MODULE
VASCULAR
NEUROSURGERY SPESIALIST PROGRAME UNIVERSITY of AIRLANGGA
201 6
Aneurysmal SAH +
ICD-10: I 67.1
1. Definition • Aneurysms: cerebrovascular disorders such as weakness cerebral artery or vein wall that causes
(Definition) dilation of local or balooning blood vessel. etiology:
- head trauma
- atherosclerosis or hypertension
- embolism: atrial myxoma
- infection: mycotic aneurysm
- congenital
• If there is rupture of the aneurysm will cause to happen SAH. SAH is bleeding in the subarachnoid cavity.
etiology:
- Trauma: The most frequently
- Spontaneous: aneurysm rupture (75-80%), AVM (4-5%), vasculitis, tumoral bleeding,
cerebral artery dissection, small superficial artery ruptures and infudibulum, blood clotting disorders,
dural
sinus thrombosis, spinal AVM, etc.
2. History - If the aneurysm is small, often asymptomatic.
- term effects because giant aneurysms:
1. brainstem compression: hemiparese
2. cranial neuropathy: double vision, impaired vision, facial pain
3. suppression of the pituitary gland and stalk aneurysm intra-suprasell
Hormonal disorder.
- If the aneurysm rupture causes bleeding SAH:
1. severe headache suddenly (97%), vomiting, syncope, neck pain (meningismus), photophobia, until
loss of consciousness
2.If accompanied ICH, showed the weakness of the limbs, language disorders, seizures, and vision
disorders
3. Low back pain
There is a classification of Hunt and Hest to assess the degree of clinical symptoms in a ruptured aneurysm
Hunt and Hess classification
Level decryption 1
Asymptomatic or mild headache and mild neck stiffness 2
cranial nerve palsy (III, VI) .nyeri moderate to severe head, neck stiffness 3
Mild focal deficit, lethargy, confusion 4
Stupor, hemiparese moderate to severe, deserbrasi 5
Commas in, decerebrate
This classification is used as an indicator of prognosis and management of ruptured aneurysm election.
Grade 1 and 2 operated on immediately after the aneurysm was diagnosed. Grade ≥ 3
postponed surgery until clinical improvement (grade 1 or 2) Exceptions timing of operation in
case of life-threatening ICH.
3. Physical Examination SAH:
- Meningism with pathological reflexes
- Hypertension
- loss of consciousness due to: ICT increases, ICH, hydrocephalus, diffuse ischemia, seizures
- ocular hemorrhage
4. Criteria for Diagnosis clinical
Radilologis
5. Diagnosis of work Unruptured aneurysm (I67.1) ruptured
aneurysm (I60.7) a-SAH (I60)
6. Diagnosis • AVM
• Brain haemorrhage due to hypertension
• Cerebral vein thrombosis
• SAH due to trauma
• intratumoral bleeding
• Pitutiary tumor
• Moyamoya disease
•
Vein of gallen
malformation
7. Investigations Lumbar puncture: most sensitive to SAH (opening pressure increases), xantocrom, cell counts of>
100,000, increased protein, normal or decreased glucose
False positives: traumatic taps
Radiological:
Recommendation Grad e
Reko
No. Examination mend Ref
ation
1 CT
scan
To detect> 90% SAH when the onset of bleeding occurred in
1C 5
24 hours
insensitive to SAH 24-48 hours, preferably 4-7 days
2 MRI Flair most sensitive MRI imaging to detect SAH 2C 6
3 MRA
a sensitivity of 95% for aneurysm size> 35 mm
2A 7
detecting aneurysms 97%. Can describe the shape
4 CTA of the aneurysm 3D crucial for surgical planning 2A 7
1) The gold standard of evaluation eneurisma palsy.
5 Cerebral 1A 7,11
angiogram
Fisher Gr ade
grade
CT scan 1 There does not appear bleeding 2
SAH thickness <1 mm 3
SAH thickness> 1 mm (high risk occurs vasospasm) 4
SAH + IVH / ICH 8. Therapy
Management aneurysm, depends on the rupture or unruptur:
1. Penatalakasanaan ruptured aneurysm
• Management of ruptured aneurysms, pay attention to potential problems in SAH, including:
1. Rebleeding
2. hydrocephalus 3. Delayed Ischemic Neurologic Deficit (dind) due to vasospasm
4. hyponatremia and hypovolemia
5. DVT and pulmonary embolism
6. Seizures
7. Determine the location of the source of bleeding / ruptured aneurysm
Procedures (ICD 9 CM) Grad e
Reko
No. Therapy mend Ref
ation
a) Maintaining CBF • increasing the CPP, improve the rheological,
blood, maintain euvolemia, keep ICP
b) Neuroprotektan: there has been no effective
drugs c) Observation strict in ICU (with
monitor VS), bed rest with head-up sleeping
position 30 °,
d) Diet: NPO (greenberk p 1041)
e) Intravenous fluids (to prevent cerebral salt
wasting): NS + 20 mEq KCl / L ~ 2 ml /
kg / hour. If HCT <40%, 5% albumin
500cc
f) Drugs:
• anticonvulsant prophylaxis
2B 8
• Sedation
1 medical
• analgesia
• Dexametasone, reduce headaches and
neck. Generally given pre-op
• Purgative
1A 9.12
• anti vomiting
• Vasospasm treatment in cases of
hemorrhage SAH:
- calcium channel blockers :
nomidipin (nimotop) 4x60mg dlm 96
hours
after SAH. Tablets and IV equally
effective.
(Grade 1A)
9
- intra arterial vasospasm metal treatments endovasculer
g) Oxygenation: 2 lpm if necessary
h) Blood pressure: TDS keep 120-150mmHg
(Hypertension extreme
Upgrade
unclipped
risks
aneurysm •
rebleeding,
hypotension • ischemia) i) laboratory: DL, electrolytes,
BGA, PTT / APTT, HCT
j) Ragiologis: X-ray thorax serial to
condition stable (evaluation triple treatment H), transcranial doppler.
a) hydrocephalus
1. Acute: • 50% improved spontaneous
• rest with H & H grade IV-V: ventrikulostomi
with ICP 15-25 mmHg. Prevent rapid drop in ICT, increasing the risk of rebleeding.
2. Chronic: controversy
b) Aneurysms: cliping surgery and endovascular
coiling is done to reduce the occurrence of
rebleeding. 1. Endovascular
a) Trombosing aneurysm:
2. Coiling simple
3. The use of intracranial stent-assisted coiling
stenting (stent Leo,
solitair stent, stent enterprise, etc.)
4. Coiling using a compliant balloon
(Hyperform®, hyperglide
balloon, etc.) at the time of installation of coil
2B 10
2 Operations and 5. Flow diverter (pipe line, etc.) in the case of
intervention large size aneurysm (Giant Aneurysm)
b) Trapping preceded Compliant Balloon
1B 2.3
Occlusion Test uses Ballon
c) ligation of the proximal (Hunterian ligation)
for giant aneurysm
2. Surgery
• Clipping: Gold standard. Replacing the clip on the
neck of the aneurysm to seal the relationship
between the aneurysm from circulation without
any other normal blood pembulih clogs.
• Wrapping or coating using a muscle, cotton or
muslin, plastic resins, teflon and fibrin glue
• The combination of difficult cases requires
surgery and endovaskuler. Example: Giant
aneurysm do trapping and surgical bypass
•
proximal ligation
for giant aneurysm
(Hunterian ligation)
•
Coilling (ICD-9: 39.52) Clipping (ICD-9: 39.51)
Older age (> 75 years) young age
Clinical Grade ugly MCA aneurysm
Ruptured aneurysms that are difficult to access Giant aneurysms (diameter> 20mm)
Dg aneurysm morphology: dome-neck ratio Symptoms of an aneurysm mass effect
> 2, neck diameter <5 mm
Aneurysms of the posterior circulation Small aneurysms (diameter 1,5-2mm)
Plavix drug consumption Wide neck aneurysm
Fail in clipping or technically difficult Residual aneurysm coiling post
The timing of surgery:
1) Early (<48-96 hours) • Lower risk of rebleeding • Facilitating vasospasm therapy • lavage clot potential as agents spasmogenik • low mortality • Requirements:
o Good medical condition
o Hunt and Hess grade • 3
o SAH vasospasm potentially thick
o Conditions that would complicate management, ex: TD dud stable, seizures
o SAH thick with future effect
o early Rebleeding
o Indication of imminent rebleeding
2) Late (> 10-14 days post-SAH)
• Clinical condition or age is ugly and old patients
• Ugly neurological condition (Hunt & Hess • 4) • controversy
• Aneurysms are difficult in the clip because of the size and location
• Severe cerebral edema
• active vasospasm
• In the surgical treatment, there are some approach is used based on the location and morphology of the
aneurysm. Among them:
a) Pterional
b) Subfrontal
c) Anterior interhemispheric
d) Transcallosal
e) Transylvian or superior temporal gyrus • MCA aneurysm
f) Subocipital or subtermporal-trantentorial
2. Management unruptur aneurysm
• Indications management on unruptur aneurysm:
a. Symptomatic: that intolerable pain, impaired vision
b. Giant aneurysms in the ring clinoid
c. Aneurysms enlarged on serial imaging
• The choice of therapy in non rupture is non-medical (clipping or coiling)
9. Education • Risk factors for aneurysms
• travel sickness
• complication
• Therapy
• prognosis
10. Prognosis • Prognosis depends on several things:
1. The location and extent of the aneurysm
2. Age
3. The general clinical condition
4. Status of the neurological using Hunt and Hess grade Hunt and Hess 1 and 2 good outcome, grade • 3 ugly outcome, meningaal or permanent paralysis.
