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PATOPHYSIOLOGY &PATOPHYSIOLOGY &
MANAGEMENT OF STROKEMANAGEMENT OF STROKE
Abdul GofrAbdul Gofr
Neurology Department oNeurology Department o
Medical FacultyMedical Faculty
Gadjah Mada UniversityGadjah Mada University
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Stroke: DefnitionStroke: Defnition
Stroke is clinically defned as aStroke is clinically defned as aneurologic syndrome characterizedneurologic syndrome characterizedby acute disruption o blood ow toby acute disruption o blood ow to
an area o the brain andan area o the brain andcorresponding onset o neurologiccorresponding onset o neurologicdefcits related to the concerneddefcits related to the concernedarea o the brainarea o the brain
Nurs Clin N Am 2002;37:35-57
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Causes o StrokeCauses o Stroke
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1
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Defnition o Ischemic StrokeDefnition o Ischemic Stroke
Almost 80% oAlmost 80% ostrokes are romstrokes are roman emboli or aan emboli or athrombusthrombus
Embolic &Embolic &ThromboticThromboticstrokes arestrokes areISCHEICISCHEIC
! "#% o strokes! "#% o strokes
are romare romhemorrha$e ithhemorrha$e ithan e'en smalleran e'en smaller(ercenta$e(ercenta$ecause) b*cause) b*
h*(o(erusionh*(o(erusion
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Dr.J.Husada 11-2003
Apoptotic
Cell Death
Necrotic
Cell Death
Ischemic
Injury
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Aterosclerotic is a normal response to arterialendotel injuryAterosclerotic plaque forming, start in youngClinical manifestation : acute and tent to occur one
time because sudden plaque rupture
1. Vascular : Aterosclerotic process
2. Biochemistry change /cellular
chemist
2 process in ischemic stroke:2 process in ischemic stroke:
C I h i
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Causes o Ischaemic
!"#$%&
Blocka'e o (loo' lo) (y ateroma* em(oli*an' ateroscelerotic
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EmbolicEmbolic
+nce in *our+nce in *our
brain thebrain the
embolusembolus
e'entuall* tra'else'entuall* tra'els
to a bloo) 'esselto a bloo) 'essel
small enou$h tosmall enou$h to
block its (assa$eblock its (assa$e
The embolusThe embolus
lo)$es therelo)$es there
blockin$ theblockin$ the
bloo) 'essel an)bloo) 'essel an)
causin$ a strokecausin$ a stroke
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Adapted from Goldstein, et al. Circulation2001;10:1!"1#2.
6! "#ararin$6! "#ararin$%&! "aspirin$%&! "aspirin$
AtrialAtrial
fbrillationfbrillation
"non'valvular$"non'valvular$
%(')(! #ith statins in patients%(')(! #ith statins in patients#ith *no#n coronary heart disease#ith *no#n coronary heart disease
H*(erli(i)emiaH*(erli(i)emia
++! reduction in hypertensive++! reduction in hypertensive
diabetics #ith tight blood pressurediabetics #ith tight blood pressurecontrolcontrol
DiabetesDiabetes
,(! #ithin & year- baseline,(! #ithin & year- baselineater , yearsater , years
.mo*ing.mo*ing
)(! ' +(!)(! ' +(!/ypertens/ypertensionion
0is* reduction #ith0is* reduction #ithtreatmenttreatment
FactorFactor
Potential Stroke Risk Reduction for IndividualsPotential Stroke Risk Reduction for Individuals
AHA GuidelinesAHA Guidelines
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Stroke: ClassifcationStroke: Classifcation
schemic strokeschemic stroke: Account for 80%. Results from: Account for 80%. Results fromocclusion in the blood vessel supplying the brainocclusion in the blood vessel supplying the brain
hromboti
hromboti : !cclusion due to: !cclusion due to
atherothrombosis of small"large vesselsatherothrombosis of small"large vessels
supplying the brainsupplying the brain
#mboli
mboli : !cclusion due to embolus arising: !cclusion due to embolus arising
either from heart $e.g. atrial fibrillationeither from heart $e.g. atrial fibrillation
valvular disease& or blood vesselvalvular disease& or blood vessel
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'lassification $cont.&'lassification $cont.&
(emorrhagic strokeemorrhagic stroke: Account for )0%. Results from: Account for )0%. Results fromrupture of blood vessels leading to bleeding inrupture of blood vessels leading to bleeding in
brainbrain
ntracerebral:
ntracerebral: *leeding +ithin the brain due to*leeding +ithin the brain due to
rupture of small blood vessels. !ccurs mainlyrupture of small blood vessels. !ccurs mainly
due to high blood pressuredue to high blood pressure
,ubarachnoid:
ubarachnoid: *leeding around the brain-*leeding around the brain-
commonest cause is rupture of aneurysm.commonest cause is rupture of aneurysm.
