Cerebrovascular disease

dr. Halomoan Saragi Sp,S

RSUD Dok 2 Jayapura
PAPUA

Stroke General

1. Defenisi
Stroke ad suatu keadaan defisit neurologi fokal (hemiparese, Afasia, disartria, hemihipestesi)
Maupun global (↓kesadaran) yang terjadi secara mendadak / tiba2 dlm waktu 24 jam atau
berakhir dengan kematian yg semata mata ad karena ggn vaskuler di otak serta mempunyai
pola gejala yg berhubungan dgn waktu (temporal profile) ==> (improving, worsening, stable)

A stroke, also known as a cerebrovascular accident or CVA is when part of the brain loses its blood
supply and the part of the body that the blood-deprived brain cells control stops working. This loss of
blood supply can be ischemic because of lack of blood flow, or hemorrhagic because of bleeding into
brain tissue. A stroke is a medical emergency because strokes can lead to death or permanent
disability.

Key word : Tiba2, Defisit Neurology

Pada stroke di jumpai
1. Defisit neurologi
2. Mendadak
3. 24 jam atau berakhir dengan kematian
4. Gangguan vaskuler di otak
5. Temporal profile

Kontinuitas supplai darah keotak sgt penting agar dpt menjamin stabilitas fungsi otak.
*5-10 detikTerhentinya sirkulasi darah dlm 5-10 detik saja akan menghilangkan kesadaran
*3 menit Bila lebih dari 3 menit akan terjadi iskemia serebral yg irrepairable di substansia
grisea kortek,nucleus sel basalis sel Purkinye.
Konsumsi oksigen otak sgt tinggi dibandingkan organ lain yi (3,3-3,5)cc/100 gram otak/
menit.
*1 jamDlm waktu satu jam saja sirkulasi otak terhenti seluruh neuron otak akan nekrosis

2. Sinonim
1. Stroke
2. Cerebrovascular accident (CVA)
3. Brain attack
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3. ICD
ICD-10 : I61.-I64.
ICD-9 : 434.91

4.Anatomy Vascularisasi otak

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5.Prevalency / Statistic
Kompas.com -Penyakit stroke menjadi peny penyebab kematian tertinggi di Indonesia.
Di urutan kedua diisi tuberkulosis, kemudian kecelakaan lalu lintas.

6.Etiology, Types, Classification

Stroke membuat aliran darah ke otak menjadi terganggu atau berkurang, keadaan ini akan
membuat otak kehilangan oxygen dan nutrisi lainnya, yang mana dapat membuat sel sel otak
jadi mati sehingga fungsi otak berkurang atau otak tidk berfungsi lagi atau mati
1.Stroke Infark / Ischemic
1.1.Stroke Infark Atherotrombotic
1.2.Stroke ThromboEmboli
2.Stroke Hemorhage
2.1.Stroke Hemorrhage / Perdarahan IntraSerebral
2.2.SAB (Subarahnoidbleding
3.TIA = ministroke

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  Transient ischemic attack, TIA, or ministroke (The stroke symptoms resolve within
minutes, but may take up to 24 hours on their own without treatment. This is a
warning sign that a stroke may occur in the near future.)
 A transient ischemic attack (TIA or mini-stroke) describes an ischemic stroke that is
short-lived where the symptoms resolve spontaneously. This situation also requires
emergency assessment to try to minimize the risk of a future stroke. By definition, a
stroke would be classified as a TIA if all symptoms resolved within 24 hours.

7. Faktor resiko
7.1. Faktor yg tdk dpt dimodifikasi
-1. Usia- -2. Jenis kelamin
-3. Herediter -4. Ras etnik

7.2. Faktor yg dpt dimodifikasi

1. RW Stroke

2. Hipertensi

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3. Peny jtg

Fibrilasi atrial
↓
kardioembolisme,
↓
Kontraksi ventrikel kiri ↓
↓
fibrinogen, D-dimer dan faktor von
Willebrand ↑
↓
Membentuk trombus => jtg MCI
↓
Otak=> strok iskemik

4. DM

5.TIA

6.Hiper kholesterol

7.Penggunaan kontreseps oral

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 Gagasan yg mendasari ad efek hormon
estradiol dlm dosis tinggi (150 mcgs) yg
diduga meningkatkan resiko stroke karena
meningkatkan kekentalan darah.

