REFLEKSI KASUS

STROKE
HEMORAGIK
AMINAH ZAHRA, S.KED
FARIS PUTRA H, S.KED
OSY LU’LU A, S.KED
RAMA AGUNG P, S.KED

PRECEPTOR:
DR. NOFLIH SULISTIA, SP.RAD
 STATUS PASIEN
IDENTITAS KELUHAN UTAMA
• Nama : Ny. T Penurunan kesadaran sejak 2 hari
• Usia : 57 tahun yang lalu
• No RM : 608986
• Agama : Islam
• Alamat : Kp. Garuntang Lk II, Panjang
• Status : Menikah
KELUHAN TAMBAHAN
• Pekerjaan : IRT Lemah anggota kiri, nyeri kepala,
• Tanggal masuk : 24 September 2019 muntah, kejang
• Tanggal pemeriksaan: 25 September 2019
RIWAYAT PENYAKIT SEKARANG

Pasien datang dengan penurunan kesadaran mendadak pada

Senin, lalu 30 menit kemudian dibawa ke puskemas dan dirujuk ke
RS. Pasien sebelumnya ingin melaksanakan sholat dan tiba-tiba
terjatuh diikuti dengan kaku pada anggota gerak dan kejang ±2
menit setiap 30 menit. Pasien sempat mengeluh sakit kepala
sebelum kejadian. Muntah >3x dan muntah menyemprot
RIWAYAT PENYAKIT DAHULU RIWAYAT PENYAKIT KELUARGA
• Hipertensi >3 tahun • Hipertensi (-)
rutin minum obat • DM (-)
• DM 1 tahun rutin • Stroke (-)
minum obat

RIWAYAT PRIBADI
Pasien tidak mengatur pola makan,
jarang berolahraga
Riwayat merokok (-)
PEMERIKSAAN FISIK

STATUS PRESENT
GCS : E2V1M4
Kesadaran : stupor
Keadaan umum : tampak sakit berat

TANDA-TANDA VITAL
Tekanan darah : 180/120 mmHg
Nadi : 126x/m
Frekuensi napas : 26x/m
Suhu : 37,7 oC
SpO2 : 97%
PEMERIKSAAN FISIK

KEPALA
Mata : reflek cahaya (-/-), pupil isokor 3 mm
bulat ditengah
Telinga : sekret (-), perdarahan (-)
Hidung : sekret (-), perdarahan (-)
Bibir : perdarahan (-)

LEHER
Pembesaran KGB : (-)
Pembesaran tiroid : (-)
JVP : tidak meningkat
PEMERIKSAAN FISIK

THORAX ABDOMEN
Cor Inspeksi : Datar
Inspeksi : Ictus cordis tidak terlihat Auskultasi : BU (+) normal
Palpasi : Ictus cordis teraba di ICS 5 Palpasi : massa (-)
linea axilla anterior Perkusi : Timpani
Perkusi : Batas jantung normal
Auskultasi : BJ I-II regular, murmur (-)
EKSTREMITAS
Pulmo Superior : edem (-)
Inspeksi : Simetris, lesi (-) Inferior : edem (-), ulkus (-)
Palpasi : Ekpansi dinding dada simetris
Perkusi : Sonor
Auskultasi : Vesikuler (+), rhonki (-),
wheezing (-)
PEMERIKSAAN FISIK

STATUS NEUROLOGIS
Nervus cranial : tidak dapat dinilai
Reflek fisiologi : ↑ ekstremitas kiri, ekstremitas
kanan sulit dinilai
Reflek patologi : kaki kiri babinsky (+), Oppenheim (+),
Gordon (+), gonda (+), Schaefer (+)
Motorik : tidak dapat dinilai, ekstremitas kiri
lebih jatuh
Sensorik : tidak dapat dinilai
 PEMERIKSAAN LABORATORIUM

Parameter Hasil Nilai Rujukan Parameter Hasil Nilai Rujukan

Hb 10,7 11,5-16,5 g/dl Basofil 0 0-1%
Leukosit 14.300 4.500-11.000/μl Eosinofil 0 2-4%
Eritrosit 3,9 juta 3,8-5,8 juta/μl Batang 0 3-5%
Trombosit 257.000 154.000-386.000/μl Segmen 92 50-700%
Ht 31 37-47% Limfosit 4 25-40%
MCV 79 76-96 fL Monosit 4 2-8%
MCH 27 27-32 pg GDN 227 <110 mg/dl
MCHC 34 30-35 g/dl GD2PP 286 <140 mg/dl
HbA1c % 6,3 <5,7%
CT-SCAN

