3''d F3'>)

TGT PD $ FAKTOR UTAMA TGT PD $ FAKTOR UTAMA

#. TEKANAN (DARAH) PERFUSI KE OTAK #. TEKANAN (DARAH) PERFUSI KE OTAK

. TAHANAN PD PERIFER OTAK. TAHANAN PD PERIFER OTAK

$. DRH VISKOSITAS @ DAYA KOAGULASI ,Pa O8CO ,dan 9H$. DRH VISKOSITAS @ DAYA KOAGULASI ,Pa O8CO ,dan 9H

BRAIN NEEDS CONTINUOUSLY & OPTIMAL BLOOD SUPPLY "#$ %'"("')*+O2N',-..* -/01 5 – 7 ,. % BLOOD,(01" )' % /'1##0"

CEREBRAL BLOOD !LO CB!9 DEPENDS ON :

•CEREBRALL PERFUSION PRESSURE (CPP)• CEREBRAL PERIPHERAL RESISTANCE•FACTORS OF BLOOD VISCOSITY,COAGULOBILITY, 9H, Pa O8CO '5BRAIN

TEK.PERFUSI, DITENTUKAN OLEH TEK.PERFUSI, DITENTUKAN OLEH

#.#. TD SISTEMIK ?ANTUNG,DARAH,PB DRH TD SISTEMIK ?ANTUNG,DARAH,PB DRH

.. AUTOREGULASI PB ARTERIOL OTAK AUTOREGULASI PB ARTERIOL OTAK

$.$. TAHANAN PERIFER (OTAK) TAHANAN PERIFER (OTAK)

( DAYA AUTOREGULASI P.D. OTAK( DAYA AUTOREGULASI P.D. OTAK

2 KEMAMPUAN KHUSUS ARTERIOL OTAK U8 VASOKONSTR. BILA TD SISTEMIK2 KEMAMPUAN KHUSUS ARTERIOL OTAK U8 VASOKONSTR. BILA TD SISTEMIK ↑↑

@ MELEBAR (VASODILATASI) BILA TDS@ MELEBAR (VASODILATASI) BILA TDS ↓↓))

CPP CEREBRAL PER!USION PRESSURE9(;0"(<" /* :

1. SYSTEMIC BP ( MABP24an a&%&/a3 3''d 9&++7&)*a&% , 3''d @ :a+-.-'nd/%/'n

MABP 2 #8$( # SBP DBP )2. CEREBRAL VASCULAR AUTOREGULATION

(AUTOREGULATION) = The neurohuor!" #n$uen%e on &r!#n !r'er#o"e#!e'er

!!#n*' CPP %h!ne* #n orer 'o !#n'!#ne CB+ ,. CEREB.PERIP-ERAL RESISTANCE

BLOOD FACTORS

. DARAH . DARAH VISKOSITAS VISKOSITAS KOAGULOBILITAS KOAGULOBILITAS

KDR 8 TEK.PARSIAL GAS KDR 8 TEK.PARSIAL GAS

1 P1 PAA COCO<< ↑↑ 8 P8 PAAOO<<↓↓ 8PH8PH ↓↓ V.DILATASIV.DILATASI

1 P1 PAA COCO<< ↓↓ 8 PAO8 PAO<< ↑↑8 PH8 PH ↑↑ VASOKONSTVASOKONST

BLOOD FACTORS

•VISCOSITY %* ;:/+-'+/%6, %* < :3'-/%6 1; %* <CBF

•COAGULOBILITY %* 4'& -'a73a31; +3'>& 1;

< CBF•BLOOD ACIDIY %* ; a-/d 1; VASODILATION

• %* <a-/d VASOCONSTRICTION

PEMBAGIAN STROK

•STROK ISKEMIK ( NHS ) TROMBOSIS

• EMBOLUS

• VASKULITIS• HEMODINAMIK

STROK HEMORAGIK (HS) .PIS (ICH)

.PSA (SAH)

FAKTOR RISIKO

•HT, P.?TG, DM, MEROKOK,OBESE,DISLIP

•USIA TUA, HIPERHOMOSISEIN,PERNAH TIA8STROK

•ANOMALI PB.DRH

•OBAT

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