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8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
1/23
Case Report
INFARCTION STROKE
By:
Ary Anggi Kristiana
1408465581
Supervisor:
dr. Rii Sui!"dr!# Sp.S
$E%ART&ENT OF NE'RO(O)*
&E$ICA( SC+OO( 'NI,ERSIT* OF RIA'
ARIFIN AC+&A$ )ENERA( +OS%ITA(
%EKANBAR'
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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-015
KE&ENTRIAN %EN$I$IKAN $AN KEB'$A*AAN
FAK'(TAS KE$OKTERAN 'NI,ERSITAS RIA'
S&FBA)IAN SARAFSere/!ri!/ : Gedung Kelas 03, RSUD Arifin Achmad Lantai 04Jl. Mustia, !el". 0#$%'(4000)&mail * saraffur+gmail.cm
% E K A N B A R '
I. %ATIENTS I$ENTIT*
-ame Mrs.
Age #4 /ears $ mnths
Gender emale
Address Jalan 1angtuah Gang 1angtuah -. 44 2eanaru
Religin Mslem
Marital Status Married
ccu"atin 1use5ife
Date f Admissin -6emer, 74th 70%8
Medical Recrd (0 '% 99
II. ANA&NESIS
Allanamnesis :-6emer, 78th 70%8;
Cie2 Co3p!i"/
!he 5eaness n the right arm and leg
%rese"/ I"ess +is/ory
Since a da/ efre admissin, the "atient has cm"lained the 5eaness n
her right arm and leg. At first, the "atient has cm"lained the numness
and then 5eaened suddenl/ 5hen she 5e u" n the mrning. She ne6er
cm"lained the numness efre.
urthermre, the "atient
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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3; Ne S/i22"ess * -egati6e
4; Cr!"i! Nerves
%. Cr!"i! "erve I O2!/ory;
Right Left nter"retatinSense f Smell =an
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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#. Cr!"i! "erve ,II F!i!;
Right Left nter"retatin
!ic
Mtr Sense f !aste
=h6ste Sign
:&;
-rmal=an
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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I,. &OTOR S*STE&
Right Left nter"retatin
U""er )9tremit/ Strength
Distal
2r9imal
!ne
!r"h/
n6luntar/ m6ements
=lnus
%
%
-rmal
)utr"h/
:&;
:&;
8
8
-rmal
)utr"h/
:&;
:&;
1emi"aresis
:UM- !/"e;
L5er )9tremit/
Strength
Distal2r9imal
!ne
!r"h/
n6luntar/ m6ements
=lnus
%%
)utr"h/
:&;
:&;
88
)utr"h/
:&;
:&;
1emi"aresis:UM- !/"e;
d/
!r"h/
n6luntar/ m6ements
Adminal Refle9
)utr"h/
:&;
:&;
)utr"h/
:&;
:&;
-rmal
,. SENSOR* S*STE&
Right Left nter"retatin
Light !uch
2ain
!em"erature
=an
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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ains/
=haddc
1ffman !rmer
"enheim
Schaefer 2rimiti6e Refle9
2almmental
Snut
:&;
:&;
:&;
:&;
:&;
:&;
:&;
:&;
:&;
:&;
:&;
:&;
:&;
:&;
2athlgic refle9 :&;
- 2rimiti6e Refle9
,II. COOR$INATION
Right Left nter"retatin
2int t "int m6ements
Eal heel t teGait
!andem
Rmerg
=an
)e"er! S/!/us : 1/"ertensin :%#0>'0 mm1g;
Co9"i/ive Fu"/io" : =gniti6e m"airment
Ne S/i22"ess : -egati6e
Cr!"i! Nerves : D/sarthria
&o/ori : 1emi"aresis :UM- !/"e;
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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Se"sory : =an
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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I,. (ABORATOR* AN$ RA$IO(O)* FIN$IN)S
1. Bood Rou/i"e Nove37er# -4/ -015;
? 1emglin * %7.7 g>dL
? 1ematcrit * 34 H
? Leuc/te * $.$00>mm3
? !hrmc/te * 74#.000>mm3
nter"retatin* -rmal
-. Bood Ce3is/ry
Nove37er# -4/ -015;
? )uose : 155 39d(
? Ureum * 3'.4 mg>dL
? =reatinin * 0.($ mg>dL
? AS! * %(.$ U>L
? AL! * %7 U>L
)lectrlite*
? Sdium * %44.' mml>L
? 2tassium * 7.'( mml>L
? =hlride * %%8.( mml>L
Nove37er# -5/ -015;
? =hr * %$8 mg>dL
? 1DL * 4$.0 mg>dL
? !rigl/ceride * #8 mg>dL
? Uric acid * $.3 mg>dL? LDL =hlesterl * %04 mg>dL
? LD2 * %44 U>L
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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@. Ee/ro!rdio9r!py
nter"retatin * s/nus rithm, n anrmal mr"hlg/ 5a6es.
