STROKE

Dodik Tugasworo

PENYAKIT SARAF
NYERI
SAKIT KEPALA
MIGREN
VERTIGO
KESEMUTAN
PARKINSON
EPILEPSI
INFEKSI OTAK
GANGGUAN INGATAN
GANGGUAN PERKEMBANGAN ANAK
GANGGUAN GERAK
TUMOR OTAK
GEGAR OTAK
PIKUN BUYUTAN
STROKE

KENAPA BISA STROKE ?

BAGAIMANA GEJALA STROKE ?
BAGAIMANA CARA
PENGOBATANNYA ?
BAGAIMANA PERAWATAN SETELAH
STROKE ?
BAGAIMANA HIDUP DENGAN
STROKE DAN HIDUP DENGAN
PENDERITA STROKE ?

APAKAH STROKE ?
SUHARTO
GUS DUR

MENDADAK

MENCEMASKAN
MENAKUTKAN
MENGGELISAHKAN

KESEMBUHAN
KECACATAN
KEMATIAN

STROKE

Penyakit dengan mortalitas tinggi

ke 3 di AS (sesudah penyakit jantung & kanker)
(Laporan ke Presiden, 1964 - 65)
mengenai (insidensi) hampir 400.000/thn (AS,
Whisnant, 1971)
membunuh 200.000 orang/tahun (AS, Kurtzke,
1980)
Di Indonesia 2008 Stroke penyebab kematian
No 1

INDONESIA & NEG. BERKEMBANG : PREVAL &

MORTALITAS MENINGKAT
STROKE adalah MASALAH KESH. MASYARAKAT

Problems (United State)

160.000 death / years

730.000 new case and recurrent stroke (97)

A new case stroke every minute

Death case stroke every three minute

direct-costs $ 27 billion

indirect-costs $ 13 billion (1996)

Out Come of Acute Stroke patients

Stroke Unit Dr Kariadi Hospital Semarang 2001
150
100
50
0

Ischaemic
Recovery

Haemorrhagic
Force discharge

Death

BATASAN STROKE
W.H.O 1986 memberikan batasan sbb ;
Suatu TANDA-TANDA KLINIS
yang
BERKEMBANG
CEPAT
akibat
GANGGUAN FUNGSI - OTAK FOKAL
atau GLOBAL dengan GEJALA GEJALA
yg berlangsung 24 jam atau lebih /
menyebabkan KEMATIAN tanpa sebab
lain selain VASKULER

STROKE (BRAIN ATTACK)

(Adams Jr 2003)

S lurred speech, difficulty understanding others

L egs clumsy or numb
O ne side of body affected
Weakness
H eadache, unusually severe (or facial numbness)
E yes: loss of sight (in one eye or both eyes)
A rms clumsy or numb AND/OR
D izziness

INCIDENCE OF THE MAIN CAUSES OF STROKE

Anatomi Otak Kita

Otak kita terdiri atas 2 belahan, otak KIRI

dan otak KANAN
Otak kiri berfungsi sebagai pemantau dan
pelaksana the three Rs (Reading, wRiting
and aRhithmetic), bersifat logis analistis
Otak kanan pola kognitif yang intuitif
holistik, memproses segala informasi
secara simultan, memandang problem
secara holistis, jauh kedepan, mengenal
wajah orang dan melihat sifat sifat
secara keseluruhan. Imajinasi, persepsi
visual, orientasi tempat, emosi.

ANATOMI DAN FUNGSI OTAK

O T A K

BERAT :
1200 - 1400 GRAM
(2 % BB)

KUMPULAN
PUSAT-PUSAT
TUGAS BERAT
PERLU MAKANAN YANG CUKUP
DAN TERATUR
TIAP MENIT : 800 CC OKSIGEN
100 MGR GLUKOSA
TERHENTI
30 DETIK
TERHENTI
3 MENIT
TERHENTI
8 MENIT

SEL TERGANGGU
SEL MATI

KECACATAN
MENINGGAL

Gejala dan tanda yang timbul pada

stroke harus sesuai daerah yang
terkena.
Cacat yang timbul pada stroke
umumnya terjadi akibat kerusakan
pada area motorik di otak.
Gejala yang timbul pada stroke
tidak selalu nyata, kadang ringan
dan tersamar (misal bahasa,
memori, emosi, perilaku,
demensia, dsb)

