Patophysiology and Management of Stroke-Okt2014

7/24/2019 Patophysiology and Management of Stroke-Okt2014

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PATOPHYSIOLOGY &PATOPHYSIOLOGY &

MANAGEMENT OF STROKEMANAGEMENT OF STROKE

Abdul GofrAbdul Gofr

Neurology Department oNeurology Department o

Medical FacultyMedical Faculty

Gadjah Mada UniversityGadjah Mada University


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Stroke: DefnitionStroke: Defnition

Stroke is clinically defned as aStroke is clinically defned as aneurologic syndrome characterizedneurologic syndrome characterizedby acute disruption o blood ow toby acute disruption o blood ow to

an area o the brain andan area o the brain andcorresponding onset o neurologiccorresponding onset o neurologicdefcits related to the concerneddefcits related to the concernedarea o the brainarea o the brain

Nurs Clin N Am 2002;37:35-57


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Causes o StrokeCauses o Stroke


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1


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Defnition o Ischemic StrokeDefnition o Ischemic Stroke

Almost 80% oAlmost 80% ostrokes are romstrokes are roman emboli or aan emboli or athrombusthrombus

Embolic &Embolic &ThromboticThromboticstrokes arestrokes areISCHEICISCHEIC

! "#% o strokes! "#% o strokes

are romare romhemorrha$e ithhemorrha$e ithan e'en smalleran e'en smaller(ercenta$e(ercenta$ecause) b*cause) b*

h*(o(erusionh*(o(erusion


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Dr.J.Husada 11-2003

Apoptotic

Cell Death

Necrotic

Cell Death

Ischemic

Injury


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Aterosclerotic is a normal response to arterialendotel injuryAterosclerotic plaque forming, start in youngClinical manifestation : acute and tent to occur one

time because sudden plaque rupture

1. Vascular : Aterosclerotic process

2. Biochemistry change /cellular

chemist

2 process in ischemic stroke:2 process in ischemic stroke:

C I h i


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Causes o Ischaemic

!"#$%&

Blocka'e o (loo' lo) (y ateroma* em(oli*an' ateroscelerotic


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EmbolicEmbolic

+nce in *our+nce in *our

brain thebrain the

embolusembolus

e'entuall* tra'else'entuall* tra'els

to a bloo) 'esselto a bloo) 'essel

small enou$h tosmall enou$h to

block its (assa$eblock its (assa$e

The embolusThe embolus

lo)$es therelo)$es there

blockin$ theblockin$ the

bloo) 'essel an)bloo) 'essel an)

causin$ a strokecausin$ a stroke


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Adapted from Goldstein, et al. Circulation2001;10:1!"1#2.

6! "#ararin$6! "#ararin$%&! "aspirin$%&! "aspirin$

AtrialAtrial

fbrillationfbrillation

"non'valvular$"non'valvular$

%(')(! #ith statins in patients%(')(! #ith statins in patients#ith *no#n coronary heart disease#ith *no#n coronary heart disease

H*(erli(i)emiaH*(erli(i)emia

++! reduction in hypertensive++! reduction in hypertensive

diabetics #ith tight blood pressurediabetics #ith tight blood pressurecontrolcontrol

DiabetesDiabetes

,(! #ithin & year- baseline,(! #ithin & year- baselineater , yearsater , years

.mo*ing.mo*ing

)(! ' +(!)(! ' +(!/ypertens/ypertensionion

0is* reduction #ith0is* reduction #ithtreatmenttreatment

FactorFactor

Potential Stroke Risk Reduction for IndividualsPotential Stroke Risk Reduction for Individuals

AHA GuidelinesAHA Guidelines


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Stroke: ClassifcationStroke: Classifcation

schemic strokeschemic stroke: Account for 80%. Results from: Account for 80%. Results fromocclusion in the blood vessel supplying the brainocclusion in the blood vessel supplying the brain

hromboti

hromboti : !cclusion due to: !cclusion due to

atherothrombosis of small"large vesselsatherothrombosis of small"large vessels

supplying the brainsupplying the brain

#mboli

mboli : !cclusion due to embolus arising: !cclusion due to embolus arising

either from heart $e.g. atrial fibrillationeither from heart $e.g. atrial fibrillation

valvular disease& or blood vesselvalvular disease& or blood vessel


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'lassification $cont.&'lassification $cont.&

(emorrhagic strokeemorrhagic stroke: Account for )0%. Results from: Account for )0%. Results fromrupture of blood vessels leading to bleeding inrupture of blood vessels leading to bleeding in

brainbrain

ntracerebral:

ntracerebral: *leeding +ithin the brain due to*leeding +ithin the brain due to

rupture of small blood vessels. !ccurs mainlyrupture of small blood vessels. !ccurs mainly

due to high blood pressuredue to high blood pressure

,ubarachnoid:

ubarachnoid: *leeding around the brain-*leeding around the brain-

commonest cause is rupture of aneurysm.commonest cause is rupture of aneurysm.