!ther causes: (ead inury!ther causes: (ead inury
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Stroke: ,re)is(osin$ actorsStroke: ,re)is(osin$ actors Age $risk doubles forAge $risk doubles for
every decade / age &every decade / age & 1ender1ender
$males/females&$males/females& 2amily history of2amily history of
stroke"IAstroke"IA
(ypertension(ypertension 3iabetes3iabetes (yperlipidemia(yperlipidemia (yperhomocysteinemia(yperhomocysteinemia
!besity!besity
,moking,moking
Atrial fibrillation
trial fibrillation
,edentary lifestyle,edentary lifestyle
3rug abuse $e.g.3rug abuse $e.g.
cocaine use&cocaine use&
(ormone(ormonereplacement therapyreplacement therapy
!ral contraceptive!ral contraceptive
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0is* Factors or .tro*e0is* Factors or .tro*e
Non+,o'iia(le
#isk -actors or !troke$Age
$%e&$'ace(et)nicity$*amily )istory
Modifable 0is*Modifable 0is*Factors or .tro*eFactors or .tro*e66
H*(ertensionH*(ertension
DiabetesDiabetes
Smokin$Smokin$
H*(erli(i)emiaH*(erli(i)emia
Caroti) stenosisCaroti) stenosisAtrial fbrillationAtrial fbrillation
http://www.clevelandclinicmeded.com/diseasemanagement/neurology/stroke/stroke.htmhttp://www.clevelandclinicmeded.com/diseasemanagement/neurology/stroke/stroke.htmhttp://www.clevelandclinicmeded.com/diseasemanagement/neurology/stroke/stroke.htm7/24/2019 Patophysiology and Management of Stroke-Okt2014
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Stroke: S*m(tomsStroke: S*m(toms
+nset o stroke s*m(toms+nset o stroke s*m(toms
'aries as (er t*(e o stroke:'aries as (er t*(e o stroke:
- 1hrombotic stro*e1hrombotic stro*e: De'elo(: De'elo(more $ra)uall*more $ra)uall*
- 2mbolic stro*e2mbolic stro*e: Hits su))enl*: Hits su))enl*
- /emorrhagic stro*e/emorrhagic stro*e: Hits: Hitssu))enl* an) continues to orsensu))enl* an) continues to orsen
S k SSt k S t
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Stroke: S*m(tomsStroke: S*m(toms
.cont/.cont/ 3i44iness3i44iness 'onfusion'onfusion
5oss of balance"coordination5oss of balance"coordination 6ausea"vomiting6ausea"vomiting 6umbness"+eakness on one side of the body6umbness"+eakness on one side of the body
,ei4ure,ei4ure ,evere headache,evere headache 7ovement disorder"speech disorder"blindness etc7ovement disorder"speech disorder"blindness etc
$depending on the area of brain affected&$depending on the area of brain affected&
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,ymptom and ,ign,ymptom and ,ign
'onsider stroke in any patient presenting +ith'onsider stroke in any patient presenting +ithacuteacute
neurological deficit or any alteration in level ofneurological deficit or any alteration in level of
consciousness.consciousness.
'ommon signs of stroke include the follo+ing:'ommon signs of stroke include the follo+ing: Acute hemiparesis or hemiplegiaAcute hemiparesis or hemiplegia 'omplete or partial hemianopia monocular or'omplete or partial hemianopia monocular or
binocular visual loss or diplopiabinocular visual loss or diplopia
3ysarthria or aphasia3ysarthria or aphasia Ataia vertigo or nystagmusAtaia vertigo or nystagmus ,udden decrease in consciousness,udden decrease in consciousness
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Transient Ischemic Attack .TIATransient Ischemic Attack .TIA
11ini stroke2ini stroke2 Stroke s*m(toms last or less than 34 hoursStroke s*m(toms last or less than 34 hours
.usuall* "0 to "# mins.usuall* "0 to "# mins 5esult as a brie interru(tion in bloo) 6o to5esult as a brie interru(tion in bloo) 6o to
brainbrain E'er* TIA is an emer$enc*E'er* TIA is an emer$enc* TIA ma* be a arnin$ si$n o a lar$er strokeTIA ma* be a arnin$ si$n o a lar$er stroke ,atients ith (ossible TIA shoul) be e'aluate),atients ith (ossible TIA shoul) be e'aluate)
b* a (h*sicianb* a (h*sician
Diagnosis o acute ischemicDiagnosis o acute ischemic
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Diagnosis o acute ischemicDiagnosis o acute ischemic
stro*estro*e
9hysical eamination9hysical eamination 6eurological 6eurological#amination#amination
*rain imaging $cranial ' and"or 7RI&: 3etect*rain imaging $cranial ' and"or 7RI&: 3etect
small vessel disease. (elps to effectivelysmall vessel disease. (elps to effectively
discriminate bet+een ischemic and hemorrhagicdiscriminate bet+een ischemic and hemorrhagic
stroke and stroke from brain tumoursstroke and stroke from brain tumours
3oppler ultrasonography"Angiography: 3etect3oppler ultrasonography"Angiography: 3etect
large vessel atherosclerosislarge vessel atherosclerosis
#'1"#chocardiography: 3etect cardiac embolism#'1"#chocardiography: 3etect cardiac embolism
#clusion of conditions mimicking stroke#clusion of conditions mimicking stroke$hypoglycemia migraine sei4ure&$hypoglycemia migraine sei4ure&
Ischemic stroke )ia$nosticIschemic stroke )ia$nostic
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Ischemic stroke )ia$nosticIschemic stroke )ia$nostic
al$orithmal$orithmAcute ocal (rain 'eicit
ea' C"
Ischemic !troke
&C
&cho
CA#DIAC&,B$0I!,
0A#& A#"A"$!C0$!I!