• overall mortality of ~ 45%, most improved dg little or no neurological.
• morbidity: paralysis medium - weight ~ 30%, 66% post-clipping does not improve quality of life
• Before surgery: rebleeding is a major cause of morbidity and mortality of ~ 15-20% within the first 2
weeks. • After surgery: vasospasm caused the deaths (7%), and neurological deficit (7%)
11. reviewers were critical 1. Prof. Dr. Abdul Hafid Bajamal, dr., Sp.BS
2. Dr. Agus Turchan, dr., Sp.BS
3. Dr. M. Arifin Parenrengi, dr., Sp.BS
4. Dr. Joni Wahyuhadi, dr., Sp.BS
5. Dr. Eko Agus Subagyo, dr., Sp.BS
6. Dr. Asra Al Fauzi, dr., Sp.BS
7. Wihasto Suyaningtyas, dr., Sp.BS
8. Muhammad Faris, dr., Sp.BS
9. Rahadian Indarto, dr., Sp.BS
10. Fahmi Achmad, dr., Sp.BS
11. Nur Setiawan Suroto, dr., Sp.BS
12. Irwan Barlian Immadoel Haq, dr, Sp.BS
13. Tedy Apriawan, dr., Sp.BS
14. Heri Subianto, dr., Sp.BS
12. Medical Indicators Improvement of neurological status.
13. Bibliography 1. Spetzler RF, Riina HA, Lemole GM Jr: Giant aneurysms. Neurosurgery 49: 902-908, 2001
2. Spetzler RF, RA Hanel: Surgical treatment of complex intracranial aneurysms. Neurosurgery [SHC Suppl 3]:
SHC1289-SHC1299 2008 3. Morris Pearse: Practical Neuroangiography second edition. Lippincott Williams & Wilkins,
2007
4. Spetzler RF, Kalani MYS, Nakaji Peter: Neurovasculer second surgery edition. Thieme, 2015
5. JJ Perry, Stiell IG, Sivilotti ML, Bullard MJ, Emond M, Symington C, Sutherland J, Worster A, Hohl C, Lee JS,
Eisenhauer MA, Mortensen M, Mackey D, Pauls M, Lesiuk H, Wells GA. Sensitivity of computed tomography
performed within six hours of onset of headache for the diagnosis of subarachnoid haemorrhage: prospective
cohort study.BMJ. 2011; 343: d4277
6. Wiesmann M, Mayer TE, Yousry I, Medele R, Hamann GF, Brückmann H. Detection of hyperacute
subarachnoid hemorrhage of the brain by using magnetic resonance imaging.J Neurosurg. 2002; 96 (4): 684.
7. Lu L, Zhang LJ, Poon CS, Wu SY, CS Zhou, Luo S, Wang M, Lu GM. Digital subtraction CT angiography for
detection of intracranial aneurysms: comparison with three-dimensional digital subtraction angiography. Radiology.
2012 February; 262 (2): 605-12. Epub 2011 Dec 5.
8. Marigold R, Günther A, Tiwari D, Kwan J. antiepileptic drugs for the primary and secondary prevention of
seizures after subarachnoid haemorrhage. Cochrane Database Syst Rev. 2013 Jun; 6
9. Dorhout Mees SM, Rinkel GJ, Feigin VL, algra A, van den Bergh WM, Vermeulen M, van Gijn J.
Calcium antagonists for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2007
10. AR Dehdashti, Rilliet B, Rufenacht DA, de Tribolet N. A shunt-dependent hydrocephalus after rupture
of intracranial aneurysms: a prospective study of the influence of the treatment modality. J Neurosurg. 2004;
101 (3): 402.
11. AU Chappell ET, Moure FC, Good MC. Comparison of computed tomographic angiography with digital
subtraction angiography in the diagnosis of cerebral aneurysms: a meta-analysis. Neurosurgery. 2003; 52 (3):
624
12. Abruzzo T, C Moran, Blackman KA, Eskey JK, Lev R, Meyer P, Narayanan S, Prestigiacomo CJ.
Invasive interventional management of post-hemorrhagic cerebral vasospasm in Patients with aneurysmal
subarachnoid hemorrhage.J Neurointenvent surgery. 2012
AVM
ICD-10: I 67.1
1. Definition - Arteriovenous malformation / AVM is a congenital disorder caused by abnormal dilatation of blood
(Definition) vessels of the arterial blood flow is directly related to draining vein without mealui kapier normal tissue.
Not available in nidus of brain parenchymal tissue.
- Often found as a complication of bleeding (risk of spontaneous bleeding occurs 2-4% / year), rare
seizures
- The blood flow in the AVM changed from the low pressure at the time of birth, into the pressure was high -
as an adult so that AVM lesions tend to enlarge. 2. History Symptoms that may arise:
1. ICT symptoms increased because of bleeding (most often): 50%. The peak incidence age of 15-20 years
2. Seizures
3. Effects period, ex: trigeminal neuralgia for CPA AVM
4. Ischemia: steals effect
5. Headache
3. Physical Examination A visible sign
• Signs of ICT increases
• cranial nerve palsy due to the effects of future
• weakness of limbs due to ischemia
• Bruit (especially the dural AVM)
4. Investigation Radiologis:
Recommendation Grad e
Reko
No. Examination mend Ref
ation
1 CT scan
Overview 'flow void', the sensitivity of CT scans will be increased
2B 4
when accompanied by CT angiography
2 MRI
MRI is very sensitive to the identification of the AVM nidus
2A 3
Gold standard diagnosis 1C 4
3 angiography
1) CT scan: good quality detect hemorrhage and calcification 2) MRI: AVM morphology and get rid of DDX 3) angiography: visible Tangle of vessels, feeding artery, draining veins visible
the arterial phase
5. Criteria for Diagnosis 1. Anamnesis according above
2. Clinical examination according above
3. Imaging studies corresponding above
6. Diagnosis
AVM Grading is based on the following classification,
Spetzler Martin AVM grading system
Graded Feature Points
Small size (<3
cm) Medium (3-6 cm) 1
Large (> 6 cm) 2
3
Eloquence of adjacent brain
Non eloquent 0
Eloquent 1
Pattern of venous drainage
superficial only 0
Deep 1
Grading is used as the basis for determining prognosis and selection of treatment
7. Diagnosis • cavernous hemangioma
• Dural arteriovenous fistula
• amyloid angiopathy • cerebral aneurysm • Cerebral venous thrombosis • brain hemorrhage
• Moyamoya disease • Vein of gallen malformation • Tumor
8. Therapy
• There are 4 options AVM management, diperimbangkan diberdasarkan grade Spetzler-Martin. Pembendahan
action is the gold standard, which is indicated in grade 1-3. Multimodality therapy were considered for AVM
with grade III-IV. For grade V-VI konservatif.diutamakan to AVM rupture or rupture of an insane history
kukan action be dah
Procedures (ICD 9 CM) Grad e
Reko
No. Therapy mend Ref
ation
1 Operations Surgery is the primary choice 1B 4
• Effective at ~ 20% of cases
2 Radiation
• Stereotactic radiosurgery (SRS) • small size
1B 5
<2.5-3 cm nidus, lies in
Embolization as adjunctive therapy
- embolization using glue (hystoacryl lipiodol or
EVOH (Onyx, etc)
- embolization transvenous (TRENSH) 2B 6
3 Endovascular using EVOH and balloon assisted (compliant
balloon)
The combination of embolization to shrink nidus,
followed by stereotactic
9. Education • Risk factors for AVM
• travel sickness
• complication
• Therapy
• prognosis
10. Prognosis • Prognosis depends on several things:
o In case of spontaneous bleeding, mortality of 30-50%
o The smaller the size, the more deadly because of the risk of further bleeding
big
o Large size associated with morbidity, the risk of further seizures
big
• Based on the grade Spetzler-Martin:
11. Medical Indicators Improvement of neurological status
12. Critical Reviewers 1. Prof. Dr. Abdul Hafid Bajamal, dr., Sp.BS
2. Dr. Agus Turchan, dr., Sp.BS
3. Dr. M. Arifin Parenrengi, dr., Sp.BS
4. Dr. Joni Wahyuhadi, dr., Sp.BS
5. Dr. Eko Agus Subagyo, dr., Sp.BS
6. Dr. Asra Al Fauzi, dr., Sp.BS
7. Wihasto Suyaningtyas, dr., Sp.BS
8. Muhammad Faris, dr., Sp.BS
9. Rahadian Indarto, dr., Sp.BS
10. Fahmi Achmad, dr., Sp.BS
11. Nur Setiawan Suroto, dr., Sp.BS
12. Irwan Barlian Immadoel Haq, dr, Sp.BS
13. Tedy Apriawan, dr., Sp.BS
14. Heri Subianto, dr., Sp.BS
13. Bibliography 1. Piepgras DG, Sundt TM Jr, Ragoowansi AT, Stevens L. Seizure Outcome in Patients with surgically treated
cerebral arteriovenous malformations. Neurosurg. 1993 January; 78 (1): 5-11.
2. Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR, Al-Shahi Salman R, Vicaut E, Young
WL,
Houdart E, Cordonnier C, Stefani MA, Hartmann A, von Kummer
R, Biondi A, Berkefeld J, Klijn CJ, Harkness K, Libman R, Barreau X, Moskowitz AJ, ARUBA
international investigators. Medical management with or without interventional therapy for unruptured
brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomized trial. Lancet.
