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    Stroke Hemoragik: Dr. Puji Pinta O. Sinurat, Sps Bagian Neurologi Fk-Umi 2019

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    Desima Tamara sinurat
    This document discusses hemorrhagic stroke, which can be either intracerebral or subarachnoid. Intracerebral hemorrhage involves bleeding directly into the brain tissue, often due to hypertension. Subarachnoid hemorrhage involves bleeding into the subarachnoid space, commonly from aneurysms or arteriovenous malformations. Clinical presentation, risk factors, diagnosis, complications, and treatment approaches are described for both types of hemorrhagic stroke.

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    Stroke Hemoragik: Dr. Puji Pinta O. Sinurat, Sps Bagian Neurologi Fk-Umi 2019

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    Desima Tamara sinurat
    150 views28 pages
    This document discusses hemorrhagic stroke, which can be either intracerebral or subarachnoid. Intracerebral hemorrhage involves bleeding directly into the brain tissue, often due to hypertension. Subarachnoid hemorrhage involves bleeding into the subarachnoid space, commonly from aneurysms or arteriovenous malformations. Clinical presentation, risk factors, diagnosis, complications, and treatment approaches are described for both types of hemorrhagic stroke.

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    STROKE HEMORAGIK

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    This document discusses hemorrhagic stroke, which can be either intracerebral or subarachnoid. Intracerebral hemorrhage involves bleeding directly into the brain tissue, often due to hypertension. Subarachnoid hemorrhage involves bleeding into the subarachnoid space, commonly from aneurysms or arteriovenous malformations. Clinical presentation, risk factors, diagnosis, complications, and treatment approaches are described for both types of hemorrhagic stroke.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    150 views28 pages

    Stroke Hemoragik: Dr. Puji Pinta O. Sinurat, Sps Bagian Neurologi Fk-Umi 2019

    Uploaded by

    Desima Tamara sinurat
    This document discusses hemorrhagic stroke, which can be either intracerebral or subarachnoid. Intracerebral hemorrhage involves bleeding directly into the brain tissue, often due to hypertension. Subarachnoid hemorrhage involves bleeding into the subarachnoid space, commonly from aneurysms or arteriovenous malformations. Clinical presentation, risk factors, diagnosis, complications, and treatment approaches are described for both types of hemorrhagic stroke.

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    of 28

    STROKE HEMORAGIK

    Dr. Puji Pinta O. Sinurat, SpS


    Bagian Neurologi FK-UMI
    2019
    STROKE HEMORAGIK

    1. PERDARAHAN INTRA SEREBRAL

    2. PERDARAHAN SUB ARACHNOID


    Hemorrhagic Stroke
     Intracerebral

    ◦ Blood leaks directly into brain


    parenchyma
    ◦ HTN most common cause
    Hemorrhagic Stroke
     Subarachnoid
    ◦ Blood leaks from
    cerebral vessel into
    subarachnoid
    space
    ◦ If arterial, sudden
    and painful
    ◦ Aneurysms and
    AVMs
    Distribution of ICH

    LOCATION % OF CASES
    Putamen 30-50

    Subcortical Whitematter 30

    Thalamus 10-15

    Pons 5-12

    Cerebellum 9

    The American Academy of Neurology Institute, 2012.


    Types of ICH

    Primary (80-90% of cases) : when ICH


    originates from spontaneous rupture of
    small arteries or arterioles damaged by :
    chronic hypertension or cerebral amyloid
    angiopathy
    Secondary : when ICH results from
    trauma, rupture of an aneurysm, vascular
    malformation, coagulopathy or other
    causes
    Etiologi:
     Hipertensif
     Non-hipertensif

    - cerebral amyloid angiopathy


    (CAA)
    - antikoagulansia / thrombolitik
    - neoplasma
    - drug abuse
    - aneurisma / AVM
    - idiopatik - dll.
    PIS Hipertensif
     Penderita hipertensi kronis:
    arteriosklerotik pemb.darah kecil 
    perubahan2 pd.ddg. pemb.darah 
    aneurisma (Charcot Bouchart neurysm)
     pecah  PIS
     Lokasi:

    - talamus - kapsula interna


    - basal ganglia - lobar dll.
     Cerebral amyloid angiopathy (15% cases)

    = Deposition of beta-amyloid protein in media


    and
    adventitia of brain arteries and arterioles leed
    to loss of smooth muscle wall, wall thickening
     micro aneurysma formation (Wiswanathan A,
    et al. Ann Neurol. 2011 Dec;70(6):871-80.)