!,A00V&!!&0 DI!&A!&
$" D&",IN&DCA!&
Doppler
,#AAngiogram
,#I
C"
Vasculopathy
Coagulopathy
C#3"$&NIC
!"#$%&
&4clu'e' hypoglycemia* migraine
)ith aura* post+sei5ure 'eicit
TIA (if CT/MR brain imaging
)ithout ischemic lesion6
7 1 hour
0acunar syn'romeCorticalsyn'rome
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AcuteAcute
TreatmentTreatment
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rr77TT,A,A
I a 7hour in)o o treatment canI a 7hour in)o o treatment can
be met thrombol*tic thera(* ithbe met thrombol*tic thera(* ith
intra'enous t7,A can be benefcial orintra'enous t7,A can be benefcial or
each o the ma9or cate$ories oeach o the ma9or cate$ories oischemic stroke:ischemic stroke:
atherothromboticatheroembolicatherothromboticatheroembolic
car)ioembolic an) small 'esselcar)ioembolic an) small 'esselocclusi'e .lacunar strokeocclusi'e .lacunar stroke
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3ntravenous 1hrombolysis3ntravenous 1hrombolysis
Intra'enous rt,A .0/; m$k$ ma
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The intra'enous a)ministration oThe intra'enous a)ministration o
stre(tokinase or treatment o stroke is notstre(tokinase or treatment o stroke is not
recommen)e) .Class III =e'el o E'i)encerecommen)e) .Class III =e'el o E'i)ence
A/A/ &he intra"enous administration o ancrod,&he intra"enous administration o ancrod,
tenecteplase,reteplase, desmoteplase,tenecteplase,reteplase, desmoteplase,
urokinase, or other thrombolytic agentsurokinase, or other thrombolytic agents
outside the setting o a clinical trial is notoutside the setting o a clinical trial is notrecommended (Class , !e"el o #"idencerecommended (Class , !e"el o #"idence
C$%C$%
H i C )i b liHe(arin or Car)ioembolic
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He(arin or Car)ioembolicHe(arin or Car)ioembolic
Stroke:Stroke:
Stroke recurrence is lo much lessStroke recurrence is lo much less
than "%)a* in frst 3 eeksthan "%)a* in frst 3 eeks
=ar$e stroke: ait 487>3 hours an)=ar$e stroke: ait 487>3 hours an)
re(eat CTre(eat CT
Small stroke: use 9u)$mentSmall stroke: use 9u)$ment
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(eparin
+)ere is no large clinical trial in t)e
literature comparing i.. )eparin as
traditionally administered to placebo-nternational %troe +rial: compared s.q.
)eparin at comparable doses to asa and
neit)er in 1/ patients: result: )eparinas not beneficial
3ancet. 1//4;/:1!/"#1
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(eparinoids
+5A%+ trial: indicated no benefit for a
367 )eparinoid in stroe 85'G 101429
%troe. 1//#;2/:2#!