ARTERIAL TERRITORRIES OF CEREBRAL HEMISPHERES

LEFT (FRONTAL); RIGHT (HORIZONTAL)

3
1

3
2

1 = nucleus lentiformis; 2 = thalamus; 3 = nucleus caudatus

Red =a.cerebri ant. Green =a.cerebri med. Yellow =a.cerebri post. Light blue =a.choroidea ant.
Dark green =a.choroidea post. Dark blue =a.commun.post

ANTERIOR AND POSTERIOR

VASCULAR SYNDROMES (FELBERG
2003)

Syndrome Localization
-----------------------------------------------------------------------------------------------------------------

Anterior (carotid) artery syndromes

Middle cerebral artery
Expressive aphasia
(motoric)
lobe
(sensoric)
Receptive aphasia
Weakness of arm and/or leg
parietal lobe
Loss of lateral visual fields
Anterior cerebral artery
Weakness of leg

Dominant posterior frontal

Dominant superior temporal lobe
Contralateral (to weakness)
Contralateral parietal lobe

Medial (parafalcine) parietal lobe

Posterior (vertebrobasilar) artery syndromes

Vertigo, nystagmus that changes with the direction
Cerebellum
of gaze, cranial nerve palsies, retropulsion
Hemiparesis, hemisensory loss, of one-half of the
Brainstem
body, swallowing difficulty

COMMON PATTERNS OF NEUROLOGIC

IMPAIRMENTS IN ACUTE ISCHEMIC STROKE
(1) (Adams 2003)
L. (DOMINANT) HEMISPHERE
(major or branch cortical infarction)

R. (NONDOMINANT) HEMISPHERE
(Major or branch cortical infarction)

- Aphasia

- Left hemiparesis

- Right hemiparesis

- Left sided sensory loss

- Right sided sensory loss

- Left sided spatial neglect

- Right sided spatial neglect

- Left homonymous hemianopia

- Right homonymous hemianopia

- Impaired right conjugate gaze

- Impaired left conjugate gaze

COMMON PATTERNS OF NEUROLOGIC

IMPAIRMENTS IN ACUTE ISCHEMIC STROKE
(2) (Adams 2003)
DEEP (SUBCORTICAL) HEMISPHERE
OR BRAINSTEM (LACUNAR STROKE)
- Hemiparesis (pure motor stroke) or
in all
sensory loss (pure sensory stroke).
- Dysarthria, including dysarthriasame
clumsy hand.
of body).
- Ataxic-hemiparesis.
- No abnormalities of cognition,
language or vision.
CEREBELLUM
- Ipsilateral limb ataxia.
- Gait ataxia.

BRAIN STEM
- Motor or sensory loss
four limbs.
- Crossed signs (signs on
side of face/other side
- Dysconjugate gaze.
- Nystagmus ; Ataxia.
- Dysarthria; Dysphagia.

FAK T O R
RISIKO
FAKTOR
PENCETUS
STROKE
(GANGGUAN PEREDARAN DARAH OTAK)
TERGANTUNG
DOKTER
PADA KECEPATAN
SPESIALIS
SARAF
BEROBATNYA

SEMBUH
SEMPURNA

MENYANDANG
CACAT
MENINGGAL

Keluhan pasien :

..

Dokter menyimpulkan : gangguan di otak

stroke

bukan stroke

tentukan jenisnya
SNH atau SH
Cara : - anamnesis
- algoritma dan penilaian dgn skor stroke
- pemeriksaan dgn menggunakan alat

Ri s k F
a c t or
Ma n a
g em e
nt

Stroke Prevention

Risk Factors1
Non modifiable

Age
Race
Gender
Family history of stroke.

Risk Factors-2
Modifiable / treatable

Hypertension atrial fibrillation

Diabetes mellitus hyperhomocysteinemia
Hyperlipidemia
hypercoagulability
Cigarette smoking oral contraceptive
Infection: chlamydia, helicobacter, viruses.
Prior stroke/TIA
carotid stenosis
Physical inactivity, obesity, sleep apnea/
snoring.
Alcohol abuse.
(Stroke, February 2001)

DIAGNOSIS JENIS STROK

Diagnosis jenis strok (SI, SH, PSA,PIS)
sejak dahulu sulit, seringkali meragukan,
lama sampai diterapkannya CT-Scanning
dalam klinik (1972).

