Dr. Syarif Indra, Sp.S Bagian Neurologi FK-Unand RS. DR.

M Djamil Padang

DEFINISI Gangguan fungsi otak akut akibat ggn suplai darah diotak, atau perdarahan yang terjadi mendadak yang menyebabkan defisit neurologik (ringan-berat-kematian)

Arteri-Arteri Serebralis

FACTORS ASSOCIATED WITH AN INCREASED RISK OF STROKE

* Epidemiologi :
- Age - Gender - Race Elderly>middle-aged or young adult > children Men > women in each age group Blacks > asians or Hispanics > whites

- Geographic region

Eastern Europe > Western Europe ; Asia > Europe or North America
Stroke or heart disease < age 60

* Family History

* Other, potentially modifiable, factors :#

Diastolic or isolated systolic hypertension Diabetes melitus , type 1 or type 2 Hyperlipidemia (hypercholesterolemia) Hyperhomocystenemia Smoking Alkohol abuse Drug abuse Oral contraceptive use

I. Faktor Resiko Yang Dapat Dikendalikan 1. HIPERTENSI Pengaruh Hipertensi 1. Sebagai faktor sekunder : - TIA (Transient Ischemic Attack) - Trombosis serebri 2. Sebagai faktor primer Arteriosklerosis mempengaruhi arteriol otak rapuh: perdarahan otak

2. Diabetes Melitus : memperlambat atherosklerotik dari arteri-arteri besar dan arteri kecil gejala lebih berat, outcome lebih buruk 3. Penyakit Jantung : atrium fibrilasi (yang lebih sering) , mitral stenosis, Coronary artery disease, Hypertensi Heart Disease, LVH, reumatik HD, endokarditis, protese katup jantung

Hiperlipidemia : kolesterol total , LDL , HDL , trigliserida 5. Obesitas : hiperagregabilitas trombosit 6. Merokok : konsentrasi fibrinogen, penebalan dinding arteri, viskositas darah 7. Obat anti hamil dgn kadar estrogen 8. Polisetemia vera Hb > 18 9. Hyperhomocysteinemia 10. Drug abuse 11. Faktor resiko yang tak dapat dikendalikan Umur, herediter, gender, race 4.

HEMATOLOGIC OR COAGULATION DISORDERS CAUSING ISCHEMIC STROKE

- Polycythemia rubra vera - Protein C or S deficiency - Antiphospholipid/ anticardiolipin antibodies - Nephrotic syndrome

- Malignancy
- Oral contraceptives - Dehydration

PATIENTS AT HIGHEST RISK

Persons with the following conditions are at the highest risk ischemic stroke : - Atrial Fibrillation - Asymptomatic stenosis of the carotid artery - Amourosis Fugax - TIA - Previous ischemic stroke

PEMBAGIAN STROKE
Berdasarkan lesi pada otak, stroke dibagi 2 :
1. Infark (non hemoragik stroke) - TIA / RIND

- Trombosis serebri
- Emboli serebri 2. Perdarahan otak (hemoragik stroke)

- Perdarahan intraserebral/serebeller - Perdarahan subarachnoid

Non Hemorhagik :
TIA (Transient Ischemic Attack) Definisi Gangguan peredaran darah otak sepintas, yang menimbulkan ggn fungsi otak sebentar, membaik sblm 24 jam Patogenese : lihat buku ajar neurologi Etio : - Spasme pembuluh darah yg sdh aterosklerotik - Mikroemboli dari jantung - Polisitemia - Kelainan paru - Steal sindrom (dari a. karotis ke subklavia )

Gejala Klinis : tergantung lokasi

1. Sistem Carotis : Amaorosis fugax, disartri, hemiparesis, reflek patologik+, hemihipestesia, afasia (hem dominan) 2. Sistem Vertebrobasiler Drop attack (khas), parese sekitar mulut, buta sepintas, diplopia, disfagia, disfungsi serebelum (dgn gejala spt ataksia , disartri, nistagmus, hipotoni, reflek menurun, vertigo dll)

Terapi :
1. Anti platelet agregasi: Aspirin, dipiridamol, pentoksifilin, indobufen, tiklopidin, cilostazol, clopidogrel 2. Obati faktor risiko 3. Pemberian obat jangka panjang (bisa bertahun-tahun)