t tana$ement o acute
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ana$ement o acuteana$ement o acute
ischemic strokeischemic stroke .ystemic thrombolysis.ystemic thrombolysis: Intra'enous: Intra'enous
recombinant tissue (lasmino$en acti'atorrecombinant tissue (lasmino$en acti'ator
.rt7,A: ?ithin hrs o onset o stroke/.rt7,A: ?ithin hrs o onset o stroke/
Dose 0/; m$k$ ma< ;0 m$/Dose 0/; m$k$ ma< ;0 m$/ Antiplatelet agentsAntiplatelet agents: As(irin "@0700 m$: As(irin "@0700 m$
ithin 347 48 hrs .not )urin$ frst 34 hrsithin 347 48 hrs .not )urin$ frst 34 hrs
olloin$ thrombol*tic thera(*/olloin$ thrombol*tic thera(*/
Clo(i)o$rel a (otential alternati'e/Clo(i)o$rel a (otential alternati'e/Combination o clo(i)o$rel an) as(irinCombination o clo(i)o$rel an) as(irin
currentl* bein$ e'aluate)currentl* bein$ e'aluate)
ana$ement o acuteana$ement o acute
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ana$ement o acuteana$ement o acute
ischemic stroke .cont)/ischemic stroke .cont)/ AnticoagulantsAnticoagulants: He(arin=?H are not: He(arin=?H are not
recommen)e) in acute treatment o ischemicrecommen)e) in acute treatment o ischemicstroke/stroke/ 0ecommended in setting o0ecommended in setting o atrialatrialfbrillationfbrillation- acute M3 ris*- prosthetic- acute M3 ris*- prosthetic
valves- coagulopathies and orvalves- coagulopathies and orprevention o D41prevention o D41//
3ntra'arterial thrombolytics3ntra'arterial thrombolytics: An o(tion or: An o(tion ortreatment o selecte) (atients ith ma9ortreatment o selecte) (atients ith ma9or
stroke o ! @ hrs )uration )ue to lar$e 'esselstroke o ! @ hrs )uration )ue to lar$e 'esselocclusion/occlusion/
E M di lC f N l i
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Emergency Medical Care for NeurologicEmergencies
Provide reassurance.
Ensure proper airway and breathing.
Place the patient in a position of comfort.
If you suspect stroke, transport immediately andnotify hospital.
Assess and care for any injuries if you suspect any
type of trauma.
ana$ement o acuteana$ement o acute
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ana$ement o acuteana$ement o acute
ischemic stroke .cont)/ischemic stroke .cont)/
5 management5 management: Shoul) be ke(t ithin hi$her: Shoul) be ke(t ithin hi$hernormal limits since lo , coul) (reci(itatenormal limits since lo , coul) (reci(itate(erusion ailure/ arke)l* ele'ate) ,(erusion ailure/ arke)l* ele'ate) ,.B330""0mmH$ mana$e) ith nitro$l*cerin.B330""0mmH$ mana$e) ith nitro$l*cerincloni)ine labetalol so)ium nitro(russi)e/ orecloni)ine labetalol so)ium nitro(russi)e/ ore
a$$ressi'e a((roach is taken i thrombol*tica$$ressi'e a((roach is taken i thrombol*ticthera(* is institute)thera(* is institute) 5lood glucose management5lood glucose management: Shoul) be ke(t: Shoul) be ke(t
ithin (h*siolo$ical le'els usin$ oral or Iithin (h*siolo$ical le'els usin$ oral or I$lucose .in case o h*(o$l*cemiainsulin .in$lucose .in case o h*(o$l*cemiainsulin .in
case o h*(er$l*cemiacase o h*(er$l*cemia 2levated body temperature management2levated body temperature management::
Anti(*retics an) use o coolin$ )e'ice canAnti(*retics an) use o coolin$ )e'ice canim(ro'e the (ro$nosisim(ro'e the (ro$nosis
UDA12 7N MANAG2M2N1 7FUDA12 7N MANAG2M2N1 7F
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UDA12 7N MANAG2M2N1 7FUDA12 7N MANAG2M2N1 7F
38/38/ .,ouratian 300.,ouratian 300
Medical interventionsMedical interventions
' 8ardiopulmonary optimi9ation' 8ardiopulmonary optimi9ation
"A58..$"A58..$' 5lood pressure control' 5lood pressure control
' 38 reduction' 38 reduction
'' UltraUltra''early hemostatic therapyearly hemostatic therapy
.urgical interventions.urgical interventions
M2D38A: MANAG2M2N1 7F 38/M2D38A: MANAG2M2N1 7F 38/
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"ouratian %(()$"ouratian %(()$
8ardiopulmonary optimi9ation " Air#ay- 5reathing-8ardiopulmonary optimi9ation " Air#ay- 5reathing-
8irculation8irculation
-s*in- sei9ures-s*in- sei9ures
$$
0eversing coagulation deects "coagulopathies and platelet0eversing coagulation deects "coagulopathies and plateletdisorders$disorders$