8.Diet yg tdk terarur

9.Obesitas A poor diet may increase the risk for stroke in

a few significant ways.
 Eating too much fat and cholesterol can
lead to arteries that are narrowed by
plaque.
 Too much salt may contribute to high
blood pressure.
 And too many calories can lead to obesity.
 A diet high in fruits, vegetables, whole
grains, and fish may help lower stroke risk

Hati2 metabolic syndrome

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 x

1. Fasting glucose ≥100 mg/dL (or receiving drug therapy for hyperglycemia)
2. Blood pressure ≥130/85 mm Hg (or receiving drug therapy for hypertension)
3. Triglycerides ≥150 mg/dL (or receiving drug therapy for hypertriglyceridemia)
4. HDL-C <40 mg/dL in men or <50 mg/dL in women (or receiving drug therapy for reduced HDL-C)
5. Waist circumference ≥102 cm (40 in) in men or ≥88 cm (35 in) in women; if Asian American, ≥90 cm
(35 in) in men or ≥80 cm (32 in) in women

Tabel TB dgn BB

10.Merokok
Merokok 
↓
kadar fibrinogen ↑
↓
7 penebalan pembuluh darah
↓
Vasculer jadi sempit dan kaku.
x
Indonesia merupakan negara
pengonsumsi rokok terbesar di
dunia setelah Cina, USA, dan
India. Rerata jumlah rokok yg
dikonsumsi perhari orang
Indonesia sekitar 10 batang

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11.Alkohol

12.Hiperurisemia

Stroke :
Aliran darah tidak lancar akibat penumpukan asam urat di pembuluh darah yang
meningkatkan resiko penyakit stroke

13.Atherosclerosisi

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3.3. Faktor Resiko stroke usia muda
1. Penyakit vaskuler2. Migrain stroke
3. Trombosis vena 4. kelainan hematologi
5. Peny jtg 6. MAV(Malformasi arteri vena) Aneurisma
7.Obat-obatan 8.Kehamilan dan puerpurium

8.Patogenesis
A stroke occurs when the blood supply to part of your brain is interrupted or severely reduced,
depriving brain tissue of oxygen and nutrients. Within minutes, brain cells begin to die
Cerebrovascular accident may be caused by any of three mechanisms.

1 2 3

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Explanation
1. Cerebral Thrombosis – blockage in the thrombus (clot) that has built up on the wall of the
brain artery.

2. Cerebral Embolism – blockage by an embolus (usually a clot) swept into the artery in the
brain.

3. Hemorrhage – Rupture of a blood vessel and bleeding within or over the surface of the
brain.

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x

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9.Signs and symptomps
Tergantung / lokasi arteri yg kena/ dan luasnya lesi yg korban
Symptoms

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Symptoms of stroke depend upon what are of the brain has stopped working due to loss of its
blood supply. Often, the patient may present with multiple symptoms including the following:
1. Acute change in level of consciousness or confusion
2. Acute onset of weakness or paralysis of half or part of the body
3. Numbness of one half or part of the body
4. Partial vision loss
5. Double vision
6. Difficulty speaking or understanding speech
7. Difficulty with balance and vertigo
The symptoms of ischemic and hemorrhagic stroke may be the same but patients with
hemorrhagic stroke may also complain more of headache and vomiting.

Brodman’s area

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Traktus Pyramimidalis
Ggn berupa Kelemahan anggota gerak yg muncul pd stroke di sebabkan ggn aliran darah pd
pusat2 motorik di otak yi di Systen pyramidal yg tdd kelompok neuron di korteks serebri yi
di girus presentralis (area 4 broadman &di sini juga terdapat suatu penataan daerah yg sesuai
dgn penataan tubuh yg dikenal sbg motor homunculus ) &traktus traktusnya yg membentang
sampai di nukleus2 dibawahnya yi traktus kortikobulbaris darikorteks serebri sampai
nukleus2 motorik dibatang otak,&dari sini traktus kortiko bulbaris ini 85 % menyilang disebut
dgn decussatiomembentuk traktus kortikospinalis lateralmenuju neuron2 motorik di kornu
anterior medulla spinalis &selebihnya 15% tdk menyilang langsung turun kebawah
membentuk traktus kortikosinalis. Impuls motorik dari pusat motorik di salurkan melalui
traktus piramidalis (UMN) ke perifer (LMN) menuju otot

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x

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Signs

The pyramidal tracts include both the corticospinal and corticobulbar tracts.
These are aggregations of upper motor neuron nerve fibres that travel from the cerebral cortex
and terminate either in the brainstem (corticobulbar) or spinal cord (corticospinal) and are
involved in control of motor functions of the body.