ANAMNESIS
Tabel 1. Perbedaan stroke hemoragik dan stroke infark
Gejala
(symptom)
-Onset/awitan
-Saat onset
-Peringatan
-Nyeri kepala
-Kejang
-Muntah
-Penurunan
kesadaran

Stroke hemoragik

Mendadak
Sedang aktif
(-)
+++
(+)
(+)
+++

Stroke
infark
Mendadak
Istirahat
(+)

(-)
(-)

Perbedaan Stroke Hemoragik dan

Stroke Infark berdasarkan anamnesis
Gejala/Simtom
Saat onset

Stroke

Stroke non

hemoragik

hemoragik

Sedang aktif

Istirahat

Peringatan (warning)

Nyeri kepala

+++

Kejang

Muntah

Penurunan kesadaran +++

Perbedaan Stroke Hemoragik dan Stroke

Infark berdasarkan tanda-tandanya
Tanda (sign)

Stroke Hemoragik

Stroke Non
Hemoragik

Bradikardi

++ (dari awal)

(hari ke-4)

Udem papil

Sering +

Kaku kuduk

Tanda Kernig,Brudzinski

++

II. STROKE BERDASARKAN PENYEBABNYA

1. STROKE HEMORAGIK = STROKE PERDARAHAN
PERDARAHAN OTAK

KURANG
DARAH
KECACATAN
PUSAT
KESADARAN
TIDAK SADAR
PUSAT NAFAS
PUSAT JANTUNG

KEMATIAN

2. STROKE NON HEMORAGIK = STROKE SUMBATAN

= SUMBATAN OTAK

A.

KECACATAN

SUMBATAN / EMBOLUS

DAERAH
MATI

B.
C.
D.

PENEBALAN DINDING

ALIRAN DARAH LAMBAT

DAERAH PENUMBRA
(DAERAH SETENGAH MATI)

HARUS DISELAMATKAN
DARAH KENTAL

FISIOTERAPI
KECACATAN DIKURANGI
SEMAKSIMAL MUNGKIN

Diagnosis Stroke
- Berdasarkan temuan klinis
- Pemeriksaan Penunjang

PEMERIKSAAN PENUNJANG
Tujuan :

-menegakkan diagnosis
-mencari faktor risiko
-mencari faktor penyulit

LABORATORIUM
1. DARAH
- Rutin
- Hematokrit
- Masa perdarahan dan pembekuan
- Gula Darah I / II
- Kolesterol total, HDL, LDL
- Trigliserid
- Asam urat
- Ureum , Kreatinin
- Elektrolit
- Khusus : - Agregasi trombosit Homocysteine
Fibrinogen

- APTT

- D-dimer

- Protein C dan S

2. LUMBAL PUNGSI
- perdarahan sub arahnoid
3. X- FOTO TORAKS
- besar jantung, penyakit paru
4. EKG
- fibrilasi atrium, iskemik/infark jantung
EKOKARDIOGRAFI
- sumber emboli di jantung dan aorta proksimal
5. NEUROSONOGRAFI
- stenosis, vaso spasme
6. ANGIOGRAFI SEREBRAL
- AVM, anuerisma

Pemeriksaan Neuroimajing/neurosonologi
(NINS) selain dengan CT Scan & MRI ialah
dengan Angiografi serebral, PET, SPECT, dan
sonografi dopler (Transcranial Doppler
Sonography = TCDS) untuk mendeteksi
stenosis vaskular ekstra dan intrakranial
untuk membantu evaluasi diagnostik,
etiologik, terapetik dan prognostik

KEUNTUNGAN TCD

EFFEKTIVE
MUDAH DIGUNAKAN
NON-INVASIVE
NON-RADIO AKTIVE
PORTABLE
MURAH
DAPAT DIULANG DAN AMAN

Report of the American Academy of Neurology (1990)

KEKURANGAN TCD

POSISI ANATOMI PEMBULUH DARAH BERBEDA, LETAK

DARI ARTERI SULIT DITEMUKAN

PENYAKIT BILATERAL SIMETRIS, VASOCONSTRICTION OR

STENOSIS PADA REGIO YANG LUAS, DAN ARTERI DISTAL
DAN ARTERI PENETRATING SULIT DIPERIKSA

SEBAGIAN PENDERITA TIDAK PUNYA WINDOW

Report of the American Academy of Neurology (1990)