5lood pressure control ":abetolol ; nicardipine 34-5lood pressure control ":abetolol ; nicardipine 34-nitroprusside not oten usednitroprusside not oten used brain edema$s nec* in neutral- patient>s nec* in neutralpositionposition ma?ma?imi9eimi9e venous out@o#
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5:77D 02..U02 MANAG2M2N1 3N 38/5:77D 02..U02 MANAG2M2N1 3N 38/"5roderic* &BBB$"5roderic* &BBB$
' 3 .5 C %)( mm /g or D5 C' 3 .5 C %)( mm /g or D5 C&+( mm /g on %&+( mm /g on %readings , minutes apartreadings , minutes apart nitroprusside (
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$$hemorrha$ic strokehemorrha$ic stroke
AnalgesicsAntian?ietyAnalgesicsAntian?ietyagentsagents: To relie'e: To relie'ehea)ache/ Anal$esics ha'in$ se)ati'ehea)ache/ Anal$esics ha'in$ se)ati'e(ro(erties are benefcial or (atients ha'in$(ro(erties are benefcial or (atients ha'in$sustaine) trauma .e/$/ mor(hine sul(hatesustaine) trauma .e/$/ mor(hine sul(hate
AntihypertensivesAntihypertensives:.e/$/ so)ium:.e/$/ so)iumnitro(russi)e labetololnitro(russi)e labetolol /yperosmotic/yperosmoticagentsagents.e/$/ mannitol.e/$/ mannitol
$l*cerol urosemi)e: To re)uce cerebral$l*cerol urosemi)e: To re)uce cerebrale)ema an) raise) intracranial (ressure/e)ema an) raise) intracranial (ressure/
AdeHuate hydration is necessaryAdeHuate hydration is necessary .urgical intervention may occasionally.urgical intervention may occasionally
be lie savingbe lie saving
0287MM2NDA137N. F7002 MM2NDA13 N F 0.U0G38A: 102A1M2N1 7F 38/.U0G38A: 102A1M2N1 7F 38/
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.U0G38A: 102A1M2N1 7F 38/.U0G38A: 102A1M2N1 7F 38/.ro)erick ";;;.ro)erick ";;;
N7N .U0G38A: 8AND3DA12.N7N .U0G38A: 8AND3DA12.&< .mall hemorrhages "E&( cm)$ or minimal&< .mall hemorrhages "E&( cm)$ or minimal
neurological defcits
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N2U07:7G38N2U07:7G38
D2120370A137N 3N 38/ ":eiraD2120370A137N 3N 38/ ":eira
%((+$%((+$2arly neurologic deterioration "2ND$ occurred in %%
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770 7U187M2 3N 38/
ouratian %(()ouratian %(()
4olume o the hematoma4olume o the hematoma"" )( cc$ )( cc$
Neurologic status "G8. scoreNeurologic status "G8. score $$
3ntraventricular e?tension o the clot3ntraventricular e?tension o the clot
/ydrocephalus/ydrocephalus
.ubarachnoid e?tension.ubarachnoid e?tension
Anticoagulation agentsAnticoagulation agents
0elative edema0elative edema
Davis L.8 %((+Davis L.8 %((+OO 3nratentorial lesion3nratentorial lesion
OO 8oronary heart disease8oronary heart disease
OO /yperthermia/yperthermia
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Cerebral oedema This is an abnormal accumulation of fluid
in the cerebral parenchyma.It is usually the result of
breakdown of the bloodbrain barrier, and it may occur
following damage initiated by several different
causes:Ischaemia, e.g. from infarction.Trauma,e.g.
from head injury.Inflammation encephalitis or meningitis.
Oveproduction of !" by choroid ple#us neoplasms
$ack
http://c/Documents%20and%20Settings/SpongeBob/My%20Documents/PRESENTASI%20KASUS%20211205%20baru.ppt#Management%20of%20acute%20ischemic%20strokehttp://c/Documents%20and%20Settings/SpongeBob/My%20Documents/PRESENTASI%20KASUS%20211205%20baru.ppt#Management%20of%20acute%20ischemic%20stroke7/24/2019 Patophysiology and Management of Stroke-Okt2014
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E)em serebri 'aso$enik meru(akan akibat (rimer )arimenin$katn*a (ermeabilitas blood brain barier
2dem serebri sitoto*si* terjadi se*under dari *erusa*anelemen seluler serebri- terlepasnya a*tor'a*tor to*si*dari netrofl dan ba*teri< .ehingga terjadi pening*atan*andungan air intraseluler- dimana terjadi *ebocoranpotasium- glu*osa diguna*an melalui gli*olisis anae
robi*- produ*sila*tatleated blood pressure usually declines
spontaneously oer t)e first 2 )ours after stroe
onset and oer?ealous use of a calcium antagonistand ot)er anti)ypertensie drugs s)ould be
aoided because t)ey can furt)er reduce cerebral
perfusion.