!ther causes: (ead inury!ther causes: (ead inury


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Stroke: ,re)is(osin$ actorsStroke: ,re)is(osin$ actors Age $risk doubles forAge $risk doubles for

every decade / age &every decade / age & 1ender1ender

$males/females&$males/females& 2amily history of2amily history of

stroke"IAstroke"IA

(ypertension(ypertension 3iabetes3iabetes (yperlipidemia(yperlipidemia (yperhomocysteinemia(yperhomocysteinemia

!besity!besity

,moking,moking

Atrial fibrillation

trial fibrillation

,edentary lifestyle,edentary lifestyle

3rug abuse $e.g.3rug abuse $e.g.

cocaine use&cocaine use&

(ormone(ormonereplacement therapyreplacement therapy

!ral contraceptive!ral contraceptive


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0is* Factors or .tro*e0is* Factors or .tro*e

Non+,o'iia(le

#isk -actors or !troke$Age

$%e&$'ace(et)nicity$*amily )istory

Modifable 0is*Modifable 0is*Factors or .tro*eFactors or .tro*e66

H*(ertensionH*(ertension

DiabetesDiabetes

Smokin$Smokin$

H*(erli(i)emiaH*(erli(i)emia

Caroti) stenosisCaroti) stenosisAtrial fbrillationAtrial fbrillation
http://www.clevelandclinicmeded.com/diseasemanagement/neurology/stroke/stroke.htmhttp://www.clevelandclinicmeded.com/diseasemanagement/neurology/stroke/stroke.htmhttp://www.clevelandclinicmeded.com/diseasemanagement/neurology/stroke/stroke.htm


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Stroke: S*m(tomsStroke: S*m(toms

+nset o stroke s*m(toms+nset o stroke s*m(toms

'aries as (er t*(e o stroke:'aries as (er t*(e o stroke:

- 1hrombotic stro*e1hrombotic stro*e: De'elo(: De'elo(more $ra)uall*more $ra)uall*

- 2mbolic stro*e2mbolic stro*e: Hits su))enl*: Hits su))enl*

- /emorrhagic stro*e/emorrhagic stro*e: Hits: Hitssu))enl* an) continues to orsensu))enl* an) continues to orsen

S k SSt k S t


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Stroke: S*m(tomsStroke: S*m(toms

.cont/.cont/ 3i44iness3i44iness 'onfusion'onfusion

5oss of balance"coordination5oss of balance"coordination 6ausea"vomiting6ausea"vomiting 6umbness"+eakness on one side of the body6umbness"+eakness on one side of the body

,ei4ure,ei4ure ,evere headache,evere headache 7ovement disorder"speech disorder"blindness etc7ovement disorder"speech disorder"blindness etc

$depending on the area of brain affected&$depending on the area of brain affected&


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,ymptom and ,ign,ymptom and ,ign

'onsider stroke in any patient presenting +ith'onsider stroke in any patient presenting +ithacuteacute

neurological deficit or any alteration in level ofneurological deficit or any alteration in level of

consciousness.consciousness.

'ommon signs of stroke include the follo+ing:'ommon signs of stroke include the follo+ing: Acute hemiparesis or hemiplegiaAcute hemiparesis or hemiplegia 'omplete or partial hemianopia monocular or'omplete or partial hemianopia monocular or

binocular visual loss or diplopiabinocular visual loss or diplopia

3ysarthria or aphasia3ysarthria or aphasia Ataia vertigo or nystagmusAtaia vertigo or nystagmus ,udden decrease in consciousness,udden decrease in consciousness


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Transient Ischemic Attack .TIATransient Ischemic Attack .TIA

11ini stroke2ini stroke2 Stroke s*m(toms last or less than 34 hoursStroke s*m(toms last or less than 34 hours

.usuall* "0 to "# mins.usuall* "0 to "# mins 5esult as a brie interru(tion in bloo) 6o to5esult as a brie interru(tion in bloo) 6o to

brainbrain E'er* TIA is an emer$enc*E'er* TIA is an emer$enc* TIA ma* be a arnin$ si$n o a lar$er strokeTIA ma* be a arnin$ si$n o a lar$er stroke ,atients ith (ossible TIA shoul) be e'aluate),atients ith (ossible TIA shoul) be e'aluate)

b* a (h*sicianb* a (h*sician

Diagnosis o acute ischemicDiagnosis o acute ischemic


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Diagnosis o acute ischemicDiagnosis o acute ischemic

stro*estro*e

9hysical eamination9hysical eamination 6eurological 6eurological#amination#amination