2014; 383 (9917): 614.
3. Saleh RS, Singhal A, Lohan D, Duckwiler G, Finn P, Ruehm S Assessment of cerebral arteriovenous
malformations with high temporal and spatial resolution magnetic resonance angiography
contrastenhanced: a review from protocol to clinical application. Top Magn Reson Imaging. 2008 Oct;
19 (5): 251-7.
4. Mohr JP, Kejda-Scharler J, Pile-Spellman J. Diagnosis and treatment of arteriovenous malformations. Curr Neurol
Neurosci Rep. 2013 February; 13 (2): 324.
5. Schäuble B, Cascino GD, Pollock BE, Gorman DA, Weigand S, Cohen-Gadol AA, McClelland RL.
Seizure outcomes after stereotactic radiosurgery for cerebral
arteriovenous malformations.Neurology. 2004; 63 (4): 683.
6. Krings T, Hans FJ, Geibprasert S, Terbrugge K Partial "targeted" embolisation of brain
arteriovenous malformations. Eur Radiol. 2010 November; 20 (11): 2723-31. Epub 2010
June
11.
Carotid Artery Stenosis
I65.2
1. Definition The condition where the narrowing or kontriksi from the carotid artery due to atherosclerosis
(Definition)
2. History - obtained risk factors such as smoking, obesity, dyslipidemia, hypertension, diabetes mellitus
- obtained Transient neurological symptoms ranging from ischemic attack (TIA) to denag stroke
3. Physical Examination General Physical Examination
(Examination by inspection, palpation, percussion and auscultation) a thorough examination to rule out other
causes of epilepsy. At the time of the seizure, the patient should be checked and managed in accordance with
the principle emergency are: secure Airway, Breathing, Circulation
Neurological examination
• The level of awareness Glasgow Coma Scale ( GCS) • Examination of one to twelve cranial nerves • Motor examination thorough
• The sensory examination thorough
• Physiological reflex examination
• Examination of pathological reflexes
4. Criteria for Diagnosis 1. History according above
2. Clinical examination in accordance Issuer
3. Investigations
5. Work Diagnosis Kartis Artery Stenosis (I65,2)
6. Diagnosis - headache
- shingles
-
Transient iskhemic
attack
- Stroke
- retinal occlusion
- neck trauma
- Subarachnoid hemorrhage
- In sexy artery verte bralis
7. Investigations grade
No Inspection Recommendation rekomend Ref
care
- To find out where the anatomy of the
carotid stenosis and its relationship
1 CTA with structures are at bone 1B 1,2,3
surrounding
- To evaluate the carotid artery with
2 MRA
menggunanakn 3D TOF (time of
1B 4,5,6,7,8
flight) or CEMRA (enhnced
contrast MRA)
3 Carotid duplex
- Detect the speed of blood flow in the
1B
9,10,11,1
carotid stenosis 2.13
ultrasound
measuring Peak systolic velocity (PSV),
end-diastolic velocity (EDV), carotid
index (peak Iinternal
carotid artery and the common carotid artery
velocity velocity)
Transcranial
- Evaluate the relationship carotid stenosis
4
with intracerebral arteries leading to the
brain 1B 14,15,16
doppler
parenchyma
5 Cerebral
- Is the gold standard for diagnostic carotid
1A 17,18,19
stenosis
Angigoaphy
8. Therapy grade
No. Therapy Procedures (ICD 9) rekomend Ref
care - Procedures with statins, anti-platelet
1 Medika mentosa therapy of hypertension and diabetes,
2A
20,21,22, 23
healthy lifestyle change
Carotid end - Is a treatment option for carotid
24,25,26,
2 arterectomy
stenosis
1A
27,28
(CEA)
- The choice of therapy for carotid
stenosis if not possible to
done operation.
Using a balloon to dilate continued
permanent carotid stenting.
Carotid Artery
- Used also protective devices against
29,30,31,
3. Angioplasty and 1A
embolism ( embolic 32.33
Stenting (CAS)
Protection Device) can form an umbrella
( umbrella) mounted while in distal
stenosis or balloon catheter that is
placed temporarily at the proximal of
stenosis
9. Education Explanations to patients and families:
• Course of the disease and complications that may occur
• Therapy and actions that will be given along with the advantages and disadvantages
• The procedure for the treatment and the treating physician
10. Prognosis Ad Vitam (Live) : Ad bonam
Ad Sanationam (cured) : Ad Dubia bonam
Ad Fungsionam (function) : Ad Dubia bonam
Prognosis carotid stenosis increases when there is clinical improvement in post-action CEA or CAS
11. reviewers were critical 1. Prof. Dr. Abdul Hafid Bajamal, dr., Sp.BS
2. Dr. Agus Turchan, dr., Sp.BS
3. Dr. M. Arifin Parenrengi, dr.,
Sp.BS
4. Dr. Joni Wahyuhadi, dr., Sp.BS
5. Dr. Eko Agus Subagyo, dr., Sp.BS
6. Dr. Asra Al Fauzi, dr., Sp.BS
7. Wihasto Suyaningtyas, dr., Sp.BS
8. Muhammad Faris, dr., Sp.BS
9. Rahadian Indarto, dr., Sp.BS
10. Fahmi Achmad, dr., Sp.BS
11. Nur Setiawan Suroto, dr.,
Sp.BS
12. Irwan Barlian Immadoel Haq, dr, Sp.BS
13. Tedy Apriawan, dr., Sp.BS
14. Heri Subianto, dr., Sp.BS
12. Medical Indicators Carotid artery stenosis management indicators are based on the state of clinical improvement.
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SVM / SVS guidelines on the management of Patients with extracranial carotid and vertebral
artery disease. Stroke 2011; 42: E464.
28. Ricotta JJ, Aburahma A, Ascher E, et al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: executive summary. J Vasc Surg 2011; 54: 832.
29. Brott TG, Brown RD Jr, Meyer FB, et al. Carotid revascularization for prevention of stroke: carotid endarterectomy and carotid artery stenting. Mayo Clin Proc 2004; 79: 1197
30. Rothwell PM, Mehta Z, Howard SC, et al. Treating individuals 3: from subgroups to individuals: general principles and the example of carotid endarterectomy.
Lancet 2005; 365: 256.
31. nternational Carotid Stenting Study investigators, Ederle J, Dobson J, et al.
Compared carotid artery stenting with endarterectomy in Patients with symptomatic carotid
stenosis (International Carotid Stenting Study): an interim analysis of a randomized controlled
trial. Lancet 2010; 375: 985. 32. Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting in
Patients with symptomatic severe carotid stenosis. N Engl J Med 2006; 355: 1660.
33. Brott TG, Hobson RW 2nd, Howard G, et al. Stenting versus endarterectomy
for treatment of carotid- artery stenosis. N Engl J Med 2010; 363: 11.
Carotid Cavernous Fistula
ICD-10: Q28.2
1. Definition An abnormal connection between the carotid artery in the cavernous sinus, which can occur spontaneously
(Definition) or acquired (trauma), CCF grouped by etiology (trauma vs. spontaneous), blood flow velocity (high flow
versus low flow), anatomy (direct vs. dural, internal carotid vs external carotid vs. both)
2. anamnesis
• There is a history of previous trauma
• obtained ptosis
• Obtained their bruit
• Obtained headache
3. Physical examination High flow: - Bruit (80%), usually Traba above eye Boal - Blurred eye sight (25- 59%) - Headache (53- 75%) - Diplopia (50-85%) - Eyeball and orbital pain (35%) - Proptosis (72-87%) - Chemosis and conjunctival injection 955-89%) - Ophthalmoplegic (50-85% N VI palsy, cerebral 67% N III, N IV palsy 49%)
Low flow: - Anterior draining dural, symptoms: khemosis, conjuntival injection, proptosis
- Dural ccf flowing backward to the inferior or superior petrosal sinuses, the symptoms are: painfull
diplopia, N III palsy, cerebral IV N, N VI palsy
Loss of vision is a major problem driaing anterior dural case with a percentage of 33%. The cause of
impaired vision - Increased intraocular pressure sejunder causing venous congestion and glaucoma
- Venous stasis retinopathy - vitreous haemorrhage - proliferative retinopathy - Ischemic optic neuropathy - Exudative retinal detachment - Complications are rare as choroidal effusion and closed angle glaucoma
4. criteria for Diagnosis 1. History according above
2. Clinical examination in accordance Issuer
3. Imaging studies corresponding Issuer
7. diagnosis Carotid cavernous fistula (ICD-10: Q28,2)
8. Diagnoses 5.
- Intracranial tumors, lymphoma, metastatic
6.
- aneurysms
- Cavernous sinus thrombosis
- Infection
- Tolosa hunt syndrome
- orbital pseudotumor
- vasculitis
- sarcoidosis 9. Examination
Support Recommendation Grad e
Reko
No. Examination mend Ref
ation
see proptosis, expansion of the cavernous sinus and
superior ophthalmic vein, extraocular muscle dilation
associated with fractures of the skull base. CTA could
1 CT Scan see their CCF especially the proximal region of the 2A 1, 2, 3
cavernous sinus
see proptosis, expansion cavernous sinus and superior
2 MRI
ophthalmic vein, and the widening of the extraocular 1C 4, 5, 6, 7
muscles. Can also see cavernous sinus flow void.