Antith*(ertensi'eAntith*(ertensi'e
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TreatmentTreatment In)icate) or:In)icate) or:
- aortic )issectionaortic )issection- acute m*ocar)ial inarctionacute m*ocar)ial inarction- heart ailureheart ailure
- acute renal ailureacute renal ailure- h*(ertensi'e ence(halo(ath*h*(ertensi'e ence(halo(ath*- thrombol*tic thera(*thrombol*tic thera(*
?hen s*stolic (ressure is "80 mm H$ or?hen s*stolic (ressure is "80 mm H$ or
hi$her or the )iastolic (ressure "0# mmhi$her or the )iastolic (ressure "0# mmH$ or hi$her/H$ or hi$her/
*lood 9ressure and hemorrhage
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g
Control of eleated blood pressure )asneer been s)on to decrease t)e ris
of ongoing or recurrent bleeding in
patients it) intracerebral )emorr)age.'ecommend treatment of moderate and
seere eleations of blood pressure
8systolic blood pressure of greater t)an1#0 mm =g or mean arterial pressure of
greater t)an 10 mm =g9.
H*(er$l*cemia & StrokeH*(er$l*cemia & Stroke
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H*(er$l*cemia & Stroke*( $ *
'ersistent hyperglycemia ()*+ mgd!$'ersistent hyperglycemia ()*+ mgd!$during the frst -* hours ater stroke isduring the frst -* hours ater stroke is
associated with poor outcomes%associated with poor outcomes%
!ower serum glucose concentrations!ower serum glucose concentrations
(possibly )*+ to )./ mgd!$ probably(possibly )*+ to )./ mgd!$ probably
should trigger administration o insulin,should trigger administration o insulin,
similar to the procedure in other acutesimilar to the procedure in other acute
situations accompanied by hyperglycemiasituations accompanied by hyperglycemia(Class a, !e"elo #"idence C$%(Class a, !e"elo #"idence C$%
Close monitorin$Close monitorin$
Tem(eratureTem(erature
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Tem(eratureTem(erature
Increase tem( increases (ercenta$eIncrease tem( increases (ercenta$eo (oor outcome in strokeo (oor outcome in stroke
Increase cerebral o
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2ever
+)ere is general agreement to
recommend treatment of t)e sources of
feer and use of antipyretics to control
an eleated body temperature 83eels of
>idence --- t)roug) , Grade C9. +)ere
are insufficient clinical data about t)e
use of )ypot)ermia to recommend t)ist)erapy.
2ever: reatment
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2ever: reatment
+reat any temperature eleations
@ata is not in as to )et)er )ypot)ermia
may be protectie
'#R#*RA5 #3#7A
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'#R#*RA5 #3#7A
=ypo"osmolar fluids, suc) as
de&trose in ater, may orsen edema.
1(2B% or B% recommended
7annitol
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7annitol
6annitol 80.2 to 0. g(g -9 gien oer
20 minutes rapidly loers intracranial
pressure and can be gien eery !
)ours.4+)e usual ma&imum daily dose
is 2 g(g.4
annitolannitol
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a o
Dose: 7 3# to #0 $ I/'/ J 7# hrs/Dose: 7 3# to #0 $ I/'/ J 7# hrs/ a
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2vents Ater .tro*e or 13A
1he combination o aspirin plus dipyridamole is moreeective than aspirin alone in preventing stro*e and
other serious vascular events in patients #ith minorstro*e and 13As< 1he ris* reduction #as greater andstatistically signifcant or studies using primarily
e?tended release dipyridamole- #hich may re@ect a truepharmacological eect or lac* o statistical po#er in
studies using immediate release dipyridamole
This meta-analysis systematically reviewed randomized controlledtrials comparing aspirin plus dipyridamole #ith aspirin alone inpatients #ith stro*e and 13A to determine the ecacy o these
agents in preventing recurrent cerebral and systemic vascular events
0ehabilitation rogram=0ehabilitation rogram=
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hysical therapy =hysical therapy = Mobili9ationMobili9ation Lal*ingLal*ing Major motor or sensory impairment o theMajor motor or sensory impairment o the
limbslimbs rescription o devices- such as a cane orrescription o devices- such as a cane or
#al*er#al*er
7ccupational 1herapy =7ccupational 1herapy = Fine movements o the handFine movements o the hand
Arm unctionArm unction Utili9ation o toolsUtili9ation o tools Assistive devicesAssistive devices Ability to unction independentlyAbility to unction independently
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American =eart Association. All rig)ts resered.American =eart Association. All rig)ts resered.