TROMBOSIS SEREBRI Gejala klinik : Defisit neurologik akut/sub akut/progresif, kesadaran biasa baik Hemiparese/hemihipestesi/disartri/babinski + Neurogenic bladder (jenis un inhibited bladder) Serangan waktu istirahat, sering usia tua >50 th Bila infark luas edema TIK bisa herniasi tentorial dalam 72 jam atau lebih kematian Nn kranial VII, XII terkena (dipersarafi oleh satu hemisfer) nn kranial lain tak kena (dipersarafi dua hemisfer)

Diagnosis : Cepat, tepat, bedakan dgn perdarahan periksa lab terkait , CT Scan kepala ( tampak bayangan hipodens ), MRI, TC doppler, kalau perlu LP
TERAPI Umum : sesuai dengan penanganan pada stroke akut ; jalan nafas, oksigenasi, atur intake cairan, sesuaikan kalori, elektrolit , atasi demam makanan tergantung kondisi umpama RG, diet rendah lemak dll

TERAPI

Khusus : 1. Antiedema : gliserol, manitol, kortikosteroid 2. Obat sitoprotektif : utk melindungi jaringan penumbra gol Ca antagonis 3. Antiplatelet agregasi 4. Anti koagulan (trombolitik), Recombinant Tissue Plasminogen Activator (rTPA) 5. Metabolik aktivator 6. Obati faktor resiko / peny penyerta

- Bila hipertensi : 3-5 hari pertama tak diturunkan kecuali hipertensi emergensi ( diast > 120 atau MABP > 140 mmHg) - Rehabilitasi, fisioterapi pasif/aktif - Resosialisasi - Bila mengenai kedua hemisfere ( yg kiri disusul yg kanan) hemiparese duplek Lesi tract pyr ki hemip ka Hemip Lesi tract pyr ka hemip ki duplex Nn kranialis ki-ka ( VII,IX,X,XI,XII) ikut lesi gangguan menelan, bicara, mimik, afasia muka topeng (pseudobulber paralise) .. tipe UMN Bedakan dengan bulber paralise ! tipe UMN

EMBOLI SEREBRI

- > 90 % dari kelainan jantung - Partikel/plaq trombus yg nempel di katup jantung lepas ke otak oklusi arteri otak Gejala klinis : Gejala motorik / sensorik sesuai lesi dll seperti pada trombosis serebri. Bila embolus besar bisa delirium, pingsan, gelisah , kesadaran menurun, kejang

Diagnosa
- Ada sumber emboli dari ( kelainan jantung ) - Gej waktu serangan sudah maksimal; gambaran klinis spt trombosis - Tanda klinis emboli pada organ lain - CT Scan : infark multipel, sekitar infark tampak petechie - Mudah meluas menjadi infark hemoragik ( dgn gejala-gejala seperti perdarahan otak )

TERAPI Khusus : anti edema, antikoagulan (trombolitik), low moleculer weight heparin (nadroparin, enoxaperin), streptokinase , rTPA, cegah emboli ulang, obati penyakit jantung lainnya spt tromb serebri

LESI BATANG OTAK - Mesensefalon Sindroma Weber : hemiplegi spast kontralateral, parese N III ipsilateral (tipe infra nuklear) - Pons Sindroma Foville : hemiparese kontralateral, konjugasi kesisi lesi. Sindroma Millard Goebler : deviasi konjugae kesisi lesi, Parese VII ipsilateral tipe infra nuklear

- Medula Oblongata Sindroma Wallenberg (tromb a. vertebral) atau a.serebelli post. inferior - vertigo, muntah, cekukan, disfagi - Analgesi, termo anastesi wajah homo lateral - Hemiparese kontralateral - Sindroma horner ( miosis, ptosis,enoptalmus) - Gejala serebelum : ataxia, hipotoni, nistagmus, vertigo

Hemorhagik Stroke
1. Perdarahan Intra Serebral
- Hemisfer (kortek atau subkortex 80%) Serebelum: 20% - Bila perdarahan kecil: bisa gejalanya spt tromb CT Scan baru ketahuan (tampak bayangan hiperdens)

Gejala Klinis
- Kesadaran menurun : 65% langsung koma, 23 % - 2 jam kemudian, 12% 2 jam bbrp hari - Mual, muntah, nafas ngorok, kejang - Hemiparese/hemi hipestesi kontra lateral - Parese nn kranialis (sesuai topik lesi)