*rain imaging $cranial ' and"or 7RI&: 3etect*rain imaging $cranial ' and"or 7RI&: 3etect

small vessel disease. (elps to effectivelysmall vessel disease. (elps to effectively

discriminate bet+een ischemic and hemorrhagicdiscriminate bet+een ischemic and hemorrhagic

stroke and stroke from brain tumoursstroke and stroke from brain tumours

3oppler ultrasonography"Angiography: 3etect3oppler ultrasonography"Angiography: 3etect

large vessel atherosclerosislarge vessel atherosclerosis

#'1"#chocardiography: 3etect cardiac embolism#'1"#chocardiography: 3etect cardiac embolism

#clusion of conditions mimicking stroke#clusion of conditions mimicking stroke$hypoglycemia migraine sei4ure&$hypoglycemia migraine sei4ure&

Ischemic stroke )ia$nosticIschemic stroke )ia$nostic


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Ischemic stroke )ia$nosticIschemic stroke )ia$nostic

al$orithmal$orithmAcute ocal (rain 'eicit

ea' C"

Ischemic !troke

&C

&cho

CA#DIAC&,B$0I!,

0A#& A#"A"$!C0$!I!

!,A00V&!!&0 DI!&A!&

$" D&",IN&DCA!&

Doppler

,#AAngiogram

,#I

C"

Vasculopathy

Coagulopathy

C#3"$&NIC

!"#$%&

&4clu'e' hypoglycemia* migraine

)ith aura* post+sei5ure 'eicit

TIA (if CT/MR brain imaging

)ithout ischemic lesion6

7 1 hour

0acunar syn'romeCorticalsyn'rome


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AcuteAcute

TreatmentTreatment


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rr77TT,A,A

I a 7hour in)o o treatment canI a 7hour in)o o treatment can

be met thrombol*tic thera(* ithbe met thrombol*tic thera(* ith

intra'enous t7,A can be benefcial orintra'enous t7,A can be benefcial or

each o the ma9or cate$ories oeach o the ma9or cate$ories oischemic stroke:ischemic stroke:

atherothromboticatheroembolicatherothromboticatheroembolic

car)ioembolic an) small 'esselcar)ioembolic an) small 'esselocclusi'e .lacunar strokeocclusi'e .lacunar stroke


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3ntravenous 1hrombolysis3ntravenous 1hrombolysis

Intra'enous rt,A .0/; m$k$ ma


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The intra'enous a)ministration oThe intra'enous a)ministration o

stre(tokinase or treatment o stroke is notstre(tokinase or treatment o stroke is not

recommen)e) .Class III =e'el o E'i)encerecommen)e) .Class III =e'el o E'i)ence

A/A/ &he intra"enous administration o ancrod,&he intra"enous administration o ancrod,

tenecteplase,reteplase, desmoteplase,tenecteplase,reteplase, desmoteplase,

urokinase, or other thrombolytic agentsurokinase, or other thrombolytic agents

outside the setting o a clinical trial is notoutside the setting o a clinical trial is notrecommended (Class , !e"el o #"idencerecommended (Class , !e"el o #"idence

C$%C$%

H i C )i b liHe(arin or Car)ioembolic


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He(arin or Car)ioembolicHe(arin or Car)ioembolic

Stroke:Stroke:

Stroke recurrence is lo much lessStroke recurrence is lo much less

than "%)a* in frst 3 eeksthan "%)a* in frst 3 eeks

=ar$e stroke: ait 487>3 hours an)=ar$e stroke: ait 487>3 hours an)

re(eat CTre(eat CT

Small stroke: use 9u)$mentSmall stroke: use 9u)$ment


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(eparin

+)ere is no large clinical trial in t)e

literature comparing i.. )eparin as

traditionally administered to placebo-nternational %troe +rial: compared s.q.

)eparin at comparable doses to asa and

neit)er in 1/ patients: result: )eparinas not beneficial

3ancet. 1//4;/:1!/"#1


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(eparinoids

+5A%+ trial: indicated no benefit for a

367 )eparinoid in stroe 85'G 101429

%troe. 1//#;2/:2#!