@iagnosis And +reatment 5f @i??iness-n Cerebroascular @isease
Ab)ul ofr
Knit Stroke 5S Sar)9ito a$ian Ilmu ,en*akit Saraakultas e)okteran Kni'ersitas a)9ah a)a Lo$*akarta
DiMMinessDiMMiness
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,re'alence,re'alence
- " in # a)ults re(ort )iMMiness in last month" in # a)ults re(ort )iMMiness in last month
- Increases in el)erl*Increases in el)erl*
- ?orsene) b* )ecrease) 'isual acuit*?orsene) b* )ecrease) 'isual acuit*
(ro(rioce(tion an) 'estibular in(ut(ro(rioce(tion an) 'estibular in(ut DiMMinessDiMMiness
- Gon7s(ecifc termGon7s(ecifc term
- DiNerent meanin$s to )iNerent (eo(leDiNerent meanin$s to )iNerent (eo(le
Coul) meanCoul) mean
7 erti$oerti$o 7 S*nco(e7 S*nco(e 7 ,res*nco(e7 ,res*nco(e
7 ?eak?eak 7 i))iness7 i))iness 7 An
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Cerebroascular @isease
E i) i l C b lE(i)emiolo$* o Cerebro'ascular
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E(i)emiolo$* o Cerebro'ascularE(i)emiolo$* o Cerebro'ascular
DiseaseDisease ##00000 stroke sur'i'ors are ali'e to)a*##00000 stroke sur'i'ors are ali'e to)a*
>00000 each *ear>00000 each *ear
- #00000 o these are frst attacks#00000 o these are frst attacks- 300000 are recurrent attacks/300000 are recurrent attacks/
0% to #0% o stroke sur'i'ors )o not re$ain0% to #0% o stroke sur'i'ors )o not re$ain
unctional in)e(en)enceunctional in)e(en)ence
"#% to 0% o all stroke sur'i'ors are"#% to 0% o all stroke sur'i'ors are
(ermanentl* )isable)(ermanentl* )isable)
I i) C b lI i) C b l
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Inci)ence o Cerebro'ascularInci)ence o Cerebro'ascular
DiseaseDisease Increases ith a$eIncreases ith a$e
38% are less than @# *rs ol)38% are less than @# *rs ol)
80% o cerebrob'ascular )isease80% o cerebrob'ascular )isease
are (re'entableare (re'entable
";% $reater in men than omen";% $reater in men than omen
?omen B @# ha'e hi$her inci)ence?omen B @# ha'e hi$her inci)ence
than menthan men
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ertebrobasilar insuOcienc*ertebrobasilar insuOcienc*
DiMMiness )i(lo(ia )*sarthria $aitDiMMiness )i(lo(ia )*sarthria $ait
ata
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American =eart Association. All ri )ts resered.American =eart Association. All ri )ts resered.
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Arise rom the subcla'ianArise rom the subcla'ian
arteriesarteries
5un alon$si)e the5un alon$si)e the
me)ullame)ulla loo) su((l* orloo) su((l* or
brainstem an) cerebellumbrainstem an) cerebellum
e* unctional Areas:e* unctional Areas:
T S(inal cor) tracts7(*rami)alS(inal cor) tracts7(*rami)al
an) s(inothalamican) s(inothalamicT Cranial ner'es 7"3Cranial ner'es 7"3
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"7 ,osterior Cerebral"7 ,osterior Cerebral
37 Su(erior Cerebellar37 Su(erior Cerebellar
7 ,ontine ranches o7 ,ontine ranches o
asilarasilar
47 Anterior Inerior Cerebellar47 Anterior Inerior Cerebellar
#7 Internal Au)itor*#7 Internal Au)itor*
@7 ertebral@7 ertebral
>7 ,osterior Inerior>7 ,osterior Inerior
CerebellarCerebellar87 Anterior S(inal87 Anterior S(inal
;7 asilar;7 asilar
DiMMinessDiMMiness
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,eri(heral causes,eri(heral causes
- canalithiasis .,,7#0%canalithiasis .,,7#0%
- 'estibular neuronitis'estibular neuronitis.lab*rinthitis73#%.lab*rinthitis73#%
- enierePs )isease7"0%enierePs )isease7"0%
- traumatrauma
- )ru$s .amino$l*cosi)es)ru$s .amino$l*cosi)es
Central causesCentral causes
- Cerebro'ascular )iseaseCerebro'ascular )isease
.'ertebrobasilar insuOcienc*7#0.'ertebrobasilar insuOcienc*7#0- )em*elinatin$ .multi(le sclerosis)em*elinatin$ .multi(le sclerosis
- )ru$s .anticon'ulsants alcohol)ru$s .anticon'ulsants alcohol
h*(noticsh*(notics
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erti$o 's/ other t*(es oerti$o 's/ other t*(es o)iMMiness)iMMiness
