SEORANG PEREMPUAN

65 TAHUN DENGAN
STROKE NON
HEMORRHAGIC DAN
ATRIAL FIBRILASI
Pembimbing:
dr. Jhon Kenedy Sp.N

Oleh:
dr. Mega Elisa Hasyim

P R E S E N TA S I K A S U S 2020 R S P K U M U H A M M A D I YA H G O M B O N G
1
 EPIDEMIOLOGI DI DUNIA

Stroke adalah penyakit terbanyak ke-2 setelah penyakit jantung sebgaai penyebab kematian di dunia.

2
 EPIDEMIOLOGI DI INDONESIA

Stroke adalah penyakit terbanyak ke-1 penyebab kematian di Indonesia.

3
 PREVALENSI

Sebanyak 10,9 per 1.000 penduduk Indonesia mengalami stroke per 2018. 

4
Disability Associated with Stroke

5
WHAT IS STROKE?

6
 What is STROKE ?
WHO, 1970
Rapidly developing clinical signs of focal (or
global) disturbance of cerebral function, lasting
more than 24 hours or leading to death, with no
apparent cause other than that of vascular origin
AHA/ASA Expert Consensus, 2013
An episode of neurological dysfunction caused
by focal cerebral, spinal, or retinal
infarction/ischemia, based on pathological,
imaging, or other objective evidence in a defined
vascular distribution; and/or clinical evidence of
cerebral, spinal cord, or retinal focal ischemic
injury based on symptoms persisting ≥24 hours
or until death, and other etiologies excluded

7
 Stroke Risk
Conditions Behaviors Family History 

• Previous Stroke or • Unhealthy Diet • Genetics and Family

Transient Ischemic • Physical Inactivity History
Attack • Obesity • Age
• High Blood Pressure • Too Much Alcohol • Sex
• High Cholesterol • Tobacco Use • Race or Ethnicity
• Heart Disease
• Diabetes
• Sickle Cell Disease

8
 ANAMNESIS
• Onset dari defisiit neurologis (lemas, baal, disfasia, dll)
• Kapan pertama kali memperhatikan adanya defisit neurologis? Apakah timbul
mendadak atau bertahap?
• Gejala apa yang teramati: lemas, baal, diplopia, disfasia, atau jatuh?
• Adakah gejala sensoris?
• Apakah gejala penyerta berikut: nyeri kepala, mual, muntah, atau kejang?
• Adakah defek neurologis lain baru-baru ini (misal TIA)
• Pernahkah pasien jatuh atau mengalami trauma kepala sebelumya
(pertimbangkan hematom subdural/ekstradural)?
• Sejauh mana disabilitas dan adakah efek gangguan fungsi oral?
• Nilailah aktivitas kehidupan sehari-hari

9
 RIWAYAT PENYAKIT DAHULU
• Adakah riwayat stroke sebelumnya. TIA, amaurosis fugax,
kolaps, kejang, atau perdarahan subaraknoid?
• Adakah riwayat penyakit vascular yang diketahu (missal:
stenosis karotis, arterosklerosis, penyakit vaskular perifer)
• Adakah riwayat perdarahan atau kecenderungan pembekuan
darah?
• Adakah kemungkinan sumber embolik (missal: fibrilasi atrium,
katup buatan, stenosis karotis, diseksi karotis atau vertebra)
• Adakah riwayat hipertensi, hiperkolesterolemia, atau merokok?

10
 OBAT-OBATAN
• Apakah pasien mengkonsumsi antikoagulan
( missal: warfarin) atau obat antiplatelet (missal:
aspirin)?
• Apakah baru-baru ini pasien mengonsumsi
trombolitik?