Transcranial Doppler
saw an increase in blood flow velocity and a 1C 4, 8, 9
3 decrease in the index pusatif carotid siphon in
Ultrasound
patients with CCF
TFCA is the gold standard for diagnosis and primary
4
(Trannsfermoral treatment for CCF 1C 10 11
Cerebral
Angiography)
10. Therapy - CCF optimal therapy is to close an abnormal connection between the internal carotid artery to the
cavernous sinus while maintaining patency of the internal carotid artery
- some prosed ur used: Procedures (ICD 9 CM) Grad e
Reko
No. Therapy mend Ref
ation
Using the arterial or venous access. Transarteri embolization is the main option for most cases of particularly high flow CCF.
For the case of low flow CCF, embolization transarteri
12, 13,
difficult because of the small arteries, tortuous
14, 15,
(Grooved) and sometimes
16, 17,
Endovaskuler multpel. The choice combination transarteri and
1 2A 18, 19,
transvenous embolization. Materials used: detachable
20, 21,
ballon, platinum coil,
22, 23,
intracerebral stenting, polyvinyl particles
24
akhohol, Ethylene Vinyl Alcohol / EVOH ( ONYX etc) and-liquid
adhesive used to close the fistula with microcatheters
superselektif.
Transarteri embolization complications include:
- embolan migration into the intracranial circulation,
causing ischemia or cerebral infarction. Therefore,
the use of anticoagulation during the procedure and
the action antiplateletpostaction
decrease rsiko ischemia or infarction
cerebral
- Pseudoaneurisma because of injury in the arterial
wall
Transvenous embolization complications include:
- ischemia or cerebral infarction
- subarachnoid hemorrhage
- ruptured sinus
- extravasation ekstradura therefore
contrast
- cranial nerve parese
Surgery is done if endovaskuler unsuccessful. Her
action includes packing in cavernous sinus fistula for
clogs, sewing or clipping siftula, sealing the fistula
2 Surgery with fascia or glue, or ligation of the internal carotid 2A 12, 15
artery.
17, 25
radiosurgery indicated when
endovaskuler approaches and surgical intervention
aksessibel not pose a high risk of morbidity.
Radiotherapy resulted in obliteration of the dural CCF
stereotactic
around 75-100% despite 1C 26, 27,
3 takes several months. The required dose of 10-40
radiosurgery 28
Gy. Before radiation, determination of lesion size
have to do with the approach endovaskuler (TFCA) to
reduce the radiation dose necessary
,
Manual compression aimed at reducing the flow of
blood to form a thrombus within the cavernous sinus.
4 Manual compression Compression 1C 29, 30,
Vascular
performed for 30 seconds ipsilateral
31
carotid several times daily for 4- 6 weeks.
,
Patients with ocular proptosis lubrican should be
given to avoid exposure keratitis
5
handling 2A 32, 33
ophthalmology Increased intraocular be given obatoba to reduce
intraocular pressure
such as acetazolamide, corticosteroids iv, b
topical blocker
11. Education Explanations to patients and families:
• Course of the disease and complications that may occur
• Therapy and actions that will be given along with the advantages and disadvantages
• The procedure for the treatment and the treating physician
12. prognosis Prognosis depends on:
1. Symptoms of the disease
2. The severity and pathogenesis of the disease
3. The accompanying disease
13. Medical indicators Improvement of neurological status
14. Critical Reviewers 1. Dr. Joni Wahyuhadi, dr., Sp.BS
2. Muhammad Faris, dr., Sp.BS
3. Prof. Dr. Abdul Hafid Bajamal, dr., Sp.BS
4. Dr. Agus Turchan, dr., Sp.BS
5. Dr. M. Arifin Parenrengi, dr., Sp.BS
6. Eko Agus Subagyo, dr., Sp.BS
7. Wihasto Suyaningtyas, dr., Sp.BS
8. Asra Al Fauzi, dr., Sp.BS
9. Rahadian Indarto, dr., Sp.BS
10. Fahmi Achmad, dr., Sp.BS
11. Nur Setiawan Suroto, dr., Sp.BS
12. Irwan Barlian Immadoel Haq, dr, Sp.BS
13. Tedy Apriawan, dr., Sp.BS
14. Heri Subianto, dr., Sp.BS
15. Literature 1. Acierno MD, Trobe JD, Cornblath WT, Gebarski SS. Painful oculomotor palsy the caused by
posteriordraining dural carotid cavernous fistulas. Arch Ophthalmol 1995; 113: 1045.
2. Coskun O, Hamon M, Catroux G, et al. Carotid-cavernous fistulas: diagnosis with spiral
CT angiography. AJNR Am J Neuroradiol 2000; 21: 712.
3. JC Rucker, Biousse V, Newman NJ. Magnetic resonance angiography source images in
carotid cavernous fistulas. Br J Ophthalmol 2004; 88: 311.
4. de Keizer R. Carotid-cavernous and orbital arteriovenous fistulas: ocular features,
diagnostic and hemodynamic considerations in relation to visual impairment and morbidity. Orbit 2003;
22: 121.
5. Hirabuki N, Miura T, Mitomo M, et al. MR imaging of dural arteriovenous malformations
with ocular signs. Neuroradiology 1988; 30: 390.
6. Vattoth S, Cherian J, Pandey T. Magnetic resonance angiographic demonstration of
carotid cavernous fistula using elliptical centric time resolved imaging of contrast
kinetics (EC-TRICKS). Magn Reson Imaging 2007; 25: 1227.
7. YW Chen, Jeng JS, Liu HM, et al. Carotid and transcranial color-coded duplex
sonography in different types of carotid-cavernous fistula. Stroke 2000; 31: 701. 8. Kilic T, Elmaci I, Bayri Y, et al. Value of transcranial Doppler ultrasonography in the
diagnosis and follow-up of carotid-cavernous fistulae. Acta Neurochir (Wien) 2001; 143: 1257.
9. DeBrun GM. Angiographic workup of a carotid cavernous sinus fistula (CCF) or what
information does the interventionalist need for treatment? , Surg Neurol 1995; 44:75.
10. Meyers PM, Halbach VV, Dowd CF, et al. Dural carotid cavernous fistula: definitive
endovascular management and long-term follow-up. Am J Ophthalmol 2002; 134: 85.
11. TK Lin, Chang CN, Wai YY. Spontaneous intracerebral hematoma from occult carotid-
cavernous fistula during pregnancy and puerperal. Case report. J Neurosurg 1992; 76: 714.
12. Lewis AI, Tomsick TA, Tew JM Jr. Management of 100 consecutive direct carotid-cavernous
fistulas: results of treatment with detachable balloons. Neurosurgery 1995; 36: 239.
13. Gupta AK, Purkayastha S, Krishnamoorthy T, et al. Endovascular treatment of direct
carotid cavernous fistulae: a pictorial review. Neuroradiology 2006; 48: 831.
14. Wang W, Li YD, Li MH, et al. Endovascular treatment of post-traumatic direct carotid-
cavernous fistulas: A single-center experience. J Clin Neurosci 2011; 18:24.
15. Ringer AJ, Salud L, Tomsick TA. Carotid cavernous fistulas: anatomy, classification,
and treatment. Neurosurg Clin N Am 2005; 16: 279.
16. Gemmete JJ, Chaudhary N, Pandey A, Ansari S. Treatment of carotid cavernous
fistulas. Curr Treat Options Neurol 2010; 12:43.
17. Phelps CD, Thompson HS, Ossoinig KC. The diagnosis and prognosis of atypical
carotid cavernous fistula (red-eyed shunt syndrome). Am J Ophthalmol 1982; 93: 423.
18. Madan A, Mujic A, Daniels K, et al. Traumatic Carotid artery-cavernous sinus fistula
treated with a covered stent. Report of two cases. J Neurosurg 2006; 104: 969.
19. Gomez F, Escobar W, Gomez AM, et al. Treatment of carotid cavernous fistulas using covered
stents: midterm results in seven Patients. AJNR Am J Neuroradiol 2007; 28: 1762.
20. Morón FE, Klucznik RP, Mawad ME, Strother CM. Endovascular treatment of high-flow
carotid cavernous fistulas by stent-assisted coil placement. AJNR Am J Neuroradiol 2005; 26: 1399.
21. Kocer N, Kizilkilic O, Albayram S, et al. Treatment of iatrogenic internal carotid artery
laceration and carotid cavernous fistula with endovascular stent-graft placement. AJNR Am J
Neuroradiol 2002; 23: 442
22. Li J, ZG Lan, Xie XD, et al. Traumatic carotid-cavernous fistulas treated with covered
stents: experience of 12 cases. World Neurosurg 2010; 73: 514.
23. Marques MC, JG Caldas, Nalli DR, et al. Follow-up of endovascular treatment of direct
carotid cavernous fistulas. Neuroradiology 2010; 52: 1127.
24. Klisch J, Huppertz HJ, Spetzger U, et al. Transvenous treatment of carotid cavernous and dural arteriovenous fistulae: results for 31 Patients and review of the literature. Neurosurgery 2003; 53:
836.
25. O'Leary S, TJ Hodgson, Coley SC, et al. Intracranial dural arteriovenous
malformations: results of stereotactic radiosurgery in 17 Patients. Clin Oncol (R Coll
Radiol) 2002; 14:97.
26. Fiore PM, Latina MA, Shingleton BJ, et al. The dural shunt syndrome. I. Management
of glaucoma. Ophthalmology 1990; 97:56.