4. Ces/ ?r!y Nove37er# -4/ -015;
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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nter"retatin* nrmal
5. +e!d CT S!" i/ou/ o"/r!s/
nter"retatin* infarctin n the left hemis"here cereri
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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,. FINA( $IA)NOSIS
- nfarctin stre
FO((O> '%
Nove37er# -6/ -015
S * lethargic, 5eaness f the right e9tremit/, a"hasia, fe6er.
O *
G=S )4M$@a"hasia
ld 2ressure %$0>(0 mm1g
1eart Rate (7 "m
Res"iratr/ Rate 77 t"m
!em"erature 3'.%?=
=gniti6e unctin * =gniti6e m"airment
-ec Stiffness * -egati6e
=ranial -er6es * D/sarthria
Mtric * right e9tremit/ hemi"aresis
Sensr/ * =an
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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ld 2ressure %$0>(0 mm1g
1eart Rate '0 "m
Res"iratr/ Rate 77 t"m
!em"erature 3'.0?=
=gniti6e unctin* =gniti6e m"airment
-ec Stiffness * -egati6e
=ranial -er6es * D/sarthria
Mtric * 1emi"aresis
Sensr/ * =an
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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Autnm/ * Anrmal urinatin and defecatin
Refle9 * -rmal
A * nfarctin stre
% *
@D RL 70 d"m
=iticlin 3 9 800 mg "er @
As"ilet 7 9 '0 mg "er ral
lic acid 7 9 400 Ig "er ral
Discussion
INFARCTION STROKE
1. $e2i"i/io"
Stroke is a""lied t a sudden fcal neurlgic s/ndrme, s"ecificall/ the
t/"e due t cerer6ascular disease. !he term cerebrovascular disease designates
an/ anrmalit/ f the rain resulting frm a "athlgic "rcess f the ld
6essels. Pathologic process is gi6en an inclusi6e meaning namel/, cclusin f
the lumen / emlus r thrmus, ru"ture f a 6essel, an altered "ermeailit/ f
the 6essel 5all, r increased 6iscsit/ r ther change in the Fualit/ f the ld
fl5ing thrugh the cereral 6essels. !he 6ascular "athlgic "rcess ma/ e
cnsidered nt nl/ in its grsser as"ects emlism, thrmsis, dissectin, r
ru"ture f a 6essel ut als in terms f the mre asic r "rimar/ disrder, i.e.,
athersclersis, h/"ertensi6e arterisclertic change, arteritis, aneur/smal
dilatin, and de6el"mental malfrmatin. )Fual im"rtance attaches t the
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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secndar/ "arench/mal changes in the rain resulting frm the 6ascular lesin.