t tana$ement o acute


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ana$ement o acuteana$ement o acute

ischemic strokeischemic stroke .ystemic thrombolysis.ystemic thrombolysis: Intra'enous: Intra'enous

recombinant tissue (lasmino$en acti'atorrecombinant tissue (lasmino$en acti'ator

.rt7,A: ?ithin hrs o onset o stroke/.rt7,A: ?ithin hrs o onset o stroke/

Dose 0/; m$k$ ma< ;0 m$/Dose 0/; m$k$ ma< ;0 m$/ Antiplatelet agentsAntiplatelet agents: As(irin "@0700 m$: As(irin "@0700 m$

ithin 347 48 hrs .not )urin$ frst 34 hrsithin 347 48 hrs .not )urin$ frst 34 hrs

olloin$ thrombol*tic thera(*/olloin$ thrombol*tic thera(*/

Clo(i)o$rel a (otential alternati'e/Clo(i)o$rel a (otential alternati'e/Combination o clo(i)o$rel an) as(irinCombination o clo(i)o$rel an) as(irin

currentl* bein$ e'aluate)currentl* bein$ e'aluate)



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ischemic stroke .cont)/ischemic stroke .cont)/ AnticoagulantsAnticoagulants: He(arin=?H are not: He(arin=?H are not

recommen)e) in acute treatment o ischemicrecommen)e) in acute treatment o ischemicstroke/stroke/ 0ecommended in setting o0ecommended in setting o atrialatrialfbrillationfbrillation- acute M3 ris*- prosthetic- acute M3 ris*- prosthetic

valves- coagulopathies and orvalves- coagulopathies and orprevention o D41prevention o D41//

3ntra'arterial thrombolytics3ntra'arterial thrombolytics: An o(tion or: An o(tion ortreatment o selecte) (atients ith ma9ortreatment o selecte) (atients ith ma9or

stroke o ! @ hrs )uration )ue to lar$e 'esselstroke o ! @ hrs )uration )ue to lar$e 'esselocclusion/occlusion/

E M di lC f N l i


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Emergency Medical Care for NeurologicEmergencies

Provide reassurance.

Ensure proper airway and breathing.

Place the patient in a position of comfort.

If you suspect stroke, transport immediately andnotify hospital.

Assess and care for any injuries if you suspect any

type of trauma.



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ischemic stroke .cont)/ischemic stroke .cont)/

5 management5 management: Shoul) be ke(t ithin hi$her: Shoul) be ke(t ithin hi$hernormal limits since lo , coul) (reci(itatenormal limits since lo , coul) (reci(itate(erusion ailure/ arke)l* ele'ate) ,(erusion ailure/ arke)l* ele'ate) ,.B330""0mmH$ mana$e) ith nitro$l*cerin.B330""0mmH$ mana$e) ith nitro$l*cerincloni)ine labetalol so)ium nitro(russi)e/ orecloni)ine labetalol so)ium nitro(russi)e/ ore

a$$ressi'e a((roach is taken i thrombol*tica$$ressi'e a((roach is taken i thrombol*ticthera(* is institute)thera(* is institute) 5lood glucose management5lood glucose management: Shoul) be ke(t: Shoul) be ke(t

ithin (h*siolo$ical le'els usin$ oral or Iithin (h*siolo$ical le'els usin$ oral or I$lucose .in case o h*(o$l*cemiainsulin .in$lucose .in case o h*(o$l*cemiainsulin .in

case o h*(er$l*cemiacase o h*(er$l*cemia 2levated body temperature management2levated body temperature management::

Anti(*retics an) use o coolin$ )e'ice canAnti(*retics an) use o coolin$ )e'ice canim(ro'e the (ro$nosisim(ro'e the (ro$nosis

UDA12 7N MANAG2M2N1 7FUDA12 7N MANAG2M2N1 7F


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UDA12 7N MANAG2M2N1 7FUDA12 7N MANAG2M2N1 7F

38/38/ .,ouratian 300.,ouratian 300

Medical interventionsMedical interventions

' 8ardiopulmonary optimi9ation' 8ardiopulmonary optimi9ation

"A58..$"A58..$' 5lood pressure control' 5lood pressure control

' 38 reduction' 38 reduction

'' UltraUltra''early hemostatic therapyearly hemostatic therapy

.urgical interventions.urgical interventions

M2D38A: MANAG2M2N1 7F 38/M2D38A: MANAG2M2N1 7F 38/


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"ouratian %(()$"ouratian %(()$

8ardiopulmonary optimi9ation " Air#ay- 5reathing-8ardiopulmonary optimi9ation " Air#ay- 5reathing-

8irculation8irculation

-s*in- sei9ures-s*in- sei9ures

$$

0eversing coagulation deects "coagulopathies and platelet0eversing coagulation deects "coagulopathies and plateletdisorders$disorders$

5lood pressure control ":abetolol ; nicardipine 34-5lood pressure control ":abetolol ; nicardipine 34-nitroprusside not oten usednitroprusside not oten used brain edema$s nec* in neutral- patient>s nec* in neutralpositionposition ma?ma?imi9eimi9e venous out@o#