11
 PEMERIKSAAN FISIK
ABC
GCS
Pemeriksaan neurologis
Head to Toe

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 NEUROLOGIC EXAMINATION
The neurologic examination includes the following:
• Mental status
• Cranial nerves
• Motor system
• Muscle strength
• Gait, stance, and coordination
• Sensation
• Reflexes
• Autonomic nervous system
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 GAJAH MADA STROKE SCORE

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 No Gejala dan Tanda Penilaian Indeks Score
1 Kesadaran (0) kompos mentis x 2,5 +
(1) Mengantuk
(2) Semi koma/ koma
SIRIRAJ STROKE SCORE
2 Muntah (0) Tidak (1) ya x2 +
3 Nyeri kepala (0)Tidak (1) Ya x2 +
4 Tekanan darah Distolik +
5 Ateroma (0) Tidak (1)Ya x (-3) -
a. DM
b. Angina pectoris
Klaudikasio
intermiten
6 Kostanta - 12 -12
Siriraj Stroke Score (SSS)
SSS > 1 = Stroke hemoragik
SSS < -1 = Stroke non hemoragik

15
 PEMERIKSAAN PENUNJANG
• CT Scan/ MRI Brain • Thorax foto
• CT/MR Angiografi Brain • Urinalisa
• EKG • Echocardiografi (TTE/TEE)
• Doppler Carotis • Pemeriksaan Neurobehavior (Fungsi
Luhur)
• Transcranial Doppler
• DSA Serebral
• Lab : Hematologi rutin, GDS, fungsi
ginjal (Ur, Cr), Activated Partial
Thrombin Time (APTT), waktu
prothrombin (PT), INR, GDP dan
G2PP, HbA1C, profil lipid, C-reactive
protein (CPR), LED, dan pemeriksaan
atas indikasi seperti : enzim jantung
(troponin / CKMB), serum elektrolit,
analisis hepatik dan pemeriksaan
elektrolit, profil lipid.
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NONCONTRAST CT
• CT scan imaging paling
mudah, cepat dan
relatif murah
• CT scan kurang sensitif
dibanding dengan MRI,
misalnya pada kasus
stroke hiperakut.
• Dapat menyingkirkan
diagnosis SH atau
massa

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CT ANGIOGRAM
• The identification of areas of stenosis
or occlusion of vessels 
• Decision to administer intravenous
tissue plasminogen activator (TPA,
specifically alteplase) can be made
with more confidence as the cause
of the stroke is more accurately
identified.
• CTA can provide images of
aneurysms and other vascular
abnormalities such as arterio-venous
malformation (AVM). 

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CT PERFUSION
During a stroke, the area of the brain
undergoing infarction has both decreased
CBF (Cerebral Blood Flow) and CBV
(Cerebral Blood Volume).
Decreased total CBV is the most specific
indicator for an area actually undergoing
irreversible ischemia or infarct and is non
salvageable.

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MAGNETIC RESONANCE IMAGING

• Conventional brain MRI studies can

take up to one hour to complete. 
• The study is not very good at
detecting cytotoxic or intracellular
edema that is seen in the acute or
less than 24 hour phase of stroke.
• Useful in the initial evaluation of the
acute stroke patient suspected of
having a subarachnoid hemorrhage.

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21
 Alteplase
• Dosis Alteplase 0.6-0.9 mg/kgBB
• Berikan bolus 10% dosis
• Sisanya di drip dalam 1 jam

22
 Alteplase Considerations
• Exclude intracranial hemorrhage as the primary cause of stroke signs
and symptoms prior to initiation of treatment (see Contraindications)
• Administer as soon as possible but within 3 hr after onset of symptoms;
AHA/ASA 2019 Acute Stroke Guidelines recommend use within 4.5 hr of
stroke onset
• Monitor and control blood pressure during and following administration
• In patients without recent use of oral anticoagulants or heparin,
treatment can be initiated prior to the availability of coagulation study
results
• Discontinue if the pretreatment INR is >1.7 or the aPTT is elevated

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Blockage of one blood vessel will cause
ischemia within 5 minutes STROKE
Time Neurons Synapses Lost Myelinated Premature Aging
Lost fibers Lost
1 second 32,000 230 million 200 m 8.7 hours