The corticospinal tract conducts impulses from the brain to the spinal cord. It is made up of a
lateral and anterior tract. The corticospinal tract is involved in voluntary movement. The
majority of fibres of the corticospinal tract cross over in the medulla, resulting in muscles
being controlled by the opposite side of the brain

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x

xxxx

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X

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10. Diagnose
10.1. USG Leher

10.2. (Neuroimaging)

x
X

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10.1.1.Hemorrhage stroke

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x

x
x

Anatomy location of stroke

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  Axial noncontrast computed
tomography scan of the brain of a 60-
year-old man with a history of acute
onset of left-sided weakness.
 Two areas of intracerebral hemorrhage
are seen in the right lentiform nucleus,
with surrounding edema and effacement
of the adjacent cortical sulci and right
sylvian fissure.
 Mass effect is present upon the frontal
horn of the right lateral ventricle, with
intraventricular extension of the
hemorrhage.

x
10.1.2.Stroke Ischemic

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10.2.

12-lead ECG of a patient with a stroke, showing large deeply inverted T-waves. Various ECG
changes may occur in people with strokes and other brain disorders

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10.4. Angiogram
is an invasive procedure in which a catheter is inserted into an artery and passed through the blood
vessels to the brain. Once the catheter is in place, contrast dye is injected into the bloodstream and X-
ray images are taken. This test is used to diagnose and determine the location of aneurysms and AVMs

Narrowed carotid artery lumen on MRA

10.5.Lumbar puncture
is an invasive procedure in which a hollow needle is inserted into the subarachnoid space of the spinal
canal to detect blood in the cerebrospinal fluid (CSF). If a hemorrhagic stroke is suspected, the doctor
may perform a lumbar puncture.

11.Terapi
11.1.Farmakology
From onset of symptoms, there is only a 3 to 4 1/2 hour window to use clot-busting drugs
(thrombolytics) to try to restore blood supply to the affected part of the brain.

TTIK Mannitol
Neuroprotector : Citicoloin, Pyracetam
Hipertensi Anti HT

11.2.Non Farmakology
11.2.1. Fisioterapi
Kasus2 stroke yg perlu di lakukan fisioterapi
Apraxia
is the inability to control your muscles, making movements uncoordinated and jerky.

Dysarthria

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is a loss of control over muscles in the face and mouth. A person's voice may sound slurred,
muffled, or hoarse. The mouth may droop on one side of the face because of muscle weakness.
Exercises can strengthen these muscles.

Dysphagia
is difficulty swallowing, making eating and drinking a challenge and choking a danger. Tongue
and lip exercises can help individuals regain control.

Paralysis
is a loss of muscle function and sensation in an area of the body.

Hemiparesis
is a weakness of muscles on one side of the body. Improving posture, range of motion, and
strength can help individuals regain control.

Hemianopia
is the loss of sight in half of the visual field.

 Aphasia Speech Therapy

x
Aphasia, caused by damage to the brain's language center, is a total or partial loss of the ability
to understand or use words. Some people quickly and completely recover from aphasia after a
stroke. Others may have permanent speech and language problems, which can range from
trouble finding words to being unable to speak. Some people have problems understanding
what others are saying or have trouble with reading, writing, or math. In other cases, someone
may have trouble talking but can understand what others say

11.2.2. Diet

11.2.3.Olah raga ringan

11.2.4.Neuro surgery

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Figure 2. Summary of indications for surgical removal of intracranial hematomas

11.2.5. Neuro Intervention

12.Komplikasi stroke
12.1. Komplikasi neurologi
12.1.1.Edema otak
-Edema otak lokaledem otak regionaledema otak umum (terberat pd hari ke 3-5)
-Gejala awal
*↓kesadaran *Bradikardi
* Papil edema *Tek LCS ↑, prot (+)
*TIK ↑ - Ted dar sistemik ↑

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 xBrain edema

12.1.2.Infark berdarah=Hemorrhagic Cardioembolic Stroke

Figure 1: The patient's initial CT

brain showing multiple areas of
ischemic infarcts, the largest of
which is in the distribution of the
right middle cerebral artery, with a
small area of focal hemorrhagic
transformation (arrow).