27. Tishler RB, Loeffler JS, Lunsford LD, et al. Tolerance of cranial nerves of the
cavernous sinus to radiosurgery. Int J Radiat Oncol Biol Phys 1993; 27: 215.
28. Higashida RT, Hieshima GB, Halbach VV, et al. Closure of carotid cavernous sinus fistulae
by external compression of the carotid artery and jugular vein. Acta Radiol Suppl 1986; 369: 580.
29. Halbach VV, Higashida RT, Hieshima GB, et al. Dural fistulas involving the cavernous
sinus: results of treatment in 30 Patients. Radiology 1987; 163: 437.
30. Kai Y, Hamada J, Morioka M, et al. Treatment of cavernous sinus dural arteriovenous
fistulae by external manual compression of the carotid. Neurosurgery 2007; 60: 253. 31. Luo CB, Teng MM, Yen DH, et al. Endovascular embolization of recurrent traumatic
carotid cavernous fistulas with detachable balloons previously managed. J Trauma 2004; 56: 1214.
32. Halbach VV, Hieshima GB, Higashida RT, Reicher M. Carotid cavernous fistulae:
indications for urgent treatment. AJR Am J Roentgenol 1987; 149: 587.
33. Chen CC, Chang PC, Shy CG, et al. CT angiography and MR angiography in the evaluation
of carotid cavernous sinus fistula prior to embolization: a comparison of techniques. AJNR Am J Neuroradiol
2005; 26: 2349.
DISEASE-MOYA MOYA
ICD-10: I 67.5
1. Definition
Rare vascular disorders, characterized by the progressive narrowing of the blood vessels in the arterial circle at
the
(Definition)
base of the brain ( circle of Willis). Characterized by bilateral stenosis or occlusion of the arteries in the circle of
Willis
so that more prominent collateral circulation.
2. History The symptoms and clinical course varies:
- No symptoms until that result in severe neurologic deficits are temporary.
- Adults are more in line with bleeding;
- cerebral ischemic events are more common in children.
- Children can have hemiparesis, monoparesis, sensory disturbance, involuntary movements,
headache, dizziness, or seizures. Mental retardation or persistent neurological deficit.
- Intraventricular, subarachnoid or intracerebral hemorrhage sudden onset is more common in
adults.
3. Physical Examination General Physical Examination
(Examination by inspection, palpation, percussion and auscultation)
• Physical examination was first priority in the evaluation of A ( airways), B
(Breathing), and C ( circulation)
Neurological examination
• The level of awareness Glasgow Coma Scale ( GCS)
• Physical examination findings depend on the location and severity of hemorrhage or ischemic.
4. Investigations - CT Scan
- angiography:
- Cerebral angiography is the standard criteria for the diagnosis of Moyamoya disease. The following findings
can support the diagnosis:
- Stenosis or occlusion in the terminal part of the internal carotid artery or the proximal portion or
anterior cerebral artery.
- Abnormal blood vessel tissue around the area occlusive or stenosis.
- Findings were found bilaterally (Although some patients may be at
and then progressive unilateral involvement). Magnetic resonance angiography (MRA) can be
performed.
SPECT (Single photon emission computerized tomography)
Recommendation Grad e
Reko
No. Examination mend Ref
ation
Overview on cortical and subcortical infarcts, found
1 CT scan in early stage MMD Suzuki 1 or 2 2B 4
2 MRI
In contrast T1 or T1 flair obtained picture ' ivy
2A 5
sign '
angiography MRA can memeberikan stenosis picture 1C 6
3 or occlusion of the distal ICA, CTA showed abnormal
collateral vessel or vessels in the basal ganglia
5. Criteria for Diagnosis 1. The history and clinical examination (as per above)
2. CT Scan Head
3. TFCA (angiography)
6. Diagnosis Moya moya disease I67.5
7. Diagnosis The history:
Anterior Circulation Stroke Blood
Basilar Artery Thrombosis
Cavernous Sinus Dyscrasias and
Stroke Syndromes Syndromes
Cerebral Aneurysms Dissection
fibromuscular dysplasia Fabry
Disease Intracranial Hemorrhage
8. Therapy -
Procedures (ICD 9 CM) Grad e
Reko
No. Therapy mend Ref
ation
Moyamoya patients are given aspirin to
children or adults who nonsimptomatik or
symptomatic ischemic Moyamoya
2C
1 Medikamentosa 7
Not recommended the use of 1C
anticoagulants old
revascularization
• The superficial temporal artery-middle cerebral
artery (STA-MCA) anastomosis
• EMS (encephalomyosynangiosis)
2 Operations
• Encephaloduroarteriosynangiosis (EDAS) 1C 8
• Encephaloduroarteriomyosynangiosis (Edams)
(ICD-9: 437.5)
• wattle synangiosis
• Omental transplantation
9. Education Explanations to patients and families:
• Course of the disease and complications that may occur
• Therapy and actions that will be given along with the advantages and disadvantages
• The procedure for the treatment and the treating physician
• Require adjuvant treatment for recovery of impaired neurological function, through medical
rehabilitation program
10. Prognosis Prognosis is affected:
- Clinical improvement can be seen after the surgical procedure immediately with the
possibility of 6-12 months will form new blood vessels as supply.
11. Medical Indicators Improvement of neurological status and the underlying disease causes moya-moya
12. reviewers were critical 1. Prof. Dr. Abdul Hafid Bajamal, dr., Sp.BS
2. Dr. Agus Turchan, dr., Sp.BS
3. Dr. M. Arifin Parenrengi, dr., Sp.BS
4. Dr. Joni Wahyuhadi, dr., Sp.BS
5. Dr. Eko Agus Subagyo, dr., Sp.BS
6. Dr. Asra Al Fauzi, dr., Sp.BS
7. Wihasto Suyaningtyas, dr., Sp.BS
8. Muhammad Faris, dr., Sp.BS
9. Rahadian Indarto, dr., Sp.BS
10. Fahmi Achmad, dr., Sp.BS
11. Nur Setiawan Suroto, dr., Sp.BS
12. Irwan Barlian Immadoel Haq, dr, Sp.BS
13. Tedy Apriawan, dr., Sp.BS
14. Heri Subianto, dr., Sp.BS
2. Library 1.Widow PH, JG Bellew, Veerappan V. Moyamoya disease: case report and literature review. J Am Assoc
osteopath. Oct 2009; 109 (10): 547-53.
2. Mineharu Y, Takenaka K, Yamakawa H, et al. Inheritance pattern of familial Moyamoya disease:
autosomal dominant fashion and genomic imprinting. J Neurol Neurosurg Psychiatry. Sep 2006; 77
(9): 1025-9.
3. Mineharu Y, Liu W, Inoue K, Matsuura N, Inoue S, Takenaka K. Autosomal dominant Moyamoya
disease maps to chromosome 17q25.3. Neurology. Jun 10, 2008; 70 (24 Pt 2): 2357-63.
4. Kim SJ, Heo KG, Shin HY, Bang OY, GM Kim, Chung CS. Association of thyroid autoantibodies with
Moyamoya-type of cerebrovascular disease: a prospective study. Stroke. Jan 2010; 41 (1): 173-6.
5. Kikuta K, Takagi Y, Nozaki K, Hanakawa T, Okada T, Mikuni N, Miki Y, Fushmi Y, Yamamoto A,
Yamada
K, Fukuyama H, Hashimoto N symptomatic microbleeds in Moyamoya disease: T2 * -weighted
gradient-echo magnetic resonance imaging study. J Neurosurg. 2005; 102 (3): 470
6. Roach ES, Golomb MR, Adams R, Biller J, Daniels S, Deveber G, Ferriero D, Jones BV, Kirkham FJ,
Scott
RM, Smith ER, the American Heart Association Stroke Council, Council on Cardiovascular Disease in
the
Young. Management of stroke in infants and children: a scientific statement from a Special Writing
Group
of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the
Young.Stroke. 2008; 39 (9): 2644.
7. Monagle P, Chan AK, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, Vesely SK,
American College of Chest PhysiciansAntithrombotic therapy in neonates and children:
antithrombotic
Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines.Chest. 2012 February; 141 (2 Suppl): 801S-e737S
8. Fung LW, Thompson D, V. Ganesan Revascularisation Pediatric Surgery for Moyamoya: a review of
the literature. Childs Nerv Syst. 2005; 21 (5): 358
Normal Pressure Hydrocephalus (NPH)
G91.2
3. Definition Condition in which a pathologically enlarged brain ventricles with initial pressure (Opening pressure) in
(Definition) the normal lumbar puncture.
