PROBLEMA UMUM DALAM

STROKE

Prof. DR. Dr. Bambang Hartono Sp.S (K)

Bagian / SMF Neurologi
Universitas Diponegoro – RS. Dr. Kariadi
Semarang
 UNTUK IKUT MENINGKATKAN
KEMAMPUAN BAHASA INGGRIS PERAWAT,
“SLIDE” DAN “HANDOUT” SEBAGIAN
DALAM BAHASA INGGRIS, TETAPI BAHASA
PENGANTAR TETAP BAHASA INDONESIA
Problem akibat stroke :

10% pasien stroke hampir pulih sempurna

25% kecacatan ringan
40% cacat sedang sampai berat, perlu perawatan
dan peralatan khusus, tergantung lingkungan
10% perlu perawatan spesial jangka panjang
di rumah-rumah perawatan khusus
15% meninggal segera setelah serangan stroke
Cacat akibat stroke :
Motorik: lemah, lumpuh
Sensorik: parestesi, hipestesii, nyeri
Otonom: Gangguan b.a.k., b.a.b., keringat
Fungsi luhur:
Kesadaran terganggu
Gangguan bahasa-wicara: afasia, disartria,dsb
Gangguan visual/visuo-spasial
Gangguan memori
AKIBATNYA:
- kepribadian dapat terganggu
- gangguan komunikasi
- kehilangan pekerjaan
- dsb
Pembagian Stroke

Ischemic stroke (Stroke non hemoragik):

Karena sumbatan aliran darah yang menuju
ke otak atau di dalam otak
 Thrombotik: Sumbatan karena proses athero-
thrombosis di cabang-cabang pembuluh darah
 Embolik: Sumbatan karena emboli yang
umumnya berasal dari penyakit jantung atau
pembuluh darah itu sendiri
Hemorrhagic stroke (Stoke hemoragik):
Akibat pecahnay pembuluh darah di dalam otak
 Intraserebral: Perdarahan ada di dalam
substansi otak umumnya karena hipertensi
 Subarakhnoid: Perdarahan di bawah selaput
otak, sehingga darah menyebar luas, dan
umumnya akibat pecahnya aneurisma
Time Course of Cerebral Ischemic Events

TIA

Stroke-in-evolution

Completed stroke
 Conditions associated with focal cerebral
ischemia
Vascular disorders Cardiac disorders Hematologic
disorders

Atherosclerosis Mural thrombus Thrombocytosis

Fibromuscular dysplasia Rheumatic heart disease Polycythemia
Inflammatory disorders Arrrhytmias Sickle cell disease
Giant cell arteritis Endocarditis Leukocytosis
SLE Mitral valve prolapse Hypercoagulable state
Polyarteritis nodosa Paradoxic embolus AT III deficiency
Granulomatous angiitis Atrial myxoma Protein C deficiency
Syphilitic arteritis Prosthetic heart valves Protein S deficiency
AIDS APC resistance
Carotid or vertebral artery Antiphospholipid
disssection Antibody
Lacunar infarction Hyperhomocystein-
Drug abuse emia
Migraine
Moyamoya syndrome
Venous or sinus thrombosis
Sites of predilection for atherosclerosis
in the intracranial circulation
Old middle cerebral artery infarct pathology
Atherosclerotic plaque within basilar artery
Waspada gejala/tanda stroke

• Mendadak lemah/lumpuh sesisi tubuh

• Mendadak bingung
• Mendadak buta/ pandangan tak jelas
• Menaddak sulit berjala, sempoyongan, vertigo
• Mendadak sakit kepala hebat
• Mendadak sulit bicara atau sulit memahami pembicaraan
Gejala Stroke
 Onset stroke
 Stroke thrombotik : bertahap makin
memburuk
 Stroke embolik: seketika langsung buruk
 Stroke hemorrhagik: mendadak buruk
dan dengan cepat memburuk
Anterior Circulation Stroke
Symptoms and Signs
Posterior Circulation Stroke
Symptoms and Signs
Stroke Mimickers
Transient Ischemic Attack (TIA)
 “Mini stroke”
 Stroke symptoms last for less than 24 hours
(usually 10 to 15 mins)
 Result as a brief interruption in blood flow to brain
 Every TIA is an emergency
 TIA may be a warning sign of a larger stroke
 Patients with possible TIA should be evaluated
PRINSIP PENGELOLAAN STROKE

STROKE AKUT:
- Penanganan segera (TIME IS BRAIN)
- Atasi kondisi emergensi yang ada (kesadaran,
nafas, tekanan darah, gula darah, tekanan
intrakranial yang tinggi,dsb)
- Atasi faktor risiko – cegah memburuknya stroke/
stroke ulang
- Atasi komplikasi yang terjadi
- Prinsip fisioterapi sesegera mungkin
STROKE POST-AKUT
- Stabilkan kondisi pasien
- Kendalikan faktor risiko
- Rehabilitasi (psikologik, fisik, sosial)
- Biasakan hidup “pasca stroke” dengan baik
Immediate General Assessment: <10 Minutes
From Arrival

