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dr. Endro Basuki Sp.BS(K) M.

Kes
 Jakarta, 8 Januari, 1953
 Dokter Umum – FK UGM, 1979
 Spesialis Bedah Saraf – FK UNPAD, 1989
 Vrije Universiteit Amsterdam, 1987 – 1988
 Magister Kesehatan – FK UGM, 2000
 Puskesmas Kec. Lamuru, Bone, 1979 – 1982
 Staf SMF Bedah Saraf RS Dr Sardjito
 As. WaDek bidang penelitian, kerjasama dan
pengabdian masyarakat FKUGM
 Pengurus Harian Komite Medik RS Dr
Sardjito/Ketua Sub Komite Etik dan Disiplin
Profesi
 Presiden of PERSPEBSI, 2013 – 2017
 Medical Advisory Board (Dewan Pertimbangan
Medik) BPJS kesehatan
 There are 2 types of stroke :
◦ Ischemic stroke (80%) and
◦ Hemorrhagic stroke (20%)
 Ischemic Stroke  Hemorrhagic Stroke
◦ Thrombus ◦ Hypertension
◦ Cardiac source ◦ Amyloid vasculopathy
◦ Large vessel or small ◦ Aneurysm
vessel atherosclerosis ◦ Arteriovenous
◦ Vasospasm malformation
◦ Hypercoagulable state ◦ Neoplasm
◦ Coagulation disorder or
anticoagulant therapy
 Age
 Heredity, race
 Hypertension
 Cardiac disease
 Diabetes
 Blood lipids, cholesterol, smoking,
diet/obesity
 Hematocrit
 Oral contraceptive

Lindsay, K. W., Bone I., Fuller G., Neurology and neurosurgery illustrated. 2010
Lindsay, K. W., Bone I., Fuller G., Neurology and neurosurgery illustrated. 2010
Lindsay, K. W., Bone I., Fuller G., Neurology and neurosurgery illustrated. 2010
 Age < 70 years
 More strongly considered in non dominant
hemisphere
 Clinical and CT evidence of acute, complete
ICA or MCA infarct and direct signs of
impending or complete severe hemispheric
brain swelling

Greenberg, M.S. 2010. Handbook of Neurosurgery


 Mortality up to 80% (mostly due to severe
postischemic edema  herniation)
 Neurosurgeons may become involved
 Aggressive therapies may reduce mortality
and morbidity

Greeenberg, M. S. 2010. Handbook of neurosurgery


 Lesion with marked mass effect, edema or
midline shift
 The symptoms appear to be due to increased ICP
or mass effect of the clot or surrounding edema
 Volume (10-30 cc)
 Persistent elevated ICP in spite of therapy (failure
of medical management)
 Rapid deterioration
 Favorable location
 Young patient (<50 yo)
 Early intervention (<24 hrs)
Day 0 Day 20
 Clinical finding and diagnosis
◦ Depend on the location and size of the hematoma
◦ During activity and manifested as sudden
neurological activity
◦ Chronic arterial hypertension
◦ Impaired consciousness (60%), degree of
impairment depend on the location, size, and
extension of the hematoma into deep structures or
the ventricles.
 Clinical finding and diagnosis
◦ Level of consciousness deteriorate in their level of
consciousness within first 24 hours, then should
be closely monitored
◦ Progression of the mass effect secondary to edema
can essentially occur within the first 2 days and late
within the second and third weeks.
◦ Treat coagulopathy if present
◦ Do a plain CT scan of the brain as initial radiologic
workup
 Clinical finding and diagnosis
◦ Location and size of the hematoma and the
presence or absence of a mass effect, perilesional
edema and ventricular extension are important to
decide on a management plan
 Management
◦ Steroids (controversial)
◦ Blood pressure management
◦ Intracranial Pressure Management
◦ Seizure after ICH
◦ Hemodilution for ICH
◦ Recombinant Activated Factor VII
◦ Neuroprotective agents
 Symptoms and signs
◦ Hallmark  sudden, severe headache, some
describe it as “worse headache of my life”
◦ Premonitory symptoms ( warning leaks or sentinel
hemorrhages) typically consisting of an unusually
severe headache of sudden onset, sometimes with
nausea, vomiting and dizziness.
 Diagnosis
◦ CT scan
◦ Lumbar puncture
◦ MRI
◦ Digital Subtraction Angiography
 General care
◦ Initial emergency ABC
◦ Level of consciousness and brief neurological exam
◦ Intubation if GCS <8
◦ Repair of aneurysm (endovascular or clipping) is
NOT a live saving procedure rather than a
rebleeding prevention and make vasospasm
treatment become safer.
 General care
◦ Most patient are admitted to an intensive care or
high intensity observation unit.
◦ Some practitioner advocate bed rest in dark room,
limited visitors and minimal stimulation but not
proven to reduce re rupture rates
◦ Adequate analgesia should be ensured and
excessive painful stimuli should be avoided
 Nursing care
◦ Bed rest until the aneurysm is obliterated or until
several days after the hemorrhage
◦ 30° head elevation
◦ Avoidance of unnecessary stimulation
◦ Graduated compression stockings on the lower
extremities
◦ Foley catheter for poor grade patient
◦ NGT for intubated patient
 Medication
◦ Stool softener
◦ Laxatives
◦ Analgesics
◦ IV fluids to maintain euvolemia
◦ Antiemetic
◦ Sucralfate or omeprazole
◦ Sedatives
◦ Anticonvulsants for seizure treatment
◦ Anti hypertension especially if not obliterated early
 Other medical care
◦ Ventricular drain for patients with neurological
compromise from ventricular dilation, >20 mmHg
until the aneurysm is obliterated, then pressure can
be >10 mmHg
 Blood pressure management
◦ Depend on time after SAH, aneurysm has been
repaired or not, ICP, and patient’s premorbid blood
pressure
◦ In day 4 until 14th more conservative treatment on
SAH because of risk of vasospasm
◦ Before repair should be “normotensive” 100 -160 to
180 systolic, if repaired hypertension is not treated
 Complication
◦ Rebleeding
 Peak at first 24 hours despite maintenance of SBP
below 150 mmHg
 Should be obliterated as soon as feasible, it reduces
risk for rebleeding, facilitates treatment of vasospasm
by increasing the safety of hemodynamic
manipulations, and allow early mobilization.
 Anti fibrinoliytic drugs for the treatment of patient
with SAH had been abandoned, but there is renewed
interest.
 Hydrocephalus
◦ The frequency is 20 %
◦ Ventricular drainage may be required
◦ Associated factors:
 Increasing age
 Preexisting or post operative hypertension
 Intraventricular hemorrhage
 Posterior circulation aneurysm
 Use of anti fibrinolytic drugs
 Hyponatremia
 Depressed level of consciousness
 Seizure
◦ Seizure occur at or around the time of SAH in up to
20% of patient
◦ Seizure are associated with brain swelling
secondary to increased cerebral blood volume
◦ Antiepileptic drug administration after SAH is
recommended to be used for patient who has
seizure before