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VASCULAR DEMENTIA, WITH LACUNAR STROKE

Kelompok VII 2012 Palembang Class

Tutor: dr. Alfian HasbiPresented by Timotius Wira Yudha

Universitas Sriwijaya 2014

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OVERVIEW

Difficult terms Anatomy and Physiology

Insight: Vascularisation, CBF Lacunar Stroke VASCULAR DEMENTIA

Problem Map Conclusion

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TERMINOLOGY

Hemiparesis Topographical disorientation

Grade II hypertension Presence of pathological reflexes BSS suggests untreated diabetes

Forget consuming medication? VICIOUS CYCLE!

Lacunar infarction MMSE

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ANAT & PHYSIOL

CNS Central Core Brain Limbic System Neocortex

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http://missinglink.ucsf.edu/lm/ids_104_cerebrovasc_neuropath/Case3/Case3Images/CerArtDistBlum1.jpg

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COMMON MECHANISMS FOR STROKAND VASCULAR DEMENTIA(Bezerra et al., 2012)

LIPOHYALINOSIS RF: Hypertension, diabetes mellitus Tunica media thickening

MICROATHEROMA RF: Hypertension, hypercholesterolaemy Classic atherosclerosis theory endothelial lesion

BOTH ARE PRESENT

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STROKE TYPE?

Age = RISK FACTOR both ISCH / HAEM Physical Exam: HTN grade II

Lab: Hyperglycaemie (DM II) NO Hyperlipidaemie / Hypercholesterolaemie

HAEMORRHAGIC?

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LACUNAR STROKE

CT Scan: Lacunar infarction on lobustemporalis sinister.

ISCHAEMY of arteries to brains internalstructures: A. lenticulostriata.

Types Motor (pure) Ataxic Dysarthria Sensory (pure) Mixed sensorimotor

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LACUNAR STROKE

EMPHASIS: Motor Capsula interna, crus posterius

Basis pontis Corona radiata

Projection of axons from cortex that will be

directed towards brainstem NO CNS axonal regeneration (which DOES

occur in periphery)

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http://missinglink.ucsf.edu/lm/ids_104_cerebrovasc_neuropath/Case3/Case3Images/CerArtDistBlum2.jpg

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VASCULAR DEMENTIA

Varying degrees of arterial occlusion createsdifferent clinical features: Consider simpleatherosclerosis vs large occlusion (STROKE).

Memory is formed in FORMATIOHIPPOCAMPALIS

Here occurs neurogenesis (Griggs, 2012:62) Supplied by A. cerebri posterior and A.

choroidea anterior The same vessels supply Crus posterius of

ca sula interna Gilro et al. 2009:609 .

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http://missinglink.ucsf.edu/lm/ids_104_cerebrovasc_neuropath/Case3/Case3Images/CerArtDistBlum1.jpg

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ATYPICAL?

25% of infarcts to A. cerebri posterior causes amnesia (Brandt et al. quoted by Romn, 2005)

LESION LOCALISATION LEFT: Verbal difficulties RIGHT: Visuospatial dysgnosie

NY. LUNA: LEFT LESION, BUT WITH VISUO-SPATIAL DIFFICULTIES?

ATYPICAL

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DIAGNOSIS

NINDS-AIREN (Romn, 2005) Simple, four characteristics

Cognitive loss Cerebrovascular lesions demonstrated by brain

imaging (CT, MRI) A temporal link between stroke and cognitive loss Exlusion of other causes of dementia (Alzheimer,

Vitamin B12 deficincy)

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THERAPY Focus on treating risk factors TO PREVENT

ANOTHER STROKES. HYPERGLYCAEMY

Biguanida (Metformin) Consider insulin if situation worsens

HYPERTENSION Hydrochlorothiazide Consider selective beta-1 receptor antagonist

Cholinesterase inh (Galantamine)? Aspirin (antiplatelet) prevent PLT aggregation.

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PREVENTION

Control risk factors! DITARY MODIFICATIONS

Eat more UFA, Blueberry PHYSICAL ACTIVITIES

3-5 days of 30 walking of 2.5 km

REDUCE STRESS Spend more time for social interactions Play computer games

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PROGNOSIS

DUBIA AD MALAM BAD 5YSR: 39%

Life expectancy is reduced on Men Low education Bad neuropsychological results

(Alagiakrishnan, 2012)

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MISCELLANEOUS

SKDI Lacunar stroke: 2 (De facto 3B) Vascular dementia: 2To diagnose, refer, and treat fully after referral

MMSE VS MOCA?

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PROBLEM MAPDiabetes mellitus (uncontrolled) Hypertension Senilitas (penuaan)

Stress oksidatif Vascular resistance \uparrow

Penggunaan energi \uparrow Afterload \uparrow

Deposit hyalin + tunica media Rawan lesi endothelial

thickening (Lipohyalinosis)Macrophage attraction

Microatheroma(Plaque buildup)

Oklusi cabang2 lenticulair A. cerebri posterior and A. choroidea anterior

Oklusi terjadi dengan derajat dan threshold yang berbeda

Ischaemic stroke in Crus posterius capsulae internae Reduksi signifikan aliran darah ke Formatio hippocampalis

Contralateral hemiparesis Presence of Problems in cognitive functioning, memorypathological reflexes

Skor MMSE pathologik Suka lupa

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CONCLUSION

Ny. Luna, 69 tahun, mengalami gangguanfungsi luhur dengan emphasis memori etcausa dementia vasculare. Selain itu, ia jugamengalami hemiparesis et causa strokelacunair di Crus posterius capsulae internae.

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REFERENCES Griggs, Richard A. 2012.Psychology: A Concise Introduction,

Third Edition . New York: Worth Publishers. Romn, Gustavo C. 2005. Current Clinical Neurology .

Clinical Forms of Vascular Dementia. Gilroy, Anne M., et al. 2009. THIEME Atlas of Anatomy . New

York: Stuggart. Alagiakrishnan, Kannayiram et al. 2012. Vascular Dementia .

http://emedicine . medscape.com/article/292105-overview,diakses 28 Oktober 2014, 13.01 WIB.

Bezerra, D. C., et al. 2012. Neurology . Risk Factors forLacune Subtypes in the Atherosclerosis Risk in Communities(ARIC) Study.

Guyton, Arthur C., John E. Hall. 2007.Buku Ajar FisiologiKedokteran . Editor: Luqman Yanuar Rachman. Jakarta: EGC.

http://emedicine/http://emedicine/http://emedicine/

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