Hemorrhagic Stroke

Alexandra Irene Click to edit Master subtitle style 0661050144

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Stroke
Stroke is a syndrome characterized by the

acute onset of a neurologic deficit that persists for at least 24 hours, reflects focal involvement of the CNS, and is the result of a disturbance of the cerebral circulation.

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Cerebral Blood Flow

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Stroke
Ischemia
Lack of O2 energy failure depolarization

glutamate release influx Na+/Ca2+ cellular swelling + mitochondrial injury + enzyme activation Necrotic and programmed cell death.

Hemorrhage
Intracerebral, Subarachnoidal, Subdural /

epidural.
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Risk Factors
Modified Unmodified
Dyslipidemia Age Smoking Habits Genetic factors. Caffeine Hyperuricemia Hyperglicemia hypertension

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Hemorrhage
Hypertensive

Non hypertensive

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Autoregulation
Rise of perfusion pressure
Pressuredependent activation of smooth muscles

Activation of phospholipase C Release of arachidonic acid

Diameter change of blood vessels

Activates protein kinase C Inhibits potassium channels Lowering membrane potential

vasoconstrict ion

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Autoregulation

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Chronic Hypertension
Chronic hypertens ion
Structural changes of walls of the arteries

Fibrinoid necrotic microane urysms

SH

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Rupture of microane urysms

Rupture of microaneurysm

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Predilection Sites
Long, narrow penetrating arteries
Caudate and putaminal branches of the MCA Branches of the basilar artery pons Thalamic branches of PCA Branches of the superior cerebellar arteries

nuclei dentata
Cerebellum substantia alba

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Clinical Findings
Sudden onset Clinical worsening due to edema Rupture to ventricles Improvemen t once deficit stabilizes
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Elevated blood pressure

Deep cerebral hemorrhage

Thalamus : Putamen :
Marked sensory disturbances Aphasia Severe motor deficit Severe motor deficit

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Lobar Hemorrhage
Symptoms and signs varies according to the

location :

Headache Vomiting Hemiparesis Hemisensory deficits Aphasia Visual field abnormalities

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Pontine hemorrhage
Coma within minutes! Rupture to the fourth ventricle Pinpoint pupils Death in 48 hours

hyperthermia

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Treatments
Cerebellar decompression Cerebral decompression Antihypertensiv e agents? Discontinuing of anticoagulant and antithrombotic CI to surgery medications

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Treatments
Thorough history. (onset, duration, loss of

consciousness, visual disturbances, risk factors, related symptoms, headache, seizure, nausea, vomiting, etc)

Physical and neurological examination. Additional examinations :

CT Brain ECG EEG
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Gas Analysis

Treatments
Oxygenization Iv fluid balance Decrease of consciousness breathing

problems prepare ICU. (+ NGT on swallowing problems)

Rise of ICP Y/N?

Control with supine position; not putting even

more pressure to the vena cava.

Rise the patients head 20 30 degree
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normovolemic state

Treatments
Other therapies related to sign and symptoms
Treatments of the risk factors (anti hypertensive

agents, anti cholesterol agents, anti diabetic agents etc)

Treatments of related symptoms : anti emetics,

proton pump inhibitors, prokinetics, antipyretics; given depending to occuring symptoms.

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Other causes of ICH

Vascular malformations Amphetamine and cocaine abuse Cerebral amyloid angiopathy Tumors Coagulopathies Anticoagulation

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Differential Diagnoses
Space Occupying Lesion (SOL) Hypoglycemia Hyperosmotic Hyperosmolar State Diabetic Ketoacidosis

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Case Report

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Identity
Mr. ED 59 years old Male Rawa Lumbu, Bekasi, West Java. Date of Admission : March 14th 2012

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History
Admitted to the ER decrease of

consciousness approximately 3 hours before admission sudden onset was not on any kind of activities followed by weakness on the right side of the body and inability to speak properly. Routine consumption of daily medicines : none. (-), loss of consciousness (-), visual disturbances (-).

History of headache (+), seizures (-), vomiting

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Previous and Family History

before. diabetes.
Family history of hypertension (+)

The patient never felt these kind of symptoms No known history of hypertension, and

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Clinical findings
GCS : E3V4M6 BP HR RR T

: 180 / 100 mmHg : 93 bpm : 24x / mnt : 36.5 C

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Neurological Findings
Cranial N. VII : Flattened right SNL Cranial N. XII : right deviation of the tongue 0000 5555 Motoric : 0000 5555 Sensoric

: symmetric : (+)

Physiologic reflexes

Pathologic reflexes : (-)

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Treatments
Oxygenization Isotonic fluid Watch on ICP rise Anti hypertensive agents with observations :

target : MAP 110 mmG

Stop bleeding : Vit K; transamines.

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Thank You
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