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5:77D 02..U02 MANAG2M2N1 3N 38/5:77D 02..U02 MANAG2M2N1 3N 38/"5roderic* &BBB$"5roderic* &BBB$

' 3 .5 C %)( mm /g or D5 C' 3 .5 C %)( mm /g or D5 C&+( mm /g on %&+( mm /g on %readings , minutes apartreadings , minutes apart nitroprusside (


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$$hemorrha$ic strokehemorrha$ic stroke

AnalgesicsAntian?ietyAnalgesicsAntian?ietyagentsagents: To relie'e: To relie'ehea)ache/ Anal$esics ha'in$ se)ati'ehea)ache/ Anal$esics ha'in$ se)ati'e(ro(erties are benefcial or (atients ha'in$(ro(erties are benefcial or (atients ha'in$sustaine) trauma .e/$/ mor(hine sul(hatesustaine) trauma .e/$/ mor(hine sul(hate

AntihypertensivesAntihypertensives:.e/$/ so)ium:.e/$/ so)iumnitro(russi)e labetololnitro(russi)e labetolol /yperosmotic/yperosmoticagentsagents.e/$/ mannitol.e/$/ mannitol

$l*cerol urosemi)e: To re)uce cerebral$l*cerol urosemi)e: To re)uce cerebrale)ema an) raise) intracranial (ressure/e)ema an) raise) intracranial (ressure/

AdeHuate hydration is necessaryAdeHuate hydration is necessary .urgical intervention may occasionally.urgical intervention may occasionally

be lie savingbe lie saving

0287MM2NDA137N. F7002 MM2NDA13 N F 0.U0G38A: 102A1M2N1 7F 38/.U0G38A: 102A1M2N1 7F 38/


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.U0G38A: 102A1M2N1 7F 38/.U0G38A: 102A1M2N1 7F 38/.ro)erick ";;;.ro)erick ";;;

N7N .U0G38A: 8AND3DA12.N7N .U0G38A: 8AND3DA12.&< .mall hemorrhages "E&( cm)$ or minimal&< .mall hemorrhages "E&( cm)$ or minimal

neurological defcits


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N2U07:7G38N2U07:7G38

D2120370A137N 3N 38/ ":eiraD2120370A137N 3N 38/ ":eira

%((+$%((+$2arly neurologic deterioration "2ND$ occurred in %%


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770 7U187M2 3N 38/

ouratian %(()ouratian %(()

4olume o the hematoma4olume o the hematoma"" )( cc$ )( cc$

Neurologic status "G8. scoreNeurologic status "G8. score $$

3ntraventricular e?tension o the clot3ntraventricular e?tension o the clot

/ydrocephalus/ydrocephalus

.ubarachnoid e?tension.ubarachnoid e?tension

Anticoagulation agentsAnticoagulation agents

0elative edema0elative edema

Davis L.8 %((+Davis L.8 %((+OO 3nratentorial lesion3nratentorial lesion

OO 8oronary heart disease8oronary heart disease

OO /yperthermia/yperthermia


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Cerebral oedema This is an abnormal accumulation of fluid

in the cerebral parenchyma.It is usually the result of

breakdown of the bloodbrain barrier, and it may occur

following damage initiated by several different

causes:Ischaemia, e.g. from infarction.Trauma,e.g.

from head injury.Inflammation encephalitis or meningitis.

Oveproduction of !" by choroid ple#us neoplasms

$ack
http://c/Documents%20and%20Settings/SpongeBob/My%20Documents/PRESENTASI%20KASUS%20211205%20baru.ppt#Management%20of%20acute%20ischemic%20strokehttp://c/Documents%20and%20Settings/SpongeBob/My%20Documents/PRESENTASI%20KASUS%20211205%20baru.ppt#Management%20of%20acute%20ischemic%20stroke


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E)em serebri 'aso$enik meru(akan akibat (rimer )arimenin$katn*a (ermeabilitas blood brain barier

2dem serebri sitoto*si* terjadi se*under dari *erusa*anelemen seluler serebri- terlepasnya a*tor'a*tor to*si*dari netrofl dan ba*teri< .ehingga terjadi pening*atan*andungan air intraseluler- dimana terjadi *ebocoranpotasium- glu*osa diguna*an melalui gli*olisis anae

robi*- produ*sila*tatleated blood pressure usually declines

spontaneously oer t)e first 2 )ours after stroe

onset and oer?ealous use of a calcium antagonistand ot)er anti)ypertensie drugs s)ould be

aoided because t)ey can furt)er reduce cerebral

perfusion.