 Assess ABCs, vital signs

 Provide oxygen by nasal cannula
 Obtain IV access; obtain blood samples
(CBC, electrolytes, coagulation studies)
 Check blood sugar; treat if indicated
 Perform general neurological screening
assessment
 Immediate Neurological Assessment:
<25 Minutes From Arrival

 Review patient history

 Establish onset (<3 hours required for thrombolytics)
 Perform physical examination
 Perform neurological examination:
Determine level of consciousness (Glasgow Coma Scale)
Determine level of stroke severity (NIH Stroke Scale)
 Order urgent noncontrast CT scan
(door-to–CT scan performed: goal <25 min from arrival)
 Perform lateral cervical spine x-ray (if patient comatose/history
of trauma)
NINDS-Recommended Stroke Evaluation Targets
for Potential Thrombolytic Candidates

Time Target

Door to doctor 10 minutes

Door to CT completion 25 minutes
Door to CT read 45 minutes
Door to treatment 60 minutes
Access to neurological expertise* 15 minutes
Access to neurosurgical expertise* 2 hours
Admit to monitored bed 3 hours
 *By phone or in person
 Imaging
 Emergent CT:
 CT will likely be normal in early infarction
(less than 6 hours)
 CT very sensitive for acute hemorrhage
 MRI:
 Diffusion weighted imaging highly sensitive
and specific for stroke
 Carotid Ultrasound
 EKG/ echocardiogram
 Angiography
The concept of molecular penumbra with layers
emanating from the infarct core.
MRA of left PCA stenoses
CT Scan Stroke hemoragik (Intraserebral)
CT Scan Stroke hemoragik (Intraserebral)
CT Scan Stroke hemoragik (Subarachnoid)
 Acute / Subacute
Complications of Stroke
Neurological

Elevated intracranial pressure Herniation

Hemorrhagic transformation Seizures

Cerebral edema

Hydrocephalus

Recurrent stroke
 Acute / Subacute
Complications of Stroke
Medical
Urinary tract infection
Pneumonia
Airway obstruction Cardiac arrhythmias

Hypertension Decubitus ulcers

Dehydration Joint problems

Electrolyte disturbances Stress hyperglycemia

Pulmonary embolism Stress ulcers (gastrointestinal)

Deep venous thrombosis

 Stroke Risk Factors
Uncontrollable Controllable

Age High blood pressure

Gender Diabetes mellitus
Race Atrial fibrillation and other
Family history heart diseases
of stroke Aortic arch atheromas
Hematologic disorders
Cigarette smoking
Alcohol
Obesity
Dyslipidemia
 Prevention of Stroke:
Interventions commonly used

Type of Intervention Example (s)

Anti-platelet agents Aspirin

Ticlopidine
Clopidogrel

Oral anticoagulants Warfarin

Lipid-lowering agents Bile acid sequestrans

Niacin/nicotinic acid
Fibric acid derivatives
HMG-CoA reductase inhibitors

Surgery Carotid endarterectomy

RINGKASAN
 Akibat umum dari stroke adalah cacat atau meninggal
dunia.
 Stroke adalah emergensi, perlu penanganan segera.
Makin dini ditangani hasilnya makin baik
 Penanganan segera perlu dilakukan khususnya terhadap
ABC (airway, breathing, and circulation (life support),
terutama pada pasien yang terganggu kesadarannya.
 Selama perawatan harus dicegah dan diatasi komplikasi
stroke. Rehabilitasi sangat penting bagi pasien stroke
 Stroke bisa dicegah baik pencegahan primer atau sekunder.
 Pengamatan terhadap faktor risiko penting, terutama
gaya hidup / “life style”
STAF BAGIAN/SMF NEUROLOGI
RS Dr KARIADI

Prof. DR. Dr. Bambang Hartono Sp.S(K) – Kepala Bagian/SMF

Dr. M.N.Jenie Sp.S(K) – Kepala Unit Nyeri & Vertigo
Dr. Endang Kustiowati Sp.S(K) – Kepala Unit Stroke & Epilepsi
Dr. M. Noerjanto Sp.S(K) – Kepala Unit Gangguan Medulla Spinalis
Dr. Dani Rahmawati Sp.S – Kepala Unit Neurologi Anak/ Perilaku -EMG
Dr. Aris Catur Bintoro Sp.S – Kepala Unit EEG
Dr. Dodik Tugasworo Sp.S – Kepala Unit Neurovaskuler /TCD
Dr. Retnaningsih Sp.S- Kepala Unit Neurologi Emergensi
Dr. Hexanto Muhartomo Sp.S, M.Kes – Kepala Perpustakaan
Terima Kasih