1 minute 1.9 million 14 billion 12 km 3.1 weeks

1 hour 120 million 830 billion 714 km 3.6 years

Complete 1.2 billion 8.3 trillion 7140 km 36 years

Time is Brain! Time lost is Brain lost

Saver JL, Stroke 2006

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 WHY EARLY DETECTION ?
ISCI Guideline 2010
• Increase % of patients age ≥18 y.o presenting within 3
hours of stroke onset, who are evaluated within 10
minutes of arriving in the emergency department
• Increase % of patients receiving appropriate
thrombolytic and antithrombotic therapy
• Increase % of stroke patients who receive appropriate
medical management within the initial 24-48 hours of
diagnosis for prevention of complications
• Improve patient outcome and family education
 Cincinnati Stroke Scale
A Checklist for Emergency Medical Dispatchers
3-Question Checklist Score
1. Ask patient to smile
Normal 0
Slight difference 1
Obvious difference 3
Cannot complete at all
2. Ask patient to raise both arms above head
Both arms raise equally 0
One arm higher than the other 1
Cannot complete request at all
3. Ask patient to say “the early bird catches the worm”
Total score:
Said correctly 0
3 Clear evidence of stroke
Slurred speech 3
2 Strong evidence of stroke
Garbled or not understood 3 1 Partial evidence of stroke
Cannot complete request at all 0 No evidence of stroke
 STROKE IS TIME CRITICAL ABC & Fast Diagnosis

• Maintain ABC
• Knowing neurologic signs & symptoms
• Perform focused neurologic exams
• Clinical exams in 10 minutes time !!!
• If suspected stroke  perform urgent Brain CT-Scan
• This part must be done in Health Facility which has CT-Scan
• Consult to neurologist for Reperfusion/Recanalization Therapy and
Acute Stroke Care
 Intravenous thrombolysis
 Intraarterial thrombolysis
 Mechanical thrombectomy
NIH-Recommended ED Response Time
DTN ≤60 min : the “golden hour” for evaluating & treating acute stroke

T=0 ≤10 min ≤ 15 min ≤ 25 min ≤ 45 min ≤ 60 min

Suspected Initial MD evaluation Stroke team CT scan CT & labs rt-PA
stroke patient(including patient notified initiated interpreted given if
arrives at history, lab work (including patient
stroke unitinitiation, & NIHSS) neurologic is eligible
expertise)

NINDS NIH website. Stroke proceedings. Latest update 2008.

 INCLUSION CRITERIA
The Golden Hour 1.
2.
Clinical signs and symptoms of definite acute stroke
Clear time of onset
3. Presentation within 3 hrs of acute onset
4. Haemorrhage excluded by CT scan
5. Age 18 - 80 years old
6. Consent to treat (every effort must be made to contact next of kin)

THROMBOLYSIS PATHWAY EXCLUSION CRITERIA

7. Rapidly improving or minor stroke symptoms (NIHSS 1-4)
➊Arrival to ED 8. NIHSS < 5 or >25
9. Stroke or serious head injury within 3 months
➋A&PE assessment 10. Major surgery, obstetrical delivery, external heart massage in last 14 days
11. Seizure at onset of stroke
➌Neurologist & Stroke team notified 12. Prior stroke and concomitant diabetes
13. Severe haemorrhage in last 21 days
➍Order priority CT Brain 14. Increase bleeding risk
15. History of central nervous damage (neoplasm, haemorrhage, aneurysm,
➎Lab & ECG exams DTN spinal or intracranial surgery or haemorrhagic retinopathy)
60 min16. Blood pressure above 185 mmHg systolic or 110 mmHg diastolic
17. Symptoms suggestive of SAH (even if CT is normal)
➏CT scan performed
18. Known clotting disorder
➐CT report obtained 19. APTT abnormal, INR>1.5
20. Suspected iron deficient anaemia
➑Patient informed and consent obtained 21. Thrombocytopenia <100,000
22. Hypoglycaemia or hyper glycaemia <50 mg/dL >400 mg/dL
➒Reconstitution and drawing up of 23. Bacterial endocarditis, pericarditis
24. Acute pancreatitis
Alteplase
25. Ulcerative GI disease in last 3 months, oesophageal varices, arterial-
aneurysm, arterial/venous malformation.
➓Thrombolysis is initiated
26. Severe liver disease including cirrhosis, acute hepatitis
 · IGD (Triage) Pasien dicurigai Gejala FAST : (Lihat Ceklis)
· Ruang Rawat Stroke
-Face (mulut mencong)
-Arm (lemah separuh badan)
-Speech (pelo/afasia)
DOKTER EMERGENSI
CURIGA STROKE AKUT < 4.5 jam) -Time last normal (< 6 jam)