Antith*(ertensi'eAntith*(ertensi'e


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TreatmentTreatment In)icate) or:In)icate) or:

- aortic )issectionaortic )issection- acute m*ocar)ial inarctionacute m*ocar)ial inarction- heart ailureheart ailure

- acute renal ailureacute renal ailure- h*(ertensi'e ence(halo(ath*h*(ertensi'e ence(halo(ath*- thrombol*tic thera(*thrombol*tic thera(*

?hen s*stolic (ressure is "80 mm H$ or?hen s*stolic (ressure is "80 mm H$ or

hi$her or the )iastolic (ressure "0# mmhi$her or the )iastolic (ressure "0# mmH$ or hi$her/H$ or hi$her/

*lood 9ressure and hemorrhage


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g

Control of eleated blood pressure )asneer been s)on to decrease t)e ris

of ongoing or recurrent bleeding in

patients it) intracerebral )emorr)age.'ecommend treatment of moderate and

seere eleations of blood pressure

8systolic blood pressure of greater t)an1#0 mm =g or mean arterial pressure of

greater t)an 10 mm =g9.

H*(er$l*cemia & StrokeH*(er$l*cemia & Stroke


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H*(er$l*cemia & Stroke*( $ *

'ersistent hyperglycemia ()*+ mgd!$'ersistent hyperglycemia ()*+ mgd!$during the frst -* hours ater stroke isduring the frst -* hours ater stroke is

associated with poor outcomes%associated with poor outcomes%

!ower serum glucose concentrations!ower serum glucose concentrations

(possibly )*+ to )./ mgd!$ probably(possibly )*+ to )./ mgd!$ probably

should trigger administration o insulin,should trigger administration o insulin,

similar to the procedure in other acutesimilar to the procedure in other acute

situations accompanied by hyperglycemiasituations accompanied by hyperglycemia(Class a, !e"elo #"idence C$%(Class a, !e"elo #"idence C$%

Close monitorin$Close monitorin$

Tem(eratureTem(erature


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Tem(eratureTem(erature

Increase tem( increases (ercenta$eIncrease tem( increases (ercenta$eo (oor outcome in strokeo (oor outcome in stroke

Increase cerebral o


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2ever

+)ere is general agreement to

recommend treatment of t)e sources of

feer and use of antipyretics to control

an eleated body temperature 83eels of

>idence --- t)roug) , Grade C9. +)ere

are insufficient clinical data about t)e

use of )ypot)ermia to recommend t)ist)erapy.

2ever: reatment


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2ever: reatment

+reat any temperature eleations

@ata is not in as to )et)er )ypot)ermia

may be protectie

'#R#*RA5 #3#7A


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'#R#*RA5 #3#7A

=ypo"osmolar fluids, suc) as

de&trose in ater, may orsen edema.

1(2B% or B% recommended

7annitol


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7annitol

6annitol 80.2 to 0. g(g -9 gien oer

20 minutes rapidly loers intracranial

pressure and can be gien eery !

)ours.4+)e usual ma&imum daily dose

is 2 g(g.4

annitolannitol


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a o

Dose: 7 3# to #0 $ I/'/ J 7# hrs/Dose: 7 3# to #0 $ I/'/ J 7# hrs/ a


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2vents Ater .tro*e or 13A

1he combination o aspirin plus dipyridamole is moreeective than aspirin alone in preventing stro*e and

other serious vascular events in patients #ith minorstro*e and 13As< 1he ris* reduction #as greater andstatistically signifcant or studies using primarily

e?tended release dipyridamole- #hich may re@ect a truepharmacological eect or lac* o statistical po#er in

studies using immediate release dipyridamole

This meta-analysis systematically reviewed randomized controlledtrials comparing aspirin plus dipyridamole #ith aspirin alone inpatients #ith stro*e and 13A to determine the ecacy o these

agents in preventing recurrent cerebral and systemic vascular events

0ehabilitation rogram=0ehabilitation rogram=


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hysical therapy =hysical therapy = Mobili9ationMobili9ation Lal*ingLal*ing Major motor or sensory impairment o theMajor motor or sensory impairment o the

limbslimbs rescription o devices- such as a cane orrescription o devices- such as a cane or

#al*er#al*er

7ccupational 1herapy =7ccupational 1herapy = Fine movements o the handFine movements o the hand

Arm unctionArm unction Utili9ation o toolsUtili9ation o tools Assistive devicesAssistive devices Ability to unction independentlyAbility to unction independently


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American =eart Association. All rig)ts resered.American =eart Association. All rig)ts resered.

