VASCULAR DEMENTIA,

WITH LACUNAR STROKE

Kelompok VII 2012 Palembang Class
Tutor: dr. Alfian Hasbi
Presented 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
TERMINOLOGY
Hemiparesis
Topographical disorientation
Grade II hypertension
Presence of pathological reflexes
BSS suggests untreated diabetes
Forget consuming medication?
VICIOUS CYCLE!
Lacunar infarction
MMSE
ANAT & PHYSIOL
CNS
Central Core Brain
Limbic System
Neocortex




CBF
50-65 mL / 100 g
750-900 mL / (Guyton, 2007:801)
MEAN FLOW
A. cerebri posterior?
COMMON MECHANISMS FOR STROKE
AND 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
STROKE TYPE?
Age = RISK FACTOR both ISCH / HAEM
Physical Exam: HTN grade II
Lab: Hyperglycaemie (DM II)
NO Hyperlipidaemie / Hypercholesterolaemie
HAEMORRHAGIC?
LACUNAR STROKE
CT Scan: Lacunar infarction on lobus
temporalis sinister.
ISCHAEMY of arteries to brains internal
structures: A. lenticulostriata.
Types
Motor (pure)
Ataxic
Dysarthria
Sensory (pure)
Mixed sensorimotor
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)

VASCULAR DEMENTIA
Varying degrees of arterial occlusion creates
different clinical features: Consider simple
atherosclerosis vs large occlusion (STROKE).
Memory is formed in FORMATIO
HIPPOCAMPALIS
Here occurs neurogenesis (Griggs, 2012:62)
Supplied by A. cerebri posterior and A.
choroidea anterior
The same vessels supply Crus posterius of
capsula interna (Gilroy et al., 2009:609).

ATYPICAL?
25% of infarcts to A. cerebri posterior causes a
mnesia (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

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)

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.
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
PROGNOSIS
DUBIA AD MALAM
BAD 5YSR: 39%
Life expectancy is reduced on
Men
Low education
Bad neuropsychological results
(Alagiakrishnan, 2012)
MISCELLANEOUS
SKDI
Lacunar stroke: 2 (De facto 3B)
Vascular dementia: 2
To diagnose, refer, and treat fully after referral
MMSE
VS MOCA?
PROBLEM MAP
Diabetes 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, memory
pathological reflexes
Skor MMSE pathologik Suka lupa
CONCLUSION
Ny. Luna, 69 tahun, mengalami gangguan
fungsi luhur dengan emphasis memori et
causa dementia vasculare. Selain itu, ia juga
mengalami hemiparesis et causa stroke
lacunair di Crus posterius capsulae internae.
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 for
Lacune Subtypes in the Atherosclerosis Risk in Communities
(ARIC) Study.
Guyton, Arthur C., John E. Hall. 2007. Buku Ajar Fisiologi
Kedokteran. Editor: Luqman Yanuar Rachman. Jakarta: EGC.

CREDITS
dr. ALFIAN HASBI
Fachra Afifah Aliati
Nikodemus Tobing
Achmad Randi Raharjo
Ni Komang Leni W.
Reijefki Irlastua
Audy Andana Rosidi
Rezky Novia Indriani
Adisti Meirizka
Intan Fajrin Karimah
Maya Chandra Dita
Vina Chantyca Ayu