INTERPRETASI
• Jaringan lunak ekstra calvaria dan calvaria
masih memberikan bentuk dan densitas yang
normal
• Lesi hiperdens, batas tegas, tepi ireguler,
berukuran ±3,5x2x3 cm di subkortikal
temporoparietalis kanan yang mengobliterasi
thalamus kanan dan corona radiata kanan
dengan lesi hipodens disekitarnya yang
mendesak ventrikel Ia
 CT-SCAN

INTERPRETASI
• Lesi hiperdens mengisi falx cerebri, sisterna
ambiens dan sisterna quadrigeminal
• Lesi hiperdens mengisi sistem ventrikel
dengan ukuran yang melebar disertai lesi
hipodens difus disekitarnya
• Daerah sela tursika dan jukstasella serta
daerah cerebello-pontin angle masih dalam
batas normal
CT-SCAN

INTERPRETASI
• Tampak kalsifikasi fisiologis di daerah
glandula pinealis, pleksus choroideus
bilateral
• Mastoid air cell bilateral yang terscanning
tampak normal
• Sinus maksilaris kiri terisi lesi hipodens
• Bulbus okuli dan ruang retrobulbar bilateral
dalam batas normal
• Tidak tampak pergeseran struktur garis
tengah
CT-SCAN

KESAN
• Perdarahan intraserebri di subkortikal
temporo-parietalis kanan yang
mengobliterasi thalamus kanan dan
corona radiata kanan dengan edema
perifokal
• Perdarahan subarachnoid falx cerebri,
sisterna ambiens dan sisterna
quadrigeminal
• Perdarahan inraventrikuler dengan
hydrocephalus non communicans akut
DIAGNOSIS TATALAKSANA

DIAGNOSIS KLINIS O2 3L/m

Hemiplegi sinistra spastik, penurunan RL 20 tpm
kesadaran, muntah proyektil, cephalgia, Ranitidin 2x150 mg iv
kejang umum tonik Ceftriaxone 2x1000 mg iv
PCT 3x500 mg per NGT
DIAGNOSIS TOPIS Amlodipine 1x10 mg per NGT
Intracerebrovascular hemisfer dextra Fenitoin kapsul 3x1
DIAGNOSIS ETIOLOGI NGT
ICH, IVH, SAH
Kateter
Konsul Sp. BS
Konsul Sp.PD
PROGNOSIS

QUO AD VITAM QUO AD QUO AD

FUNCTIONAM SANATIONAM

Malam Dubia ad malam Dubia ad malam

 TINJAUAN
PUSTAKA

16
 Stroke is damage of brain tissue caused by a sudden reduction or
interruption in blood supply

Hemorrhagic stroke is a condition of rupture of one artery in the brain

that triggers bleeding around the organ that ↓ brain blood flow → ↓
brain oxygenation → brain cells death and permanently disrupted the
brain function

DEFINITION
17
”
ETIOLOGY

Chronic Ruptur of
hypertension malformation of
artery and vein

Ruptur of Traumatic brain

aneurism bags injury
Symptoms

Sudden neurological deficit

• Hemiparesis
• Seizure
• Loss of conciousness
High intracranial pressure
• Vomitus
• Severe headache
Symptom depends on the location and size of the haemorrhage
 The Principles of CT Scan

Also known CAT scan is a

procedure that combines many
x-ray images with the aid of a
computer to generate cross-
sectional and 3 dimensional
views of anatomy.
How does a CT scanner work?

Combines x-ray with

advanced computers
X-ray equipment spins around
in a circle inside the machine
The patient is put on a table
that moves slowly while
images are taken
How does the procedure work?

X-ray are a form of radiation, different body parts absorb in

varying degrees

Numerous x-ray beams & set of electronic x-ray detectors

rotate around patient

At the same time, the examination table is moving through

the scanner so that x-ray beam follows a spiral path

A special computer program processes this large volume of

data to create 2 D cross sectional images of the body, then
displayed on a monitor
Common CT assigned attenuation values
- Air: -1000 HU or less (black)
- Fat: -100 HU (dark gray)
- Water: 0 HU (gray)
- Bone: +1000 HU
- Blood: 55-75 HU
- Kidney: 30 HU
- CSF: 0-10 HU
Indication

- Broken bones (skull, spine, ribs, extremities)

- Blood clots in the brain & chest
- Abnormalities of the lungs
- Inflammation in the abdomen
- Stones (in gallbladder or kidney)
- Blocked bowel passage or twist bowel
- Cancers in various organs & body parts
- Paranasal sinuses abnormality
WHAT IS CONTRAST CT?