!hese are f t5 main t/"es ischemia, 5ith r 5ithut infarctin, and hemrrhage
and unless ne r the ther ccurs, the 6ascular lesin usuall/ remains silent. !he
nl/ e9ce"tins t this statement are the lcal "ressure effects f an aneur/sm,
6ascular headache :migraine, h/"ertensin, tem"ral arteritis;, multi"le small
6essel disease 5ith "rgressi6e ence"hal"ath/ :as in malignant h/"ertensin r
cereral arteritis;, and increased intracranial "ressure :as ccurs in h/"ertensi6e
ence"hal"ath/ and 6enus sinus thrmsis;. Als, "ersistent acute h/"tensin
ma/ cause ischemic necrsis in regins f rain et5een the 6ascular territries f
crtical 6essels, e6en 5ithut 6ascular cclusin.%
Mre than an/ ther rgan, the rain de"ends frm mment t mment n
an adeFuate su""l/ f 9/genated ld. =nstanc/ f the cereral circulatin is
assured / a series f arrece"trs and 6asmtr refle9es under the cntrl f
centers in the l5er rainstem. structin f an arter/ / thrmus r emlus is
the usual cause f fcal ischemic damage, ut failure f the circulatin and
h/"tensin frm cardiac decm"ensatin r shc, if se6ere and "rlnged
enugh, can "rduce fcal as 5ell as diffuse ischemic changes.%
cal cereral ischemia differs fundamentall/ frm glal ischemia. n the
latter state, if aslute, there is n cereral ld fl5 f the entire rain and
irre6ersile destructin f neurns ccurs 5ithin 4 t ' min at nrmal d/
tem"erature. n fcal ischemia, there is nearl/ al5a/s sme degree f circulatin
:6ia cllateral 6essels;, "ermitting t a 6ar/ing e9tent the deli6er/ f 9/genated
ld and glucse.
!he effects f a fcal arterial cclusin n rain tissue als 6ar/ de"ending
n the lcatin f the cclusin in relatin t a6ailale cllateral and anastmticchannels. f the structin lies "r9imal t the circle f Eillis :t5ard the heart;,
the anterir and "sterir cmmunicating arteries f the circle are ften adeFuate
t "re6ent infarctin. n cclusin f the internal cartid arter/ in the nec, there
ma/ e anastmtic fl5 frm the e9ternal cartid arter/ thrugh the "hthalmic
arter/ r 6ia ther smaller e9ternalinternal cnnectins. Eith lcage f the
6erteral arter/, the anastmtic fl5 ma/ e 6ia the dee" cer6ical, th/rcer6ical,
r cci"ital arteries r retrgrade frm the ther 6erteral arter/. f the cclusin
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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is in the stem "rtin f ne f the cereral arteries, i.e., distal t the circle f
Eillis, a series f meningeal interarterial anastmses ma/ carr/ sufficient ld
int the cm"rmised territr/ t lessen :rarel/ t "re6ent; ischemic damage.
!here is als a ca"illar/ anastmtic s/stem et5een adacent arterial ranches,
and althugh it ma/ reduce the siBe f the ischemic field, "articularl/ f the
"enetrating arteries, it is usuall/ nt significant in "re6enting infarctin. !hus,
in the e6ent f cclusin f a mar arterial trun, the e9tent f infarctin ranges
frm nne at all t the entire 6ascular territr/ f that 6essel. et5een these t5
e9tremes are all degrees f 6ariatin in the e9tent f infarctin and its degree f
cm"leteness.%
Additinal ischemia-modifying factors determine the e9tent f necrsis.
!he s"eed f cclusin assumes im"rtance gradual narr5ing f a 6essel all5s
time fr cllateral channels t "en. !he le6el f ld "ressure ma/ influence the
result h/"tensin at a critical mment ma/ render anastmtic channels
ineffecti6e. 1/"9ia and h/"erca"nia are "resumed t ha6e deleterius effects.