@iagnosis And +reatment 5f @i??iness-n Cerebroascular @isease

Ab)ul ofr

Knit Stroke 5S Sar)9ito a$ian Ilmu ,en*akit Saraakultas e)okteran Kni'ersitas a)9ah a)a Lo$*akarta

DiMMinessDiMMiness


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,re'alence,re'alence

- " in # a)ults re(ort )iMMiness in last month" in # a)ults re(ort )iMMiness in last month

- Increases in el)erl*Increases in el)erl*

- ?orsene) b* )ecrease) 'isual acuit*?orsene) b* )ecrease) 'isual acuit*

(ro(rioce(tion an) 'estibular in(ut(ro(rioce(tion an) 'estibular in(ut DiMMinessDiMMiness

- Gon7s(ecifc termGon7s(ecifc term

- DiNerent meanin$s to )iNerent (eo(leDiNerent meanin$s to )iNerent (eo(le

Coul) meanCoul) mean

7 erti$oerti$o 7 S*nco(e7 S*nco(e 7 ,res*nco(e7 ,res*nco(e

7 ?eak?eak 7 i))iness7 i))iness 7 An


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Cerebroascular @isease

E i) i l C b lE(i)emiolo$* o Cerebro'ascular


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E(i)emiolo$* o Cerebro'ascularE(i)emiolo$* o Cerebro'ascular

DiseaseDisease ##00000 stroke sur'i'ors are ali'e to)a*##00000 stroke sur'i'ors are ali'e to)a*

>00000 each *ear>00000 each *ear

- #00000 o these are frst attacks#00000 o these are frst attacks- 300000 are recurrent attacks/300000 are recurrent attacks/

0% to #0% o stroke sur'i'ors )o not re$ain0% to #0% o stroke sur'i'ors )o not re$ain

unctional in)e(en)enceunctional in)e(en)ence

"#% to 0% o all stroke sur'i'ors are"#% to 0% o all stroke sur'i'ors are

(ermanentl* )isable)(ermanentl* )isable)

I i) C b lI i) C b l


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Inci)ence o Cerebro'ascularInci)ence o Cerebro'ascular

DiseaseDisease Increases ith a$eIncreases ith a$e

38% are less than @# *rs ol)38% are less than @# *rs ol)

80% o cerebrob'ascular )isease80% o cerebrob'ascular )isease

are (re'entableare (re'entable

";% $reater in men than omen";% $reater in men than omen

?omen B @# ha'e hi$her inci)ence?omen B @# ha'e hi$her inci)ence

than menthan men


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ertebrobasilar insuOcienc*ertebrobasilar insuOcienc*

DiMMiness )i(lo(ia )*sarthria $aitDiMMiness )i(lo(ia )*sarthria $ait

ata


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American =eart Association. All ri )ts resered.American =eart Association. All ri )ts resered.


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Arise rom the subcla'ianArise rom the subcla'ian

arteriesarteries

5un alon$si)e the5un alon$si)e the

me)ullame)ulla loo) su((l* orloo) su((l* or

brainstem an) cerebellumbrainstem an) cerebellum

e* unctional Areas:e* unctional Areas:

T S(inal cor) tracts7(*rami)alS(inal cor) tracts7(*rami)al

an) s(inothalamican) s(inothalamicT Cranial ner'es 7"3Cranial ner'es 7"3


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"7 ,osterior Cerebral"7 ,osterior Cerebral

37 Su(erior Cerebellar37 Su(erior Cerebellar

7 ,ontine ranches o7 ,ontine ranches o

asilarasilar

47 Anterior Inerior Cerebellar47 Anterior Inerior Cerebellar

#7 Internal Au)itor*#7 Internal Au)itor*

@7 ertebral@7 ertebral

>7 ,osterior Inerior>7 ,osterior Inerior

CerebellarCerebellar87 Anterior S(inal87 Anterior S(inal

;7 asilar;7 asilar

DiMMinessDiMMiness


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,eri(heral causes,eri(heral causes

- canalithiasis .,,7#0%canalithiasis .,,7#0%

- 'estibular neuronitis'estibular neuronitis.lab*rinthitis73#%.lab*rinthitis73#%

- enierePs )isease7"0%enierePs )isease7"0%

- traumatrauma

- )ru$s .amino$l*cosi)es)ru$s .amino$l*cosi)es

Central causesCentral causes

- Cerebro'ascular )iseaseCerebro'ascular )isease

.'ertebrobasilar insuOcienc*7#0.'ertebrobasilar insuOcienc*7#0- )em*elinatin$ .multi(le sclerosis)em*elinatin$ .multi(le sclerosis

- )ru$s .anticon'ulsants alcohol)ru$s .anticon'ulsants alcohol

h*(noticsh*(notics


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erti$o 's/ other t*(es oerti$o 's/ other t*(es o)iMMiness)iMMiness