Dalam 10 menit :
CODE STROKE
1. EKG
2. GDS (stick)
ACTIVATE CODE STROKE 3. Lab (bila perlu)
(Warfarin  INR ; NOAC  APTT)
4. Order Urgent CT/MRI Brain
5. Nilai NIHSS
Konsul / Refer cito ! 6. Pasang iv-line
Urgent Neurologi 7. Call Neurologist
CT/MRI Brain DPJP NEUROLOGI
DPJP Neurologi
· Konfirmasi Stroke Iskemik
· Klarifikasi onset gejala
· NIHSS
ELIGIBILITAS TROMBOLISIS · Order Obat Alteplase (Actilyse®)
Lihat Ceklis

·Dosis Alteplase 0.6-0.9

mg/kgBB
START TROMBOLISIS · Berikan bolus 10% dosis
· Sisanya di drip dalam 1 jam

TRANSFER KE RUANGAN
(STROKE UNIT/Bangsal
Neuro/HCU/ICU)
31
PRESENTASI KASUS

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 IDENTITAS PASIEN
Nama : Ny. S
Usia : 64 tahun
Alamat : Gombong
No RM : 4013xx
Tanggal masuk : 11 Mei 2020

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 ANAMNESIS
Pasien datang ke IGD PKU Gombong dengan keuhan bicara pelo dan
lemas anggota badan sebelah kanan mendadak. Keluhan dirasakan sejak
8 jam sebelum masuk rumah sakit. Kemarin malam pasien bangun tidur
untuk ke kamar mandi tapi tidak bisa jalan. Pasien sama sekali tidak bisa
menggerakkan kaki dan tangan kanan. Paginya pasien dibawa ke IGD
oleh keluarga karena keluhannya belum tidak ada perbaikan gejala.
Saat di IGD pasien masih sadar. Pasien dapat diajak komunikasi,
namun tidak jelas ketika berbicara. Keluhan lain seperti demam, nyeri
kepala, mual, muntah, diare, kejang, disangkal oleh pasien dan keluarga
pasien.

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 RIWAYAT PENYAKIT DAHULU
o Riwayat keluhan serupa : disangkal
o Riwayat sakit jantung : sejak 1 tahun yang
lalu.
Dada berdebar kadang disertai nyeri dada. Pasien berobat ke
dokter umum dekat rumah dan obat di minum sampai habis.
Pasien tidak ingat nama obatnya. Namun setelah obat habis
pasien tidak berobat lagi dan belum pernah ke dokter spesalis
jantung.
o Riwayat sakit gula : disangkal
o Riwayat tensi tinggi : disangkal
o Riwayat rawat inap di RS sebelumnya : disangkal
o Riwayat alergi obat dan makanan : disangkal

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 ANAMNESIS SISTEM
Cerebrospinal Kardiovaskuler
• Demam (-), kejang (-), sakit • Jantung berdebar (-), nyeri
kepala (-), kepala berputar (-), dada (-), hipertensi (-),
hemiparese (+), sulit bicara (+) gangguan irama (+)

Respirasi Gastrointestinal
• Batuk (-), pilek (-), sesak napas (-) • Mual (-), diare (-), sulit BAB
(-), BAB darah (-)

Urogenital
• BAK keruh (-)

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 STATUS GENERALIS
Keadaan Umum:
GCS: E4V5M6
Tanda vital
TD : 171/95 mmHg
HR : 84 kali/ menit, ireguler, isi cukup, tegangan cukup
RR : 20 kali/ menit, reguler, kedalaman cukup
Suhu : 36,5° C per aksiler

37
 PEMERIKSAAN FISIK
Kepala Leher Cor
Kepala: Mesosefal
I : IC tak kuat angkat
Mata: CA -/-, pupil isokor
3mm/3mm, reflex cahaya (+/+)
P: IC di SIC 5
Mulut : mukosa basah P: batas jantung kesan tdk melebar
Leher : JVP 5 cm, pulsasi A. A: BJ I II tunggal, ireguler,
karotis teraba kuat murmur (-), gallop (-)

Abdomen
I: datar Pulmo
A: BU + normal
P: timpani, pekak berlih (-)
I : pengembangan dada kanan = kiri
P: Supel, NT (-), hepar lien tidak P: fremitus raba kanan = kiri
teraba membesar P: sonor/sonor
A: SDV: +/+, RBH -/-
Ekstremitas RBK -/-, Wheezing -/-
Akral dingin Edem