TCD HAS ESTABLISHED VALUE IN :

DETEKSI STENOSIS BERAT (>65%) DI PEMBULUH

DASAR OTAK
DAPAT MEMBERI GAMBARAN SIRKULASI KOLATERAL
DENGAN MENGETAHUI REGIO PADA STENOSIS BERAT
OR SUMBATAN
DAPAT EVALUASI DAN MENGIKUTI PASIEN DENGAN
VASOKONSTRIKSI PADA SEMUA KASUS, KHUSUSNYA
SETELAH SAH
DETEKSI AVM DAN MELIHAT SUPPLY ARTERI DAN
GAMBARAN ALIRAN
DAPAT UNTUK MELIHAT KEMATIAN OTAK
PUSING KRONIS, MIGREN, VERTIGO

Report of the American Academy of Neurology (1990)

KEGUNAAN TCD :

DETEKSI STENOSIS BERAT (>65%) DI PEMBULUH

DASAR OTAK
DAPAT MEMBERI GAMBARAN SIRKULASI KOLATERAL
DENGAN MENGETAHUI REGIO PADA STENOSIS BERAT
OR SUMBATAN
DAPAT EVALUASI DAN MENGIKUTI PASIEN DENGAN
VASOKONSTRIKSI PADA SEMUA KASUS, KHUSUSNYA
SETELAH SAH
DETEKSI AVM DAN MELIHAT SUPPLY ARTERI DAN
GAMBARAN ALIRAN
DAPAT UNTUK MELIHAT KEMATIAN OTAK
PUSING KRONIS, MIGREN, VERTIGO

Report of the American Academy of Neurology (1990)

CT Scanning tanpa kontras merupakan

pemeriksaan baku emas untuk menentukan jenis
patologi strok, lokasi dan ekstensi lesi, serta
menyingkirkan lesi non vaskular
(Konsensus Nasional 1999).

Godfrey HOUNSFIELD (1971) ahli fisika dan James

AMBROSE (1972) dokter radiologi Inggris, pada
1979 memperoleh anugrah NOBEL untuk penemuan
CT Scan, yang dengan sinar-X diubah
impuls
listrik, memproyeksi titik-titik tubuh menjadi
gambar 2 dimensi dengan bantuan komputer

Pemeriksaan MRI diindikasikan untuk

diagnosis jenis lesi patologik strok dengan
lebih tajam (Konsensus Nasional 1999).
RaYmod DAMADIN (1960), menggunakan
MRI dalam riset; atas dasar interaksi
gelombang RADIO dgn inti PROTON dlm
MEDAN MAGNIT yg kuat tanpa sinar-X, dgn
gambar tajam; dan digunakan di RS (1980
an)

KONTRA INDIKASI MRI

Kontra indikasi relatif :
1. Artificial joint
2. Middle ear protesis
3. Corpus alienum/benda-benda logam
4. Hamil muda
Kontra indikasi absolut
1. Terhadap penderita dgn alat pemacu
jantung
2. terhadap pend. dgn hemostatic clip
(cerebral aneurysma.

KELEBIHAN DAN KEKURANGAN

MRI

Kelebihan :
1. Non invasive
2. Banyak potongan yg dpt dilakukan secara langsung
3. Dgn akurat sangat tinggi
hampir semua jaringan
4. Tdk memakai sinar-X
5. Tdk merusak keshehatan pd penggunaannya yg tepat
6. Banyak pekerjaan yg dpt dikerjakan tanpa zat kontras
7. Potongan yg dihasilkan dpt 3 dimensi (aksial, frontal,
dan sagital) dan malah banyak potongan dapat dibuat
hanya dlm datu waktu (dpt membuat > 8 potongan
sekaligus)

KELEBIHAN DAN KEKURANGAN

MRI

Kekurangan :
1.Tdk
dpt
digunakan
u/penderita
gawat
darurat/darurat akut, yg non koperatif / anakanak karena pem ini memerlukan wkt yg lama,
dan alat-alat bantu yg bersifat ferromagnetik
tdk dpt masuk ke ruang pemeriksaan (gantry)
2. Sementara pemeriksaan berlangsung ada
suara gaduh
3. Biaya pemeriksaan dan pemeliharaan lebih
tinggi dari biaya pemeriksaan radiologi lainnya.