    Lancet Neurol 2005;4:662-72


    Gejala klinis.
     Terjadi waktu aktif
     Nyeri kepala hebat  kesadaran

    menurun  koma.
     Riwayat hipertensi kronis
     Defisit neurologis tergantung lokasi dan

    luas hematom
     Hematom di lobus frontalis &

    temporalis  kejang2 / hemiparesis


    kontralateral
    Diagnosis
     History : trauma, hypertension, prior ischemic
    stroke, DM, smoking, alcohol and prescription, over-
    the-counter, or recreational drugs such as cocaine;
    use antithrombotic, hematologic or other medical
    disorders that predispose to bleeding, such as severe
    liver disease.
     Risk factors
     Age
     Physical examination including BP, cardiac
     Laboratory testing : INR, PTT, urine tox screen, CBC,
    ECG
     CT scan features
     Further brain imaging (MRI/CTA/angiography)

    Mayer SA, Rincon F. 59th AAN 2007


    Prosedur diagnostik

     X-foto tl. Tengkorak


     Head ct scan
     LP
     Arteriografi
     MRA
    KOMPLIKASI
     HIDROSEFALUS
     HERNIASI

    - Cinguli
    - Uncal herniasi
    - Transtentorial herniasi
    DIAGNOSA BANDING

     Penyebab koma dan SOL yg lain


     Infark serebri
     Pecahnya Berry aneurism.
    Pengobatan.
     Prinsipkonservatif
     Perawatan koma
     Kontrol hipertensi: TD yg tinggi 

    perdarahan & edema serebri : MAP


    110 mmHg mulai terapi.
     Mengatasi edema serebri :

    mannitol
    Early Management
    • Airway
    • Blood pressure
    • Oxygenation
    • Hyperventilation
    • Foley’s catheter
    • NG tube
    • Position : head up
    The ICH Score: Prediction of
    30-days mortality

    Hematoma volume > 30 ml


    Glasgow Coma Scale Score < 8
    Infra tentorial location
    Iintraventrikular hemorrhage
    Age
    Calculating the ICH Score
    Glasgow Coma Scale (GCS) Score
    3–4 2
    5 – 12 1
    13 – 15 0
    ICH Volume (cc)
    > 30 1
    < 30 0
    Intraventricular Hemorrhage (IVH)
    Yes 1
    No 0
    Infratentorial Origin of ICH
    Yes 1
    N0 0
    Age (years) > 80 1
    < 80 Total Score 00- 6
    0PERATIF
     Indikasi tindakan operatif :
    - perdarahan intraserebellar > 3 cm
    - perdarahan lobar + diameter > 3
    cm + tanda2 peninggian TIK yg
    cepat /perburukan klinis  dicoba
    tindakan operatif utk life saving.
    !!! Sebelum koma dalam + pupil
    dilatasi maksimal
    Perdarahan Subarakhnoid
    (PSA/SAH)

    Penyebab yg paling sering:


    1. Trauma
    2. Spontan
    2.1. Perdarahan intraserebral
    ruang subarakhnoid
    2.2. Primer: - Aneurisma ( Berry )
    - AVM
    - dll.
    Gejala klinis:
     Sakitkepala yg hebat (occipital), muntah
     Kesadaran menurun  koma,

    tergantung luasnya perdarahan


     Tanda2 perangsangan meningeal: kaku

    kuduk
     Funduskopi: perdarahan retina
     Gangguan psikis
     Kadang2 kejang fokal / umum
    Skala Botterell dan Hunt & Hess

    Grade I. Asimptomatik atau


    sakit kepala dan kaku kuduk
    ringan
    Grade II. Sakit kepala, kaku kuduk sedang
    sampai berat tanpa gejala
    neurologik fokal
    Grade III. Drowsiness, confuse dan defisit
    neurologik fokal ringan
    Grade IV. Stupor atau semikoma, gejala
    permulaan deserebrasi dan
    ggn Vegetatif

    Grade V. koma dalam dan deserebrasi


    Prosedur diagnostik

     LP
     X-ray tl.tengkorak
     CT Scan
     Arteriografi
    DIAGNOSA BANDING

     Migraine
     Infeksi sistemik
     Meningitis / ensefalitis
     Hipertensif ensefalopati
     Arthritis cervicalis
     Infark serebri
    Komplikasi
     Perdarahan ulang

     Vasospasme

     Hidrosefalus akut
    Pengobatan
     Kesadaran menurun  perawatan
    koma
     Perawatan umum
     Bedrest total (lk. 3 minggu)
     Pengobatan simtomatik utk. Sakit
    kepala / gelisah
     Edema serebri: mannitol
     Untuk mencegah vasospasme :

    calsium entry blocker “nimodipine”


    Pengobatan (lanj)

     Tindakan operatif:
    untuk mencegah re-bleeding,
    setelah prosedur diagnostik
    (arteriografi)

    Prognosa:
    Mortalitas masih tinggi.

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