- - - -
- - - -

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 PEMERIKSAAN NEUROLOGIS
1. Kesadaran : Compos Mentis (E4M6V5)
2. Rangsang meningeal :
Kaku kuduk : -
Brudzinsky I : -
Brudzinski II : -/-
Kernig sign : kedua tungkai tidak terbatas
Lasegue sign: kedua tungkai tidak terbatas

39
3. Pemeriksaan nervus kranialis :
NI : tidak dilakukan
N II : dalam batas normal
N III, IV, VI : dalam batas normal
NV : dalam batas normal
N VII : defiasi (mulut) ke arah kiri (parese N VII
kanan sentral)
N VIII : dalam batas normal
N IX : tidak dilakukan
NX : tidak dilakukan
N XI : tidak dilakukan
N XII : defiasi lidah ke arah kanan (parese N XII
kanan)

40
4. Pemeriksaan Motorik

• Inspeksi postur : asimetrisitas (-),

gerakan involunter (-), atrofi
(-)
• Tonus : lengan : normotonus
tungkai : normotonus
• Trofi 2222 : dalam
5555 batas normal
• Kekuatan 2222 5555
:

41
5. Pemeriksaan Sensorik
Sensasi taktil : tidak didapati anastesi
Nyeri superfisial : tidak didapati analgesi
Diskriminasi dua titik : tidak didapati anastesi
Sensasi suhu : tidak dilakukan
Arah gerak sendi : tidak didapati analgesi
Sensasi getar : tidak didapati analgesi
Hipersetesi : tidak ada

42
6. Pemeriksaan koordinasi : tidak dilakukan
7. Reflek fisiologis
  Kanan Kiri
Biceps ++ ++
Triceps ++ ++
Patella ++ ++
Achilles ++ ++

43
8. Reflek patologis:
Babinski : -/-
Hoffman : -/-
Tromner : -/-
Chaddock : -/-
Gordon : -/-
Oppenhein : -/-
Gonda : -/-
Schaefer : -/-
9. Reflek vegetatif
BAK : normal
BAB : normal
44
 No Gejala dan Tanda Penilaian Indeks Score
1 Kesadaran (0) kompos mentis x 2,5 +0
(1) Mengantuk
(2) Semi koma/ koma
SIRIRAJ STROKE SCORE
2 Muntah (0) Tidak (1) ya x2 +0
3 Nyeri kepala (0)Tidak (1) Ya x2 +0
4 Tekanan darah Distolik x 0.1 + 9.5
5 Ateroma (0) Tidak (1)Ya x (-3) -0
a. DM
b. Angina pectoris
Klaudikasio
intermiten
6 Kostanta - 12 - 12
TOTAL - 2.5
Kesimpulan: SSS < - 1 = Stroke Non Hemorrhagic
Siriraj Stroke Score (SSS)
SSS > 1 = Stroke hemoragik
SSS < -1 = Stroke non hemoragik

45
 PEMERIKSAAN PENUNJANG
Lab Darah di PKU Muhammadiyah Gombong (11/05/20)
Pemeriksaan Hasil Nilai Rujukan Satuan
Darah Lengkap
Leukosit 7.40 3.6-11 rb/ul
Eritrosit 3.77 L 3.8-5.2 juta/L
Hemoglobin 10.4 L 11.7-15.5 gr/dl
Hematokrit 33.0 L 35-47 %
MCV 87.6 80-100 fL
MCH 27.7 26-34 pg
MCHC 31.7 L 32-36 g/dl
Trombosit 224 150-440 rb/ul
Hitung Jenis    
Basofil 0.5 0.0-1.0 %
Eusinofil 1.2 L 2.0-4.0 %

Neutrofil 77.3 H 50.00-70.0 %

Limfosit 16.9 L 25.0-40.0 %

Monosit 4.1 2.0-8.0 %

Profil Lemak    
Kolesterol 204 H 0-200 mg/dl
Trigliserida 54.00 0-150 mg/dl

46
 PEMERIKSAAN PENUNJANG
EKG di RS PKU Muhammadiyah Gombong (11/05/2020)

Interpretasi Atrial fibrilasi NVR HR 80-90 x/menit

Zona transisi V5-V6 Clockwise rotation

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 RONTGEN
THORAX
di RS PKU Muhammadiyah
Gombong (11/05/20)