x
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12.1.3.Aphasia

12.1.4.Epilepsi

5.Hidrocefalus
6. Perd ulang
7. Hematome intracerebral
8.Vasospasme
9. Herniasi

12..2. Komplikasi Non Neurolog (Ekstrakranial)

1. SIADH (Sindroma Inaproprite Anti Diuretik Hormone)
2. Hipertensi
3. Kelainan jtg
4. Trombosis vena dalam
5. Perdarahan salurn cernaStress ulcer
7. Hiperglikemi reaktive
8. Akibat Immobilisasi
*Pneumoni *Emboli paru
*Penj jtg *ISK
*Dekubitus *Tromboplebitis
*Kontraktur *Ankilosis sendi-sendi
*Atropiotot yg tdk terpakai

13.Prevention: Lifestyle
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1. Take your medication every day as directed. Your medication helps to thin your blood and
prevent clots.
2. Eat a healthy diet of foods low in fat, cholesterol, and salt.

3. Control your blood pressure.

4. Quit smoking.

5. Exercise regularly. You’ll feel good about yourself, alleviate depression, and build muscle
strength.

6. Get enough sleep and reduce stress.

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 7. Limit your use of alcohol. It can be risky to drink alcohol if you take certain medications.
Talk to your doctor.

8. Talk about your feelings. Sudden mood swings and depression are common and lessen
with time. A support group or counselor can help you and your family.

Case
1.Identitas : ♀/ 35 thn

2.K U : Lemah AG kanan

3.RPS
7 jam SMRS seorang ibu ketika sedang mencuci piring tiba2 merasa lemah anggota gerak
kanan, sampai terjatuh, tangan hanya bisa diangkat lalu jatuh lagi dan kaki hanya bisa
digeser. Pasien dipanggil dan digoyang badannya buka mata dan menjawab dengan benar
lalu tertidur kembali. Keluhan sakit kepala (+), muntah (+), kejang disangkal. Keluhan
pusing berputar telinga berdenging di sangkal. Pasien di bawa ke puskesmas terdekat di

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ukur TD 240/130 mmhg kemudian oleh petugas kesehatan pasien di rujuk ke RSUD Dok 2 dan
di ukur TD 200/110 mmhg.

4.RPD :
1.RW Hipertensi (+) 2 thn yg lalu kontrol dan minum obat tdk teratur
2.RW Sakit Jantung (-)
3.RW sakit DM, Kolesterol tinggi, Stroke sebelumnya (-)

5.RPK

6.Vital sign
1. Kesadaran : CM / Delirium / Apatis / Somnolen / Sopor/ Koma
2. TD : 200/110
3. Nadi : teratur 80x/m
4. RR : 20x/m
5. HR :80x/menit
6. Suhu : 37 o C

7.Status IPD

8.Status Neurology
1. RM : KK (-) / LK (tt) / Bruz I II (-/-)

2. SO :

2.1.Mata: Pupil : bulat isokor

i. Diameter ODS : 3 mm
ii. Ref cahaya : (+/+)
iii. Ref Cornea : (+/+)
iv. GBM : baik kesegala arah
v. F C : A/V 2/3 : Perdarahan (-) Excudat (-)
2.2.Wajah : Parese N VII kanan sentral
2.3.Lidah : Parese N XII kanan sentral
2.4.Mulut : -Uvula
-Arcus Pharynx
-Reflex muntah

3. Mot: 1.Inspeksi : - Atropi (-/-)

-Tremor (-/-)
2.Palpasi: hipertonus / hipotonus
3.Perkusi : Fasiculasi
4.Kekuatan :Hemiparese dextra dgn kekuatan
3/5
2/5

4. Coordinasi : Ataxia (-)

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 5. Sensorik :
5.1.Pain sensation (pin prick),
5.1.1. Hipalgesia
5.1.2. Analgesia
5.2.Light touch sensation (brush),
5.2.1. Hipoestesia
5.2.2. Anastesia
5.2.3. Hiperestesia
5.3.Position sense / Propioception
5.4.Vibration
5.5.Hemihipestesi dextra
5.6.Test Stereognosia,
5.7.Test Graphesthesia,
5.8.Test Extinction.