PENANGANAN STROKE
5

B
Penanganan Stroke Akut
Penanganan Faktor risiko
Penanganan Komplikasi
Rehabilitasi
Penanganan Post Stroke

5 "NO" OF MEIER RUGE FOR ACUTE

ISCHEMIC STROKE THERAPY (1990)

1. No antihypertensives *,
2. No diuretics,
3. No dexamethasone,
4. No glucose infusion,
5. No anticoagulant 4 hours after onset
of stroke.

* Except aortic dissection, acute myocardial

infarction, heart failure, acute renal failure,

hypertensive encephalopathy, thrombolytic
therapy (T 185/110 mm Hg) (Brott 2000).

APPROACH TO ACUTE ISCHEMIC

STROKE MANAGEMENT (5 P): (Felberg
2003)

PARENCHYMA: Management of the ischemic cascade

neuroprotective
agents. Until now none is approved by the
FDA.
PIPES (BLOOD VESSEL) :
1. Antitrombotic
1.1 Anti-platelet ASA 160-300 mg (IST 1997, CAST 1997)
1.2 Anti-coagulantia (LMWH no benefit) (Hommel 1998 , TOAST
1998, Adams
1999)
2. Trombolytic
2.1 Trombolysis IV rtPA (FDA 1996) (time window 3 hrs).
2.2 Trombolysis IA (1998) (prourokinase) time window 6 hrs.
PERFUSION: Induced hypertension ? ; Crystalloid/colloid solution
(Pentastarch?) in cardiac output 10% improved outcome;
Bed position < 300 angle.
PENUMBRA: Management of the ischemic penumbra
neuroprotectors ?
PREVENTING COMPLICATION: Control of fever; glycemic control;
DVT precautions; aspiration precaution; avoid indwelling
catheters; bowel regimen; early mobilization.

The first 30 minutes.

Rapidly stabilize the patient, insert an
IV- line. No glucose.
Make a quick but thorough
neurological assessment: stroke or non
stroke?
Withdraw blood for the most urgent
tests: blood glucose, CBC, electrolytes.
Sent the patient for brain-scan.
CDP-choline?

Common stroke mimics.

Hypoglycemia
Post-ictal state
Drug overdose
Encephalopathies with focal signs
Hyponatremia
Subdural hematoma/empyema
Concussion with neck injury
Facial nerve palsy!
Migraineous accompaniment.

The next hour.

CT-scan reveals no ICH, blood tests and
history no contra-indication for thrombolytic
therapy: r-tPA. Follow guidelines
scrupulously! May induce hemorrhagic
transformation of infarct.
Pentoxyfilline, nimodipine or piracetam ?
Cerebrolysin ? European Stroke Conference 2001.
CDP-choline?
LMWH in selected cases.

.r-tPA induced bleeding. 7%

74-year old.
2 hours after onset
BP 155/70
Normal platelets, etc.
.t-PA administered
Stuporous after 9 hrs.
Re-CT bleeding

The first 24 hours.

Observe the patient closely for any signs of
deterioration. Repeat brain scan if necessary.
Do not lower blood pressure except in the
presence of impending cardiac
decompensation.
Perform additional laboratory tests the next
day. Do not forget albumin, repeat every few
days.
Special tests may be needed to help formulate
a more rational plan of treatment.

Intravenous Pentoxyfilline.

Can be given directly, as a bolus.

Better if given at a constant rate, with a nonglucose fluid.
Dosage may be individualized for each patient.
Duration: 5-7 days, followed by oral medication.
Handschu et al: most German hospitals use either
Pentoxyfilline or piracetam for acute ischemic
stroke!
Stroke,
2001

Reperfusion injury.
In the presence of disruption of the
BBB, reperfusion may induce cerebral
edema and hemorrhage.
After a prolonged period of occlusion
leading to cellular injury: reperfusion
may result in increased production of
free radicals, gene expression and
inflammatory events augmentation
of cellular damage.