Kesan:
Oedema pulmonum
grade 0-1
Cardiomegali

48
 DIAGNOSIS
SNH dd SH
Atrial Fibrilasi NVR

49
 TATALAKSANA
• Inf NaCl 20 tpm
• Inj Ranitidin 50 mg
• Inj Citicolin 500 mg
• Drip Mecoblamin 500 mcg
• Amlodipin 10 mg

PLAN
• CT Scan kepala tanpa kontras

50
FOLLOW UP

51
 12/05/2020 DPH 1
S O
Bicara pelo, KU: GCS: E4V5M6
kelemahan TD: 140/80 mmHg
anggota HR: 80
gerak kanan RR: 20
Suhu: 36.5
Cor: BJ I II ireguler,
intensitas normal, bising -
Pulmo: SDV +/+, RBH -/-
RBK -/-, Whz -/-
A P
• SNH • Inf NaCl 20 tpm
• AF • Inj Ranitidin 50 mg / 12 jam
• Inj Citicolin 500 mg / 12 jam
• Drip Mecoblamin 500 mcg
• Amlodipin 1 x 10 mg
• Aspilet 1 x 80 mg
• Simvastatin 20 mg (0-0-1)
• Concor 2.5 mg (½-0-0)

Parese N VII dan XII

Motorik

2 5
2 5

52
 CT SCAN
KEPALA TANPA
KONTRAS
di RSUD Dr. Soedirman
12/05/2020

Kesan:
• Infarc cerebri akut di
putamen sinistra sampai
corona radiata sinistra
• Lacunar infarc di
nucleus caudatus
bilateral
• Atrophy cerebri
• Tak atampak gambaran
perdarahan maupun
SOL intra cerebral / intra
cerebellar

53
 DIAGNOSIS
Neurologi:
Diagnosis Klinis : Hemiparese dextra dengan parese N VII dextra
tipe sentral, dan parese N XII dextra tipe sentral
Diagnosis Topis : putamen sinistra sampai corona radiata
sinistra dan nucleus caudatus bilateral
Diagnosis Etiologi : Stroke Non Hemorrhagic dd SH

Kardiologi:
Atrial Fibrilasi NVR

54
 13/05/2020 DPH 2
S O A P
Bicara pelo, KU: GCS: E4V5M6 • SNH BLPL, obat pulang:
kelemahan TD: 120/80 mmHg • AF • Aspilet 1 x 80 mg
anggota HR: 80 • Piracetam 2 x 800 mg
gerak kanan RR: 20 • Amlodipin 1 x 10 mg
Suhu: 36.5 • Simvastatin 20 mg (0-0-1)
• Concor 2.5 mg (½-0-0)
Cor: BJ I II ireguler,
intensitas normal, bising -
Pulmo: SDV +/+, RBH -/-
RBK -/-, Whz -/-

Parese N VII dan XII

Motorik

2 5
2 5

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APPROACH TO PATIENT

56
 APPROACH TO PATIENT
(SUBJECTIVE)

Theory Patient
Facial droop Yes

Arm drift Yes

Speech is abnormal Yes

Time of symptom onset 8 hr

57
 Risk Factors Patient
High blood pressure -
Diabetes -
Heart and blood vessel diseases Atrial Fibrillation
High LDL cholesterol levels -
Smoking -
High blood pressure -
Brain aneurysms or arteriovenous -
malformations (AVMs)
Infections or conditions that cause -
inflammation, such as lupus or
rheumatoid arthritis
Age 64 yo
Sex woman
Family history and genetics -

58
 APPROACH TO PATIENT
(OBJECTIVE)

Pemeriksaan Paien
TD : 171/95 mmHg
HR : 84 kali/ menit, ireguler
Vital sign RR : 20 kali/ menit
Suhu : 36,5° C

Motorik 2 5
2 5
Pemeriksaan neurologis
Parese N VII dan XII

EKG Atrial Fibrilasi NSR

Lab Darah (DL, glukosa, profil lipid) Normal

CT Scan Kepala Infark

59
 APPROACH TO PATIENT
(Treatment)

tPA within 4.5 hr of stroke onset -

Aspirin Aspilet 1 x 80 mg
Medical procedures (a thrombectomy -
removes the clot from the blood vessel)

60
THANK YOU

61