4. History • Classically obtained triad: Dementia
Urinary incontinence
Trouble walking (gait disturbance)
The symptoms appear partially and slowly (gradual) 5. Physical Examination General Physical Examination
(Examination by inspection, palpation, percussion and auscultation) a thorough examination to rule out other
causes of epilepsy. At the time of the seizure, the patient should be checked and managed in accordance with
the principle emergency are: secure Airway, Breathing, Circulation
Neurological examination
• The level of awareness Glasgow Coma Scale ( GCS) • Examination of one to twelve cranial nerves • Motor examination thorough
• The sensory examination thorough
• Physiological reflex examination
• Examination of pathological reflexes
• Examination of cognitive function (MMSE)
6. Criteria for Diagnosis 1. History according above
2. Clinical examination in accordance Issuer
3. Investigations
7. Work Diagnosis Normal Pressure Hydrocephalus (G91.2)
8. Diagnosis - disease prakinson
- vascular Dementia
- Alzheimer's
- Frontal Lobe Syndrome
- Urinary system disorders
- Tu mor / lesions serebel um
9. Investigations grade
No Inspection Recommendation rekomend Ref
care
- Obtained enlargement in all the
ventricular system WITHOUT any signs
of obstruction or infection
1 CT Scan Head - The presence of periventricular edema 1A 1,2,3,4,5
(Ejection)
- Evan's ratio> 0.3
- Obtained enlargement all the ventricular
2 MRI Head
system
1B 1,2,3,4,5
- An increase in signal in the periventricular
(on FLAIR sequences)
- Evan's ratio> 0.3
- By using isotope
3 Cysternografi
with lumbar puncture. NPH
2B 1,2,3,4,5
enforced when isotopes are lost
from
cysterna in 72 hours
- In Lumbar puncture / lumbar tap test,
issued LCS kemudain much as 3050 cc
Lumbar
of clinical evaluation. Clinical
improvement will provide good results
puncture /
4
when done shunting
1A 1,2,3,4,5
lumbar tap test
- Lumbar tap test can be done up to three
times to see the real clinical improvement
- External LD also issued LCS will however
be maintained within 3-6 days (LCS can
External be issued up to 40
5 Lumbar cc), 1A 1,2,3,4,5
Drainage - Clinical improvement will provide good
results when done shunting
10. Therapy grade
No. Therapy Recommendation rekomend Ref
care
- Programmable VP shunt
provide better results Instead of the VP
shunt with fixed pressure because of
1 Programmable the ability to 1A 1,2,3,4,5
VP shunt modify
and
adjust the ventricular pressure
- VP shunt is used to steamy medium
and low pressure but
2 VP Shunt fixed the risk of 2A 1,2,3,4,5
pressure overshunting very high complication
11. Education Explanations to patients and families:
• Course of the disease and complications that may occur
• Therapy and actions that will be given along with the advantages and disadvantages
• The procedure for the treatment and the treating physician
12. Prognosis Ad Vitam (Live) : Ad bonam
Ad Sanationam (cured) : Ad Dubia bonam
Ad Fungsionam (function) : Ad Dubia bonam
Prognosis NPH operation will increase if there is clinical improvement in pre-operative CSF diversion (with
lumbar tap test or ELD)
13. reviewers were critical
1. Prof. Dr. Abdul Hafid Bajamal, dr.,
Sp.BS
2. Dr. Agus Turchan, dr.,
Sp.BS
3. Dr. M. Arifin Parenrengi, dr., Sp.BS
4. Dr. Joni Wahyuhadi, dr.,
Sp.BS
5. Dr. Eko Agus Subagyo, dr., Sp.BS
6. Dr. Asra Al Fauzi, dr.,
Sp.BS
7. Wihasto Suyaningtyas, dr., Sp.BS
8. Muhammad Faris, dr., Sp.BS
9. Rahadian Indarto, dr., Sp.BS
10. Fahmi Achmad, dr., Sp.BS
11. Nur Setiawan Suroto, dr., Sp.BS
12. Irwan Barlian Immadoel Haq, dr, Sp.BS
13. Tedy Apriawan, dr., Sp.BS
14. Heri Subianto, dr., Sp.BS
14. Medical Indicators NPH management indicators based on the state of repair of clinical triad of NPH
15. Bibliography 1. Krauss JK, Halve B. Normal pressure hydrocephalus: survey algorithms on contemporary diagnostic
and therapeutic decision-making in clinical practice. Acta Neurochir (Wien) 2004; 146: 379.
2. Tisell M, Hoglund M, Wikkelsø C. National and regional incidence of surgery for adult hydrocephalus in
Sweden. Acta Neurol Scand 2005; 112: 72.
3. Klassen BT, Ahlskog JE. Normal pressure hydrocephalus: how does the diagnosis Often hold water?
Neurology
2011; 77: 1119.
4. JA Vanneste. Diagnosis and management of normal-pressure hydrocephalus. 4. J Neurol 2000; 247: 5.
5. Petersen RC, Mokri B, Laws ER Jr Surgical treatment of idiopathic hydrocephalus in elderly
patients.Neurology 1985; 35: 307.
6. Black PM, Ojemann RG, Tzouras A. CSF shunts for dementia, incontinence, and gait disturbance. Clin
Neurosurg 1985; 32: 632.
Intracerebral hematoma SPONTANEOUS
ICD-10: I61.0
1. Definition Collection of blood in the brain parenchyma. It can be a little bleeding bleeding-fused, or blood
(Definition) vessel injury is quite large.
2. History • Obtained headache • Obtained neurological disorders (amnesia, loss of consciousness, seizures, etc.) • Obtained risk factors: hypertension, diabetes mellitus
3. Physical Examination General Physical Examination
(Examination by inspection, palpation, percussion and auscultation)
• Physical examination was first priority in the evaluation of A (
airways), B (Breathing), and C ( circulation) other tests
• High blood pressure. Cardiac Disorders. Kidney disorders
Neurological examination
• The level of awareness Glasgow Coma Scale ( GCS)
• Nerves II-III, VII peripheral nerve lesions • Fundoskopi look for signs of edema pupil, retinal detachment • Motor and sensory, compare the right and left, up and down
• Autonomis
4. Criteria for Diagnosis 1. History according above
2. Clinical examination in accordance Issuer
3. The appropriate imaging examination under
5. Work Diagnosis Intracerebral hematoma (ICD 10: I61.0)
6. Diagnosis - trauma
- epileptic fits
- drug intoxication
- P metabolic enyakit
7. Investigations Recommendation Grad
e
No. Examination Reko Ref
mend
care
CT without contrast is widely used
to evaluate the acute ICH, CT scans were able to
1 CT scan
evaluate the location and big hematoma as well 1C 1,2,3
evaluate the extension of the ventricle,
herniation, peripheral edema ,.
2 CTA CTA and MRA can be used to 2A 4.5
screening vascular abnormalities such as
aneurysm, AVM
3 MRI
GRE-T2 sequences to assess bleeding
2A 6
hyperacute, subacute, chronic
4 DSA Screening for vascular disorders such as
1C 9
AVM. aneurysm
X-thoracic images:
• Looking for heart abnormalities CT Scan Head:
• Overview hiperedens shaped biconvex
• May be accompanied by bleeding in the ventricles picture X-photo others by k eperluan
8. Therapy Recommendation Grad
e
No. Therapy Reko Ref
mend
care
When SBP> 200 mmHg or MAP> 150 mmHg
it is recommended to fast reduction of pressure
blood using continuous intravenous OAH
and monitoring every 5 minutes
When SBP> 180 mmHg or MAP> 130 mmHg
accompanied by signs of increased ICP then
Blood
OAH administration is intermittent or
1 CPP targets continuously at 61-80 mmHg 1A 7.8
pressure
regulation
When SBP> 180 mmHg or MAP> 130 mmHg
without signs of ICT penongkatan
then the target BP is 160/90 use
OAH intravenous intermittent or
continuous observation every 15 minutes
EVD (ICD-9: 2:21)
2 Operative Indications for patients with intraventricular
1B 8
haemmorhage with neurological deficits.
Bilateral EVD can only be performed if bleeding
clogs
monroe foramen. EVD for hydrocephalus due to SAH in patients with loss of consciousness and
proved there was an increase in ICT. Patients with hydrocephalus which do not improve within 24 hours.
Posterior fossa ICH (ICD 9-01.24) diameter> 3 cm with deteriosisasi neurological or brain stem compression and / or hydrocephalus due
to obstruction of the ventricular recommended for evacuation of bleeding (Grade 1B)
Supratentorial ICH (ICD 9-01.24) The volume of> 30cc with a distance of 1 cm from the surface. The next evacuation within 96 hours after the first surgery is not recommended. Surgical intervention is not recommended in patients with full
consciousness or coma in a patient in intermediete level / stupor are candidates operation. Another thing that supports surgery
• new Genesis
• Deteriorisasi progressive neurlogis
• Location of perdaran close to the
surface of the cortex
• The location in the non-dominant hemisphere.
Hematoma small and does not give effect
period ( midlineshift <
0.5 cm), also does not provide clinical symptoms.
Injury diffusely scattered
- Treatment in the room
- Observation GCS, pupil, lateralization, and
physiology vital.
- Optimization of stabilization vital physiology,
maintain solid supply of O 2 to the brain.
- Circulation: impartial liquid NaCl-glucose
3 Non-operative infusion, prevented the occurrence of
overhydration, when it stabilized gradually
replace fluids / EN / pipe stomach.
- Haemorrhagic stroke patients with lesions
that do not require the evacuation and
patients with impaired blood gas analysis
was treated in a respirator.
- Maintain cerebral perfusion, head of
the head-up position about 30 •• to
avoid neck flexion.
- Bladder catheter is required to record the
production of urine, prevent urinary
retention, preventing the bed was wet (thus
reducing the risk of pressure sores).
- Hypertonic fluids (mannitol 20%), when
looked edema or injury that is not operable
on CT Scan. Mannitol can be administered
as a bolus of 0.5 to 1 g / kg. BB in certain
circumstances, or repeated small doses, for
example, (4-6) x 100 cc of mannitol 20% in
24 hours. Gradual discontinuation.
- Analgesic, anti-inflammatory, antipiretika:
mefenamic acid, paracetamol 500 mg 3-4
times daily or Na diklofenac 2-3 times daily
or 50 mg in adults.