Contrast is routinely employed during chest, abdomen, and

pelvis CT. A fluid containing iodine (mineral density) is injected
iv → kidney function should be normal

Helps to identify vascular structures and characterize certain

types of pathology, e.g: AVM, infection.

Indication: suspect primary or metastatic cancer, abscess,

AVM, aneurysm.
WHAT IS CTA?

Computed Tomography Angiography: computer-intensive

reconstruction of the vascular structures in the body.

Venous & arterial imaging can be performed using i.v contrast

Used to detect thrombosis within veins or arteries, stenosis,

aneurysms & AVM

Common indication: detection of pulmonary embolism

3D CT & SAGITTAL & CORONAL RECONSTRUCTION?

Software provided on CT scan allows for the conversion of axial

images into images in any other plane desired

3D computer generated pictures utilizing shading technique to

create the appearance of 3D

Helpful to evaluate facial bone fractures & acetabulum

fractures of the hip prior to reconstruction surgery
 ADVANTAGES
4. Provides very detailed image
1. Painless, noninvasive and
accurate 5. Fast & simple

6. Less sensitive to
2. Ability to image bone, patient movement than
soft tissue and blood MRI
vessels all at the same
time 7. Can be performed if
you have an implanted
3. The amount of radiation
medical device, unlike
the patient receives is
MRI
minimal
8. Less expensive than MRI
LIMITATION

Soft tissue details are better evaluated by MRI

In pregnant women, prefer MRI if it is still proper to

diagnose the condition

Overweight limit usually 450 pounds for moving

table
 RADIOLOGY
• Non contrast CT
• With any ICH the following points should be included in a report as they
have prognostic implications
• Location
• Size/volume
• Shape (irregular vs regular)
• Density (homogeneous vs heterogeneous)
• Presence/absence of IVH
• Presence/absence of hydrocephalus
• CTA: presence/absence of the CTA spot sign or a vascular malformation
FORMULA

AxBxC
2

A: greatest hemorrhage diameter in the axial plane (cm)

B: hemorrhage diameter at 90o to axial plane (cm)
C: number of CT slices with hemorrhage multiplied by the slice thickness (cm)

Baseline ICH volume >50-60 ml → poor prognostic marker

NON-CONTRAST CT-SCAN

Bleeding into the cerebral

parenchyma results in a hematoma

Varied components of the hematoma

give it a heterogeneous appearance

The attenuation of blood with a

normal hematocrit (56 HU) > gray
matter (37–41 HU) > white matter
(30–24 HU) resulting in the
‘brighter’ region
 Time Process CT
Immeadiately Bleeding into parenchyma • Hyperattenuated (brighter) lesion
on extravasation • Heterogeneous due to varied cellular
components
Minutes Clot formation, serum ↑ intensity, marked in the center of
extruded hematoma
Hours-2 weeks Vasogenic edema surrounds Hypoattenuated or “darker” appearance
bleed surrounding the hematoma
Hours Cellular debris settles in the Fluid level (with hyperattenuated
gravity dependent part dependent portion)
Days-weeks Clot breakdown by scavengers ↓ in attenuation beginning at periphery
(macrophages) toward the center
2-3 weeks Resolution or clot Same intensity as white matter
Weeks-months Cavity: collapsed or filled with Small slit like cavity which may or may not
cerebrospinal fluid be visualized
Months Encephalomalacia Hypointense (darker) area at lesion site
36
Non-
Contrast CT
Scan
 TREATMENT

▹ Monitoring: GCS, vital sign

▹ Monitoring and treatment: ICP, blood glucose
▸ Treat clinical seizures with anti-seizure drugs
▹ Blood pressure control :
1. SBP between 150 and 220 mm Hg and without contraindication
to acute BP treatment, acute lowering of SBP to 140 mm Hg is
safe and can be effective for improving functional outcome
2. ICH patients with SBP >220 mm Hg, may be reasonable to
consider aggressive reduction of BP with a continuous iv
infusion and frequent BP monitoring
References
• Benseler JS. 2006. The Radiology Handbook. Athens: Ohio University
Press.
• Rasad S. 2006. Radiologi Diagnostik. Jakarta: Fakultas Kedokteran
Indonesia.
• Herring W. 2016. Learning Radiology: Recognizing the Basics. 3rd
Edition. Philadelphia: Elsevier
• AHA/ASA. 2015. Guidelines for the Management of Spontaneous
Intracerebral Hemorrhage. USA: AHA