TimeTimecoursecourse77 'erti$o is ne'er continuous77 'erti$o is ne'er continuous

,ro'okin$,ro'okin$actorsactors77 s(ontaneousl* or ith77 s(ontaneousl* or ith(ositional chan$es(ositional chan$es

A$$ra'atin$A$$ra'atin$actorsactors77 all 'erti$o is ma)e77 all 'erti$o is ma)eorse b* mo'in$ the hea)orse b* mo'in$ the hea)

E t bli hi th E t bli hi th


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Establishin$ the cause oEstablishin$ the cause o

)iMMiness)iMMinessTime courseTime course

- ,,: lasts less than one minute sel7limite),,: lasts less than one minute sel7limite)

res(on)s (oorl* to anti7'erti$o )ru$sres(on)s (oorl* to anti7'erti$o )ru$s

- ascular: sin$le e(iso)e lastin$ minutes toascular: sin$le e(iso)e lastin$ minutes to

hoursQ usuall* )ue to mi$raine or to transienthoursQ usuall* )ue to mi$raine or to transient

ischemia o the lab*rinth or brainstemQischemia o the lab*rinth or brainstemQ

occasionall* enierePs )iseaseoccasionall* enierePs )isease

- 5ecent onset o more (rolon$e) e(iso)es5ecent onset o more (rolon$e) e(iso)escharacteristic o 'estibular neuronitis multi(lecharacteristic o 'estibular neuronitis multi(le

sclerosis 'ertebrobasilar ischemiasclerosis 'ertebrobasilar ischemia

E t bli hi th E t bli hi th


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)iMMiness)iMMiness

Associate) s*m(tomsAssociate) s*m(toms

- ertebrobasilar )isease stroke: )i(lo(iaertebrobasilar )isease stroke: )i(lo(ia)*sarthria )*s(ha$ia eakness numbness)*sarthria )*s(ha$ia eakness numbness

- enierePs )isease: aural ullness )eanessenierePs )isease: aural ullness )eaness

tinnitustinnitus

- ,s*ch,anic attack: S+ (al(itations,s*ch,anic attack: S+ (al(itations)ia(horesis)ia(horesis

- ulti(le sclerosis: 'erti$o (rece)e) b* otherulti(le sclerosis: 'erti$o (rece)e) b* other

neurolo$ic )*sunctionneurolo$ic )*sunction


)iMMiness)iMMiness


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)iMMiness)iMMiness

,rior risk actors,rior risk actors

- i$rainei$raine

- H*(ertension Diabetes ellitusH*(ertension Diabetes ellitus

smokin$ ,eri(heral ascular Diseasesmokin$ ,eri(heral ascular Disease

- Hea) in9ur*Hea) in9ur*

- ,s*chiatric illness,s*chiatric illness

,h*sical e


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estibular e


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urther stu)ies to e'aluateurther stu)ies to e'aluate

)iMMiness)iMMiness 5I5A5I5A 77 )istin$uishin$ central causes77 )istin$uishin$ central causes

TCDTCD Au)iometr*Au)iometr* 77 )istin$uishin$ (eri(heral77 )istin$uishin$ (eri(heral

causescauses

- rainstem e'oke) au)iometr*rainstem e'oke) au)iometr* 77 ;07;#%77 ;07;#%sensiti'it* or )etectin$ acoustic neuromasensiti'it* or )etectin$ acoustic neuroma

Transient Ischaemic AttackTransient Ischaemic Attack

.TIA mana$ement.TIA mana$ement


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$ The risk o stroke (ost TIA is hi$himme)iatel* ater an e'entQ u( to #%in the frst 3 )a*s an) "0% ithin the

frst eek

$ Those at hi$h risk can be

)iscriminate) rom those at lo riskb* means o clinical assessment .the

ACD3 score/

ContRR//ContRR//


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$ The ACD3 scale is a >7(oint scalebase) on clinical )ata a'ailable

beore neuroima$in$ hich can beuse) to estimate the risk o stroke

ater TIA

0ohnston et al, !ancet -++1

ana$ement o TIAana$ement o TIA


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E'aluation ithin hours ater onsetE'aluation ithin hours ater onseto s*m(tomso s*m(toms

CT scan is necessar* in all (atientsCT scan is necessar* in all (atients

Anti(latelet thera(* ith as(irin .#07Anti(latelet thera(* ith as(irin .#073# m$) consi)er use o3# m$) consi)er use oclo(i)o$rel ticlo(i)ine or as(irin7clo(i)o$rel ticlo(i)ine or as(irin7)i(*ri)amole in (atients ho are)i(*ri)amole in (atients ho are

intolerant to as(irin or those hointolerant to as(irin or those hoe