LMWH.
Usually not used as monotherapy.
Personal preference: give together with
another drug to selected stroke patients.
Start early, continue for 5-7 days.
Avoid LMWH if:
- systolic blood pressure > 180 mmHg.
- very large infarct or even a tiny bleed.

LMWH.
Usually not used as monotherapy.
Personal preference: give together with
another drug to selected stroke patients.
Start early, continue for 5-7 days.
Avoid LMWH if:
- systolic blood pressure > 180 mmHg.
- very large infarct or even a tiny bleed.

The next three days.

Watch out for brain edema!
Repeat all necessary tests as often
as necessary, including CT.
Keep the patients energy
metabolism and electrolytes in an
optimal condition.
Treat fever aggressively!

In case something goes

wrong.
Most common complications of acute
stroke:
Cerebral edema
Fever
Electrolytes imbalance
Malnutrition.
Convulsions
DVT.

Cerebral edema.
May develop acutely, usually after second
day.
Strict attention to fluid balance, avoid the use
of hypotonic solutions, such as 5% glucose.
Use mannitol with caution.
Albumin, 25% solution, helpful, especially if
serum albumin < 3.6 g/dl.
Surgical help in case everything else fails.

Fever.

May be annoying and is bad for recovery.

Prevention is better than cure: meticulous
attention to good nursing practice.
Try to determine exact cause and eradicate it.
Use suitable antibiotics as necessary.
Use water bed!
If possible treat the patient in an airconditioned room.

Fever is bad for stroke

patients!

Increases the release of excitotoxic transmitters

Increases production of free radicals
Induces more damage to BBB
Increases post-ischemic depolarization in the
penumbra.
Harmful to the recovery of cellular metabolism.
Increase lactic acidosis.

Electrolyte imbalance.
Bad for recovery, may be lifethreatening!
Repeat electrolyte test as often as
needed.
Treat promptly, do not rely on clinical
judgment alone!
Enlist the help of a good internist.
Proceed with caution, do not over-treat.

Malnutrition.
Remember to feed the patient!
Fluid infusions alone is not enough.
Starvation is very bad for the patient.
A well balanced diet is important to
the patients recovery.
Laboratory tests may help to
determine the patients nutritional
status.

Convulsions.
Occur in approximately 10-20% of stroke
patients, especially those with large
infarct.
Use parenteral dilantin except if contraindicated.
Oral route is too slow!
Control drug level and possible side
effects.
Routine administration of an
anticonvulsant is not recommended.

Deep vein thrombosis.

Not frequent in Indonesia.
Can be prevented by early
mobilization.
Use of LMWH or heparin may be
indicated.
Often overlooked unless inspected
daily!
Inspect the patients leg, daily!

Increased level of
Homocysteine.
Harmful effects due to impairment of
endothelial
function through production of hydrogen
peroxide and consumption of NO to form
nitrosohomocysteine.
Aggravates atherosclerosis and coagulation.
Provokes neuropathy, retinopathy,
nephropathy
and cerebral vasospasm in SAH

Homocysteine-2

Deficiency of folic acid, vitamin B-12, B-6,

genetic defects of certain enzymes:
methionine- synthetase,
methylenetetrahydrofolate-reductase (folic
acid), and cystathione -synthetase (B6).
Indication to treat when homocysteine levels >
14 mol/L. (folic acid + vitamins B-6 + B-12).
New data: hyper-homocysteinemia may just be
a result of the ischemic event. (Stroke, Jan.2001)

BLOOD PRESSURE
MANAGEMENT IN ICH (Broderick
1999)

- If SBP > 230 mm Hg or DBP > 140 mm Hg on 2

readings 5 minutes apart nitroprusside 0.5-10
g/kg/min.
- If SBP is 180-230 mm Hg, DBP 105-140 mm Hg, or
mean arterial BP 130 mm Hg on 2 readings 20
minutes apart labetolol, esmolol, enalapril, or
other smaller doses of titrabble IV medications eg
diltiazem, lisinopril, or verapamil.
- If SBP is < 180 mm Hg and DBP < 105 mm Hg, defer
antihypertensive therapy.
- If ICP monitoring is available, cerebral perfusion
pressure should be kept at > 70 mm Hg.