- Antisida and or antagonists H 2
- Antiepileptikum
9. Education Explanations to patients and families:
• Course of the disease and complications that may occur
• Therapy and actions that will be given along with the advantages and disadvantages
• The procedure for the treatment and the treating physician
• Require adjuvant treatment for recovery of impaired neurological function, through medical
rehabilitation program
10. Prognosis Prognosis is affected:
- Age (<50 years)
- initial GCS
- The distance between the incident and surgery
- cerebral edema
- location hematoma
- factors extracranial
11. reviewers were critical
1. Prof. Dr. Abdul Hafid Bajamal, dr.,
Sp.BS
2. Dr. Agus Turchan, dr., Sp.BS
3. Dr. M. Arifin Parenrengi, dr., Sp.BS
4. Dr. Joni Wahyuhadi, dr., Sp.BS
5. Dr. Eko Agus Subagyo, dr., Sp.BS
6. Dr. Asra Al Fauzi, dr., Sp.BS
7. Wihasto Suyaningtyas, dr., Sp.BS
8. Muhammad Faris, dr., Sp.BS
9. Rahadian Indarto, dr., Sp.BS
10. Fahmi Achmad, dr., Sp.BS
11. Nur Setiawan Suroto, dr., Sp.BS
12. Irwan Barlian Immadoel Haq, dr,
Sp.BS
13. Tedy Apriawan, dr., Sp.BS
14. Heri Subianto, dr., Sp.BS
12. Medical Indicators Improvement of neurological
status.
13. Bibliography 1. Rordorf, G, McDonald, C. 2013.Spontaneous Intracerebral Hemorrhage: Pathogenesis, Clinical Features, and
Diagnosis. Wolters Kluwe.
2. Rordorf, G, McDonald, C. 2014.Spontaneous Intracerebral Hemorrhage: Treatment and Prognosis.
Wolters Kluwe
3. Ohwaki K, Yano E, Nagashima H, Hirata M, Nakagomi T, Tamura A. Blood pressure
management in acute intracerebral hemorrhage: relationship between elevated blood pressure
and hematoma enlargement. Stroke. 2004; 35 (6): 1364.
4. Alberico RA, Patel M, Casey S, Jacobs B, Maguire W, Decker. Evaluation of the circle of Willis with
three-dimensional CT angiography in Patients with suspected intracranial aneurysms. AJNR Am J Neuroradiol.
1995; 16 (8): 1571.
5. GK Wong, Siu DY, Abrigo JM, Poon WS, Tsang FC, XL Zhu, Yu SC, Ahuja AT. Computed
tomographic angiography and Venography for young or nonhypertensive Patients with acute
spontaneous intracerebral hemorrhage. Stroke. 2011; 42 (1): 211.
6. Fiebach JB, Schellinger PD, Gass A, Kucinski T, Siebler M, Villringer A, Olkers P, Hirsch JG, Heiland
S, Wilde P, Jansen O, Rother J, Hacke W, Sartor K, Kompetenznetzwerk Schlaganfall B5Stroke
magnetic resonance imaging is accurate in hyperacute intracerebral hemorrhage: a multicenter study on
the validity of stroke imaging. Stroke. 2004; 35 (2): 502
7. Morgenstern LB, JC 3rd Hemphill, Anderson C, Becker K, Broderick JP, Connolly ES Jr, Greenberg SM,
Huang JN, MacDonald RL, MesséSR, Mitchell PH, Selim M, Tamargo RJ, the American Heart
Association Stroke Council and the Council on cardiovascular Nursing. Stroke. 2010; 41 (9): 2108
8. Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M, L Morgenstern,
Ogilvy CS, Vespa P, Zuccarello M, American Heart Association, American Stroke Association Stroke
Council, High Blood Pressure Research Council Quality of Care and Outcomes in Research
Interdisciplinary Working Group. Guidelines for the management of spontaneous intracerebral
hemorrhage in adults: 2007 update: a guideline from the American Heart Association / American
Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care
and Outcomes in Research Interdisciplinary Working Group.Stroke. 2007; 38 (6): 2001
9. Cloft HJ, Joseph GJ, Dion JE. Risk of cerebral angiography in Patients with subarachnoid hemorrhage, cerebral aneurysm, and arteriovenous malformation: a meta-analysis. Stroke
1999; 30: 317.
STROKE infarction ICD-10: I63.0
1. Definition
Focal neurological deficits caused by a blockage in the blood vessels of the brain.
(Definition)
2. History Focal neurological deficit
Asymmetrical face, loss of speech, paralyzed half of the body. Old
occurrence Fainting Headache Seizures Decreased consciousness
Alloanamnesis when an unconscious patient
medication history
History DM pain, heart disease, epilepsy, certain drugs
3. PemeriksaanFisikk PemeriksaanFisikUmum
• Pemeriksaanfisikpertama times diutamakanpadaevaluasi
• A ( airways) prevent the tongue falling menghalangai airway. stridor ?,
• B ( breathing), evaluation of normal breath sounds. There ronkhi, whezing, signs of effusion
• C ( circulation) blood pressure, pulse rate content, regularity, perfusion to peripheral tissues. Evaluation
of additional sound heart.
• The skin should be evaluated to determine if there are signs that lead to endocarditis, cholesterol
embolism, ecchymosis purpura, or signs of action for invasive procedures
PemeriksaanNeurologis
• The level of awareness Glasgow Coma Scale ( GCS)
• Nerves II-III,
• Especially cranial nerves VII nerve lesions of peripheral / central
• Fundoskopi look for signs of edema pupil, retinal detachment
• Motor and sensory, bandingkankanandankiri, lower atasdan whether there Hempiparesis
• Autonomis
4. Criteria for Diagnosis Focal neurologic deficits
The discovery of the ischemic area / infarction on CT scan and / or MRI
5. Work Diagnosis Stroke infarction (I63.0)
6. Diagnosis hypoglycemia
Hyperglycemia
7. Investigations • Are required to do a CT scan and / or MRI in all patients with either acute ischemic
stroke or hemoragic
• CTA / MRA
• DSA
Recommendation Grad e
No. Examination
Reko
Ref
mend
care
In hyperakut phase CT scan can be used to exclude a
bleeding stroke. The sensitivity of the non-contrast CT in
1 CT scan- CTA- CT stroke infarction increased after 24 hours of onset of the 2A 6
perfusion attack.
MRI sequences T1 and T2 DWI, PWI, GRE can
2 MRI diagnose acute ischemic stroke. DWI superior in
1B 7
diagnosing acute ischemic stroke within 12 hours of
onset
MRA for detecting vascular stenosis or
2B 8
3 MR Angiography occlusion.
• Also conducted inspection • Complete blood • GDA • BGA • SE • BUN / SK • ECG
• cardiac enzymes • FH and INR • LFT
• toxicology screening • Unexpected pregnancy test in women hami • Thorax photo • EEG
8. Therapy 1. If the patient has no risk to occur peningktan ICT, aspiration, or a suspicious
condition suggested Kardipulmonary flat head 0-15 degrees
2. In patients with suspected signs of increased ICP, decreased kesadran,
aspirations, decompensation cordis, or desatuari it is advisable head up 30
degrees.
Procedures (ICD 9 CM) Grad e
Reko
No. Therapy mend Ref
ation
1. Suggested alteplase intravenously at onset
less than 3 hours (Grade 1B), Anti-thrombotic
(eg aspirin) may be administered within 48
hours of onset of the case (Grade 1A)
2. The second attack prevention of stroke in
1 rtPA patients with a history of stroke or TIA
1A 9
noncardioembolic, lacunar infarction
recommended use
antiplatelet drug clopidogrel (Grade 1)
3. The use of aspirin in patients with GIT
bleeding recommended 50100 mg / day
for prevention
second stroke (Grade 1B)
4. Not recommended use
the combination of aspirin and clopidogrel in patients
with stroke or TIA noncardioembolik (Grade 1A)
The provision of anti-hypertensive medication given at
systole> 220 or diastolic> 120 atauterdapat indication is
unclear (CHD, heart failure, aortic dissection, hypertensive
2 OAH encephalopathy, GGA, or pre-eclampsia / eclampsia). 1C 10
Target blood pressure reduction is 15% of the initial tension
3 Endovasculer
Mechanical thrombectomy procedure with 1A 11
stent retriever (solitaire, etc.)
3. Antipyretic also recommended be administered to patients fever usually occurs in the
acute phase of ischemic stroke
4.
Prevention of the occurrence of complications therapy
- IMA
- Heart failure
- disfagi
- aspiration Pneumonia
- UTI
- DVT
- malnutrition
- Dehidarsi
- decubitus ulcers
- contractures
Initiation of antithrombotic drugs regularly take
9. Education nonsteroidal anti lipid
Once the acute phase has passed can begin management decrease blood terkanan Lifestyle
changes Exercise, not smoking, healthy diet
10. Prognosis Konsis patients who are good with adequate treatment at the onset of less than 4 hours gave a
good prognosis.