Altered 6iscsit/ and smlalit/ f the ld and h/"ergl/cemia are "tentiall/
im"rtant factrs ut difficult t e6aluate. inall/, anmalies f 6ascular
arrangement :f nec 6essels, circle f Eillis, and surface arteries; and the
e9istence f "re6ius 6ascular cclusins must influence the utcme.%
!he s"ecific neurlgic deficit 6iusl/ relates t the lcatin and siBe f
the infarct r fcus f ischemia. !he territr/ f an/ arter/, large r small, dee" r
su"erficial, ma/ e in6l6ed. Ehen an infarct lies in the territr/ f a cartid
arter/, as 5uld e e9"ected, unilateral signs "redminate* hemi"legia,
hemianesthesia, hemian"ia, a"hasia, and agnsias are the usual cnseFuences. n
the territr/ f the asilar arter/, the signs f infarctin are freFuentl/ ilateral andccur in cnunctin 5ith cranial ner6e "alsies and ther segmental rainstem and
cereellar signs Fuadri"aresis, hemi"aresis, and>r unilateral r ilateral sensr/
im"airment are t/"ical, cu"led 5ith di"l"ia, d/sarthria, and 6ertig in 6arius
cminatins.%
-. Ris 2!/or
Accrding t the American 1eart Assciatin :A1A;, the ris factrs f
stre are di6ided int t5, that are nt mdifiale riss factrs and mdifiale
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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ris factrs. -t mdifale ris factrs include* age, se9, l5 irth 5eight, race r
ethnicit/, and genetic factrs. Mdifiale ris factrs include* h/"ertensin,
sming, diaetes, nutritinal imalance, lac f "h/sical acti6it/, alchl
cnsum"tin, and drug ause. ncidence f stre can ccur 5ith ne r mre ris
factrs :multifactr;.%&3
T!7e @. Stre ris factrs%&3
No/ &odi2!7e &odi2!7e
% Age
7 Gender
3 Genetic
4 )thnic
% Stre histr/ %0. Sming
7 1/"ertensin %%. Alchl
3 1eart disease %7. Drug ause
4 Diaetes melitus %3. 1/"erhmsisteinemia
8 =artid stensis %4. Antid/ anti fsfli"id
$ !A %8. 1/"erurisemia# 1/"erchlesterlemia %$. )le6atin f hematcrit
' ral cntrace"tin %#. )le6atin f firingen
( esit/
@. Ci"i! &!"i2es/!/io"
!he s"ecific neurlgic deficit 6iusl/ relates t the lcatin and siBe f
the infarct r fcus f ischemia. !he territr/ f an/ arter/, large r small, dee" r
su"erficial, ma/ e in6l6ed. Ehen an infarct lies in the territr/ f a cartid
arter/, as 5uld e e9"ected, unilateral signs "redminate* hemi"legia,
hemianesthesia, hemian"ia, a"hasia, and agnsias are the usual cnseFuences. n
the territr/ f the asilar arter/, the signs f infarctin are freFuentl/ ilateral and
ccur in cnunctin 5ith cranial ner6e "alsies and ther segmental rainstem and
cereellar signs Fuadri"aresis, hemi"aresis, and>r unilateral r ilateral sensr/
im"airment are t/"ical, cu"led 5ith di"l"ia, d/sarthria, and 6ertig in 6arius
cminatins.%,7
4. &!"!9e3e"/
Stre "atients shuld e handled / a multidisci"linar/ team.