TimeTimecoursecourse77 'erti$o is ne'er continuous77 'erti$o is ne'er continuous
,ro'okin$,ro'okin$actorsactors77 s(ontaneousl* or ith77 s(ontaneousl* or ith(ositional chan$es(ositional chan$es
A$$ra'atin$A$$ra'atin$actorsactors77 all 'erti$o is ma)e77 all 'erti$o is ma)eorse b* mo'in$ the hea)orse b* mo'in$ the hea)
E t bli hi th E t bli hi th
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Establishin$ the cause oEstablishin$ the cause o
)iMMiness)iMMinessTime courseTime course
- ,,: lasts less than one minute sel7limite),,: lasts less than one minute sel7limite)
res(on)s (oorl* to anti7'erti$o )ru$sres(on)s (oorl* to anti7'erti$o )ru$s
- ascular: sin$le e(iso)e lastin$ minutes toascular: sin$le e(iso)e lastin$ minutes to
hoursQ usuall* )ue to mi$raine or to transienthoursQ usuall* )ue to mi$raine or to transient
ischemia o the lab*rinth or brainstemQischemia o the lab*rinth or brainstemQ
occasionall* enierePs )iseaseoccasionall* enierePs )isease
- 5ecent onset o more (rolon$e) e(iso)es5ecent onset o more (rolon$e) e(iso)escharacteristic o 'estibular neuronitis multi(lecharacteristic o 'estibular neuronitis multi(le
sclerosis 'ertebrobasilar ischemiasclerosis 'ertebrobasilar ischemia
E t bli hi th E t bli hi th
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Establishin$ the cause oEstablishin$ the cause o
)iMMiness)iMMiness
Associate) s*m(tomsAssociate) s*m(toms
- ertebrobasilar )isease stroke: )i(lo(iaertebrobasilar )isease stroke: )i(lo(ia)*sarthria )*s(ha$ia eakness numbness)*sarthria )*s(ha$ia eakness numbness
- enierePs )isease: aural ullness )eanessenierePs )isease: aural ullness )eaness
tinnitustinnitus
- ,s*ch,anic attack: S+ (al(itations,s*ch,anic attack: S+ (al(itations)ia(horesis)ia(horesis
- ulti(le sclerosis: 'erti$o (rece)e) b* otherulti(le sclerosis: 'erti$o (rece)e) b* other
neurolo$ic )*sunctionneurolo$ic )*sunction
Establishin$ the cause oEstablishin$ the cause o
)iMMiness)iMMiness
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)iMMiness)iMMiness
,rior risk actors,rior risk actors
- i$rainei$raine
- H*(ertension Diabetes ellitusH*(ertension Diabetes ellitus
smokin$ ,eri(heral ascular Diseasesmokin$ ,eri(heral ascular Disease
- Hea) in9ur*Hea) in9ur*
- ,s*chiatric illness,s*chiatric illness
,h*sical e
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estibular e
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urther stu)ies to e'aluateurther stu)ies to e'aluate
)iMMiness)iMMiness 5I5A5I5A 77 )istin$uishin$ central causes77 )istin$uishin$ central causes
TCDTCD Au)iometr*Au)iometr* 77 )istin$uishin$ (eri(heral77 )istin$uishin$ (eri(heral
causescauses
- rainstem e'oke) au)iometr*rainstem e'oke) au)iometr* 77 ;07;#%77 ;07;#%sensiti'it* or )etectin$ acoustic neuromasensiti'it* or )etectin$ acoustic neuroma
Transient Ischaemic AttackTransient Ischaemic Attack
.TIA mana$ement.TIA mana$ement
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$ The risk o stroke (ost TIA is hi$himme)iatel* ater an e'entQ u( to #%in the frst 3 )a*s an) "0% ithin the
frst eek
$ Those at hi$h risk can be
)iscriminate) rom those at lo riskb* means o clinical assessment .the
ACD3 score/
ContRR//ContRR//
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$ The ACD3 scale is a >7(oint scalebase) on clinical )ata a'ailable
beore neuroima$in$ hich can beuse) to estimate the risk o stroke
ater TIA
0ohnston et al, !ancet -++1
ana$ement o TIAana$ement o TIA
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E'aluation ithin hours ater onsetE'aluation ithin hours ater onseto s*m(tomso s*m(toms
CT scan is necessar* in all (atientsCT scan is necessar* in all (atients
Anti(latelet thera(* ith as(irin .#07Anti(latelet thera(* ith as(irin .#073# m$) consi)er use o3# m$) consi)er use oclo(i)o$rel ticlo(i)ine or as(irin7clo(i)o$rel ticlo(i)ine or as(irin7)i(*ri)amole in (atients ho are)i(*ri)amole in (atients ho are
intolerant to as(irin or those hointolerant to as(irin or those hoe