11. reviewers were critical 1. Prof. Dr. Abdul Hafid Bajamal, dr., Sp.BS
2. Dr. Agus Turchan, dr.,
Sp.BS
3. Dr. M. Arifin Parenrengi, dr., Sp.BS
4. Dr. Joni Wahyuhadi, dr., Sp.BS
5. Dr. Eko Agus Subagyo, dr., Sp.BS
6. Dr. Asra Al Fauzi, dr.,
Sp.BS
7. Wihasto Suyaningtyas, dr., Sp.BS
8. Muhammad Faris, dr.,
Sp.BS
9. Rahadian Indarto, dr., Sp.BS
10. Fahmi Achmad, dr., Sp.BS
11. Nur Setiawan Suroto, dr., Sp.BS
12. Irwan Barlian Immadoel Haq, dr, Sp.BS
13. Tedy Apriawan, dr., Sp.BS
14. Heri Subianto, dr., Sp.BS
12. Medical Indicators Repair common neurological status / focal
13. Bibliography 1. Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of Patients with acute
ischemic stroke: a guideline for healthcare professionals from the American Heart Association / American
Stroke Association. Stroke 2013; 44: 870.
2. Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with
ischemic stroke: a guideline from the American Heart Association / American Stroke Association
Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and
the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research
Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this
guideline as an educational tool for neurologists. Stroke 2007; 38: 1655.
3. The National Institute for Health and Clinical Excellence. Stroke: The diagnosis and acute
management of stroke and transient ischemic attacks. Royal College of Physicians, London, 2008.
http://www.nice.org.uk/CG068 (Accessed on February 01, 2011).
4. Burns JD, Green DM, Metivier K, DeFusco C. Intensive care management of acute ischemic stroke.
Emerg Med Clin North Am 2012; 30: 713
5. Lansberg MG, MJ O'Donnell, Khatri P, Lang ES, Nguyen-Huynh MN, NE Schwartz, Sonnenberg FA,
Schulman S, Vandvik PO, Spencer FA, Alonso-Coello P, Guyatt GH, Akl EA, the American College of
Chest Physicians. Antithrombotic and thrombolytic therapy for ischemic stroke: antithrombotic Therapy
and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical
Practice Guidelines. Chest. 2012; 141 (2 Suppl): e601S.
6. Wardlaw JM, Seymour J, J Cairns, Keir S, Lewis S, Sandercock P. Immediate computed
tomography scanning of acute stroke is cost-effective and improves quality of life. Stroke 2004;
35 (11): 2477.
7. Schellinger PD, Bryan RN, Caplan LR, Detre JA, Edelman RR, Jaigobin C, Kidwell CS, Mohr JP,
Sloan M, Sorensen AG, Warach S, Therapeutics and Technology Assessment Subcommittee of the
American Academy of Neurology Evidence-based guidelines : The role of diffusion and perfusion
MRI for the diagnosis of acute ischemic stroke: report of the Therapeutics and Technology
Assessment Subcommittee of the American Academy of Neurology.
8. Latchaw RE, Alberts MJ, Lev MH, JJ Connors, Harbaugh RE, Higashida RT, R Hobson, Kidwell CS,
Koroshetz WJ, Mathews V, Villablanca P, Warach S, Walters B, the American Heart Association
Council on Cardiovascular Radiology and Intervention stroke Council, and the Interdisciplinary
Council on Peripheral Vascular Disease Recommendations for imaging of acute ischemic stroke: a
scientific statement from the American Heart Association. Stroke. 2009; 40 (11): 364
9. Lansberg MG, MJ O'Donnell, Khatri P, Lang ES, Nguyen-Huynh MN, NE Schwartz, Sonnenberg FA,
Schulman S, Vandvik PO, Spencer FA, Alonso-Coello P, Guyatt GH, Ak. Antithrombotic and
thrombolytic therapy for ischemic stroke: antithrombotic Therapy and Prevention of Thrombosis,
9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Chest.
2012; 141 (2 Suppl): e601S
10. Jauch EC, Saver JL, Adams HP Jr, Bruno A, JJ Connors, Demaerschalk BM, Khatri P,
PW McMullan Jr., Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M,
Yonas H, the American Heart Association Stroke Council, Council on Cardiovascular Nursing,
Council on Peripheral Vascular Disease, Council on Clinical Cardiology. Guidelines for the early
management of Patients with acute ischemic stroke: a guideline for healthcare professionals from the
American Heart Association / American Stroke Association.Stroke. 2013; 44 (3): 870.
11. Saver JL et al. Stent-Retriever thrombectomy after intravenous t-PA vs. t-PA
Alone in Stroke. N Engl J Med 2015; 372: 2285-2295
Dural arteriovenous fistula
ICD-10: I67.1
1. Definition Dural arteriovenous fistula (DAVf) is a pathological condition which found their fistulae (relations) between the
(Definition) branches of the dural arteries with veins or the dural venous sinuses
2. History - Patients with DAVf may have no symptoms at all
- Symptoms in patients DAVf fistula usually occurs depending on the location can be: vision disturbances,
ophtlamoplegi, diplopia, atupun bleeding.
- Patients may experience symptoms of hearing voices bruit, tinnitus, diplopia, proptosis up with severe
symptoms are neurological deficits
3. Physical Examination General Physical Examination
(Examination by inspection, palpation, percussion and auscultation)
• Physical examination was first priority in the evaluation of A ( airways), B
(Breathing), and C (
circulation)
• Auscultation of the orbit, lateral orbital, supra-orbital, mastoid, and other areas in accordance
sinus venosus
Neurological examination
• The level of awareness Glasgow Coma Scale ( GCS)
• meningeal sign
• Motor and sensory, compare the right and left, up and down
• Autonomis
4. Criteria for Diagnosis 1. The history and clinical examination (as per above)
2. Investigations (according to the above)
5. Work Diagnosis Dural arteriovenous fistula I67.1
6. Diagnosis - dural AVM
- Intracranial tumors
7. Investigations No. Examination Information Grade of References
Recommendat
ion
1. CT Scan Head Nonkontras head CT scan 1A 1,2,3,4
should be performed before an
invasive examination to rule
out the presence of bleeding
2. CTA CT angiography is 1A 1,2,3,4
necessary to know the
anatomy of intracranial
pembuluhdarah
3. MRI DAVf MRI showed cortical 1B 1,2,3,4
venous dilation in the
absence
parenchymal nidus,
in addition to the MRI
also showed
thickening of the dura layer,
parenkimal arterial hypertrophy,
dilation of the vein, turtous veins,
venous thrombosis
4 Angiography (Trans-Femoral Angiography is the gold 1A 1,2,3,4
Cerebral angiography) standard for DVAf.
Angiography is for
identification purpose
arterial feeders, locations
fistula, and the pattern and
direction of venous drainage
8. Therapy No. Therapy Information Grade of References
Recommendat
ion
1. endovascular Therapy endovaskuler on 1A 1,2,3,4
DAVf is the first line, it can
be through some
kind
method well
transarterial, transvenous or
combination
use:
- embolization particles
-
Injection glue ( n-
buthylcyanoacrylate or
Ethylenvenyl
Alcohol / EVOH) through a
vein or artery s
- coiling through venou
s
to close the fistula ( packing
transvenous)
- Carotid artery stenting
2. Operation Operations carried out in 1A 1,2,3,4
(surgery) some cases, such as the
fossa skull anterior DAVf
3. Radiation therapy Radiation therapy is done by 2B 1,2,3,4
sterotaktik, and usually most
effective when combined
with endovascular or surgery
is not optimal.
9. Education Explanations to patients and families:
• Course of the disease and complications that may occur
• Therapy and actions that will be given along with the advantages and disadvantages
• The procedure for the treatment and the treating physician
• Require adjuvant treatment for recovery of impaired neurological function, through medical
rehabilitation program
10. Prognosis Prognosis is influenced by the degree of symptoms and the degree of neurological
dysfunction
11. Medical Indicators Repair and improvement of clinical status radiology
12. reviewers were critical 1. Prof. Dr. Abdul Hafid Bajamal, dr., Sp.BS
2. Dr. Agus Turchan, dr., Sp.BS
3. Dr. M. Arifin Parenrengi, dr., Sp.BS
4. Dr. Joni Wahyuhadi, dr., Sp.BS
5. Dr. Eko Agus Subagyo, dr., Sp.BS
6. Dr. Asra Al Fauzi, dr., Sp.BS
7. Wihasto Suyaningtyas, dr., Sp.BS
8. Muhammad Faris, dr., Sp.BS
9. Rahadian Indarto, dr., Sp.BS
10. Fahmi Achmad, dr., Sp.BS
11. Nur Setiawan Suroto, dr., Sp.BS
12. Irwan Barlian Immadoel Haq, dr, Sp.BS
13. Tedy Apriawan, dr., Sp.BS
14. Heri Subianto, dr., Sp.BS
15. Bibliography 1. Van Dijk JM, terBrugge KG, Willinsky RA, Wallace MC. Clinical Course of Cranial
Dural arteriovenous fistulas With Long-Term persitent Cortical Venous Reflux.
Stroke 2002; 33: 1233-1236
2. Borden JA, Wu JK, Shucart WA. A proposed classification for spinal and cranial
dural arteriovenous fistulous malformations and implications for treatment.
1995. J Neurosurg; 82 (2): 166-79.
3. Lawton MT, Chun J, Wilson CB, Halbach VV. Ethmoidal dural arteriovenous
fistulae: An assessment of surgical and endovascular management.
Neurosurgery. 1999; 45: 805-11. 4. awaguchi S, Sakaki T, Morimoto T, Hoshida T, Nakase H. Surgery for dural
arteriovenous fistula in the superior sagittal sinus and transverse sinus. J Clin Neurosci. 2000; 7: 47-9
5. Ito J, Imamura H, Kobayashi K, Tsuchida T, Sato S. Dural arteriovenous malformations of the base
of the anterior cranial fossa. Neuroradiology. 1983; 24: 149-54.