Management stre e dne / im"r6ing the general state f the "atient, treat the
ris factrs, and "re6ent cm"licatins.3&$
4.1 +yper!u/e s/!diu3
Actin at this stadium is dne at the )mergenc/ Rm, the aim is t
"re6ent the 5ides"read f rain tissue damaging. At this stage, "atients 5ere
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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gi6en 9/gen 7 L > min and cr/stallid>cllid fluid, a6id administratin f
de9trse. rain =! scan e9aminatin, electrcardigra"h/, chest &ra/, cm"lete
"eri"heral ld and "latelet cunt, "rthrmin time > -R, A2!!, ld
glucse, ld chemistr/ :including electrl/tes;, and if h/"9ia, d the ld gas
anal/sis. ther actins in the )mergenc/ Rm are "r6iding mental su""rt t
"atients and "r6ide an e9"lanatin t the famil/ t remain calm.3&$
4.- Au/e s/!diu3
4.7.% General treatment
2lace the "atient
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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mL fr 4 hurs and 800 mL fr ' hurs r until h/"tensin treated. f nt
crrected, that is s/stlic ld "ressure still (0 mm1g, d"amine 7&70 mcg > g
> minute can e gi6en until the s/stlic ld "ressure N%%0 mm1g. 3&$
f there is seiBure, gi6e diaBe"am 8&70 mg i6 sl5l/ fr 3 minutes, the
ma9imum dsage is %00 mg "er da/, fll5ed / ral administratin f
anticn6ulsants such as "hen/tin, caramaBe"ine. f the seiBure a""eared after 7
5ees, gi6en rall/ lng&term anticn6ulsant. 3&$
f there is an increased f intracranial "ressure, lus mannitl 5ere gi6en
an f 0.78 t % g > g "er 30 minutes intra6enusl/, and if reund "henmenn
sus"ected, r general cnditin deterirated, fll5ed / 0,78g > g "er 30
minutes e6er/ $ hurs fr 3&8 da/s. Mnitring f the smlarit/ shuld e
"erfrmed :370 mml;, alternati6el/ can e administered h/"ertnic slutins
:-a=l 3H; r fursemid. 3&$
4.7.7 S"ecial treatment
!he gal is t re"erfusin / administratin f anti"latelet agent such as
as"irin and anticagulant, r 5ith trml/tic rt&2A :cminant tissue
2lasmingen Acti6atr;, and neur"rtecti6e agent, such as citicline r
"iracetam. 3&$
4.@ Su7!u/e S/!diu3
Medical measures ma/ include cgniti6e thera"/, eha6ir, s5all5ing,
s"eech thera"/, and ladder training :including "h/sical thera"/;. Gi6en the lng
curse f the disease, it taes a s"ecial intensi6e treatment f "st&stre in the
hs"ital 5ith the gal f inde"endence f the "atient, understand, cm"rehend and
im"lement "rimar/ and secndar/ "re6entin "rgrams.
$
Suacute "hase treatment*$
- =ntinuing the a""r"riate treatment f acute cnditins efre- !he management f cm"licatins- Restratin > rehailitatin :as needed f "atients;, 5hich is
"h/sithera"/, s"eech thera"/, cgniti6e thera"/, and ccu"atinal
thera"/
- Secndar/ 2re6entin- amil/ educatin and discharge "lanning
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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T+E BASIC OF $IA)NOSIS
1. B!si i"i! di!9"osis
rm the histr/ taing, a #4 /ears ld 5man had a sudden 5eaness n
the right arm and leg :1emi"aresis;. And her s"eech ecame slurred and
nnfluent. She als can
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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!he gld standard e9aminatin fr diagnsing the nn hemrrhagic r
hemrrhagic stre is =! Scan. !he cnsideratin f the hemrrhagic stre
ecause f it almst has the same manifestatin, lie the immediate nset, the
"atient 5as nt in se6ere acti6it/, and there is neurlgical deficit.
5. B!si seo"d!ry di!9"osis
rm the "h/sical e9aminatin the ld "ressure is %#0>'0 mm1g. !his
is a""r"riated 5ith J-= ' criteria that fr "atient
8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana
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REFFERENCE
% R""er A1, r5n R1. Adams and @ictrK U-R. 2eanaru. 700#.
3 Earl5 =, 6an Gin J, Dennis M, Eardla5 J, amfrd J, 1ane/ G. Stre
2ractical Management. 3th )d. 700'. lac5ell 2ulishing. ".3(&40.
4 Guideline Stre !ahun 70%%. 2di Stre. 2erhim"unan Dter S"esialis
Saraf ndnesia :2)RDSS;. Jaarta. 70%%.
8 25ers EJ. A1A>ASA Guideline 70%8 A1A>ASA cused U"date f the
70%3 Guidelines fr the )arl/ Management f 2atients Eith Acute schemic
Stre Regarding )nd6ascular !reatment. A1A urnals. 70%84$*000&000.
$ Set/"rant . Stre* Geala dan 2enatalasanaan. =DK %'8>@l.3'
n.4>Mei&Juni 70%% hal.74#&780.
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