6. Vegetatif : BAB : Incontinensia (-) / Retensio (-)

BAK : Incontinensia (-) / Retensio (-)
7. Fungsi Luhur :
7.1.MMSE :
7.1.1. Score
7.1.2. Disorientasi
7.1.3. Apraxia
7.1.4. Afasia
7.2.CDT :

8. Ref Fisiology : BTR ↑ / n KPR ↑/n APR

9. Ref Patology: Babinsky (+/-)

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

9.Pemeriksaan Tambahan
9.1. Lab: as urat, kolesterol, GD
9.2. Radiology
Rontgen
Neuroimaging

10.Pemeriksaan Khusus
10.1.Stroke Skore
10.1.1.SSS (Siriraj Stroke Score)
(2.5 x PK.) + (2x muntah) + (2xNK)+ (0.1x td diastole) + (3x. Aterom) -12 = SSS =7,5
SSS berlaku < 72 jam

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10.1.2.ASGM (Algoritma Score Gajah Mada )
PK(+) , NK (+) , Babinski (+) ==>PIS
PK (+) , NK (+) , Babinski (-) ==>PIS
PK (-) , NK (+) , Baabinski (-) ==>PIS
PK (-) , NK (-) , Babinski (+) ==>Infark
PK (-) , NK (-) , Babinski (-) ==>Infark
ASGM masih bisa > 72 jam

10.2.Perbedaan Stroke
Perdarahan / Hemorhage no Klinis Penyumbatan / infark
Aktifitas 1 Onset Istirahat
Umumnya Tinggi 2 TD Umumnya Normal
Muda 3 Usia Tua
Hipertensi 4 FR Kolesterol, alkohol,DM
↑↑↑ 5 TTIK ↑
Hiperdens 6 Neuroimaging Hipodens
CT Scan
(-) 7 RW TIA Pernah / Sering
 +1 8 SSS <1
SAB Air cucian daging 9 LP Jernih

11. Stroke Fase akut

Adalah fase dimana masih bisa terjadi perubahan kearah yg lebih berat progresivitas
Pada PIS fase akut 1 minggu
Pada Infark AT 14 hari
Pada KE 14 hari

12.Anatomi Lokasi

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13.Perbedan stroke systema
Sistem Karotis Fungsi Sisten VB
a. a. INTERNAL CAROTID a.a. VERTEBRAL
b.a. MIDDLE CEREBRAL b.a. BASILER
c. a. ANTERIOR CEREBRAL c.a, POSTERIOR CEREBRAL

Hemiparese kontralateral 1. Motor hemiparese alternan

parese motorik saraf otak
sejajar/ipsilateral dgn parese
ekstrimitas)
Hemihipestesi kontralateral hipestesi
saraf otak sejajar dgn hipestesi
ekstrimitas).
hemianopsia homonim kontralateral
dysfunctio parese motorik saraf otak tdk
n sejajar/kontralateral dgn parese ekstrimitas).
2. Sensory hemihipestesi alternan
dysfunctio hipestesi saraf otak tdk sejajar dgn hipestesi
n ekstrimitas).
3. Visual hemianopsia homonim, 1 atau 2 sisi lapang
disturbanc pandang, buta cortikal (terkenanya pusat
es penglihatan di lobus oksipitalis).

4.1. Afasia 4. Higher

gangguan berbahasa, bila lesi pd cortical
hemisfer dominan, umumnya hemisfer dysfunctio
kiri), n
4.2. Agnosia
lesi pada hemisfer non-dominan).
5. Others 5.1. Loss of balance
5.2. Vertigo
5.3. Diplopia

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14.DK:
Stroke ec PIS (Perdarahan Intra Serebral) sistim karotis kiri / kanan fr hipertensi
(a)(b) (c)(d)

Stroke ec PIS (Perdarahan Intra Serebral)sistim Vertebrobasiler fr hipertensi

(a)(b) (c)(d)

Stroke ec Infark ATsistim karotis kiri / kananfr hipertensi

(a)(b) (c)(d)

Stroke ec Infark ATsistim Vertebrobasilerfr hipertensi

(a)(b) (c)(d)

Diagnosa stroke
a. Diagnosa klinis
b. Diagnosa Etiologi
c. Diagnosa Lokalisasi
d. Diagnosa faktor resiko

Diagnosa Tambahan

Differensial Diagnosa

Saran / Nasehat

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