2. Perdarahan Intra Serebeller - Darah mendesak di fossa posterior - Peningkatan TIK, pusing, muntah, singultus, ggn okulomotorius - Gejala lesi serebeler : ataxi, nistagmus, reflek fisiologis menurun dll, hemiparese (-) - Penekanan pada pons: rigiditas, dekortikasi, pupil pin point - Penekanan pada medula oblongata gejala lebih berat mengenai inti-inti nervi kranialis vital, rigiditas deserebrasi kematian

Diagnosa

Klinis, CT Scan, MRI, LP bila perlu leukosit meningkat 15-20000, hiperglikemik reaction Terapi - Pencegahan TIK meningkat herniasi (beri anti edema) - Anti konvulsi, bila TD meningkat edema meningkat TIK meningkat, hati-hati menurunkan TD - bila TD menurun iskemik meningkat segera atasi menjaga kerusakan neuron

Obat hemostasis : tranexamic acid 6 gr/hr IV 3 mg/anti fibrinolitik, cegah perdarahan ulang - Prognosis : 10 % meninggal sblm pengobatan 40 % meninggal tanpa perbaikan - Mortalitas + 60 % penyebab terbanyak : perdarahan ulang

3. Perdarahan Subarahnoid Etio : - Aneurisma intrakranial yg pecah - AV malformasi pecah - Sekunder terhadap PIS Gejala klinis - Aneurisma pesah s.kep hebat, mual, muntah - Rgs meningen kaku kuduk, brudzinski, kernig - Funduskopi: perdarahan subhialoid (+), edema papil 10% - Gejala motorik/sensorik sesuai lesi - Ggn kesadaran: variasi ringan-koma - Otonom: keringat meningkat, takikardi - Stres ulcer hematemesis - Sekitar perdarahan vasospasme iskemik infark

Diagnosis
Klinis - CT Scan kepala, bila perlu LP
-

Terapi
Antispasme disekitar perdarahan, dpt diberikan Ca antagonis Cegah perdarahan ulang: (hemost agent/sbg antifibrinolitik, anti konvulsan, atasi kegelisahan) Antiedema Antikonvulsi Nyeri kepala + cemas : analg sedatif Laxansia Anti hipertensi

Public must learn the correct response to a stroke to seek medical attention immediately BRAIN ATTACK COMMON SYMPTOMS OF STROKE Information to be Taught to the Public : - Sudden onset of the symptoms - Weakness, clumsiness, heaviness, or numbness one side of the body hand or face - Drooping of one side of the face - Slurred speech of difficulty understanding language - Loss of or blurred vision in one or both eyes - Dizziness or in balance - Unusually severe headache

INFORMATION TO BE OBTAINED IN THE FIELD BY EMERGENCY MEDICAL SERVICES

- Time of onset of neurologic symptoms

- Determine nature of neurologic symptoms :

Weakness of arm or face Slurring of speech or abnormal language - Rate GCS score : Language Eye movement Motor response - History of recent illness, surgery, or trauma - Recent use of medications

LEVEL OF EVIDENCE USED AS GUIDELINES FOR TREATMENT OF CEREBROVASCULAR DISEASE

Level I Data collected from large, randomized, controlled clinical trials which provide clear evidence of treatment effect. Data from meta-analyses can be used as supporting information. This level of evidence can be used as the basis for the strongest recommendations (grade A) Level II Data collected from randomized, controlled clinical trials which provide evidence of treatment effect. Data from meta-analyses can be used as supporting information. This level of evidence can be used as the basis recommendations of intermediate strength (grade B) Level III Data collected from nonrandomized studies that compare result of treatment with concurrent patients who do not receive the treatment.

Level IV Data collected from nonrandomized studies that compare result of treatment with concurrent patients who did not receive the treatment in the past (historical controls) Level V Data collected from case series or reports. The weakest recommendations ( Grade C) are based on levels III-V evidence

Literatur
-

Adams RD. Principles of neurology 6th ed Mc Graw Hill 1997 Caplan LR. Stroke. A Clinical Approach 2nd ed Butterworth Heinemann 1993 Guidelines Stroke 2004 (PERDOSSI) Harsono, Buku Ajar Neurologi, Bab II Harsono, Kapita selekta neurologi, Bab II Simon RP, Aminof MJ, Clinical Neurologi Adams HP. Jr et al. Management of Stroke 2 nd ed. Professional Communications. Inc 2002