Labetolol: 5-100 mg/h by intermittent bolus doses of 10-40 mg or continuous drip (2-8
mg/min).
Esmolol: 500 g/kg as a load, maintenance use, 50-200 g/kg/min.
Hydralazine: 10-20 mg Q 4-6 h
Enalapril: 0.625-1.2 mg Q 6 h as needed.

MANAGEMENT OF ICP
(Broderick 1999)
Osmotherapy:
- Mannitol 20% (0.25-0.5 g/kg every 4 h), for only 5 d.
- Furosemide (10 mg Q 2-8 h) simultaneously with mannitol.
- Serum osmolality 310 mOsm/L, measured 2 X daily.
No steroid
Hyperventilation:
- Reduction of pCO2 to 35-30 mm Hg, by raising ventilation
rate at constant tidal volume (12-14 mL/kg), lowers ICP 25%30%.
Muscle relaxants:
- Neuromuscular paralysis in combination with adequate
sedation can reduce elevated ICP.
- Vecuronium or pancuronium, with only minor histamine
liberation and ganglion-blocking effects are preferred.

RECOMMENDATIONS FOR
SURGICAL TREATMENT OF ICH
(Broderick 1999)

NON SURGICAL CANDIDATES

1. Small hemorrhages (<10 cm3) or minimal
neurological deficits.
2. GCS score 4. Except for cerebellar hemorrhage
with brainstem compression for livesaving surgery.
SURGICAL CANDIDATES
1. Cerebellar hemorrhage > 3 cm who are
neurologically deteriorating or who have brainstem
compression and hydrocepahalus from ventricular
obstruction.
2. ICH with structural lesion eg aneurysm, AVM, or
cavernous angioma.
3. Young patients with a moderate or large lobar
hemorrhage who are clinically deteriorating.

MANAGEMENT OF SAH
(1)
1. BEDREST

+ tranquilizers + head position horizontal.

2. PREVENTION OF REBLEEDING

- Antihypertensive medications (controversial)

- Antifibrinolytics:
- Tranexamic acid 6 X 1gr (7-14 days) 40% in rebleeding offset
by
43% in focal ischemic deficits (Kassell 1984).
- Tranexamic acid + nimodipine ischemic deficits (van Gijn 1992).
- Carotid ligation (indeterminate value)
- Intraluminal coils & balloons (experimental)

3. PREVENTION OF VASOSPASM

- Hypertension/hypervolemia/hemodilition (experimental)
- Calcium ch.antagonists : Nimodipine 6 X 60 mg p .o./infuse 1-2 mg/hr for
5-14 ds.
- Intracisternal fibrinolysis +antioxidant+ antiinflammatory agents
uncertain value
- Transluminal angioplasty in whom conventional therapy has failed.

MANAGEMENT OF SAH
(2)
4. HYDROCEPHALUS

- Acute (obstructive) hydrocephalus ventriculostomy.

- Chronic (communicating) hydrocephalus temporary/permanent CSF
diversion.

5. PREVENTION OF HYPONATREMIA

- Intravascular administration of isotonic fluids.

- Monitoring CVP, pulmonary capillary wedge pressure, fluid balance & body
weight.
- Volume contraction should be corrected by increasing the volume of fluids.

6. PREVENTION OF SEIZURES

- Prophylactic anticonvulsants is recommended.

- Longterm anticonvulsants not routinely recommended.

7. SURGICAL INDICATION

- RUPTURED ANEURYSMS
WFNS grade 1-3 (good-intermediate grade) surgery strongly indicated.
- UNRUPTURED ANEURYSMS
Surgery recommended
- ASYMPTOMATIC ANEURYSMS
> 1 cm operate; < 1 cm do not operate (consensus).

STROK penyakit gawat dan akut

Emergency :
Diagnosa yang tepat dan segera
sangat menentukan TERAPI yang cepat
& terarah
Morbiditas dan Mortalitas dapat
diturunkan

The Ideal Stroke team.

The team should consist of:

neurologists with special interest in stroke
neuro-radiologists, well-trained to do angiograms +
Doppler evaluation of vessels supplying the brain
A neurosurgeon, with special training in vascular
surgery.
Well-trained team of nursing personnel,
physiotherapists.
Other related specialists: social worker,
psychiatrists.
A well-run hospital with lab and imaging facilities,

Yin Yang

Thank you Terima kasih!