3 Manifestasi Klinik Stroke

MANIFESTASI KLINIK STROKE

CLINICAL DISORDERS

A. ASYMPTOMATIC

B. FOCAL BRAIN DYSFUNCTION 1. TRANSIENT ISCHEMIC ATTACK 2. S T R O K E

C. VASCULAR DEMENTIA

D. HYPERTENSIVE ENCEPHALOPATY

TRANSIENT ISCHEMIC ATTACK

1. CAROTID SYSTEM

2. VERTEBROBASILAR SYSTEM

3. BOTH

4. UNCERTAIN LOCATION

5. POSSIBLE TIA

S T R O K E

A. TEMPORAL PROFILE 1. IMPROVING STROKE 2. WORSENING STROKE 3. STABLE STROKE

B. TYPE OF STROKE 1. BRAIN INFARCTION 2. BRAIN HEMORRHAGE 3. SUBARACHNOIDAL HEMORRHAGE (SAH) 4. INTRACEREBRAL HEMORRHAGE FROM AVM

BRAIN INFARCTION

A. MECHANISM 1. THROMBOTIC 2. EMBOLIC 3. HEMODYNAMIC

B. CLINICAL CATEGORIES 1. ATHEROTHROMBOTIC 2. CARDIOEMBOLIC 3. LACUNAR 4. OTHER (ANGIOPATHY, ARTERITIS, DLL)

BRAIN INFARCTION (LANJ.)

C. SYMPTOMS AND SIGNS BY SITE (DISTRIBUTION)

1. CAROTID ARTERY SYSTEM a. INTERNAL CAROTID ARTERY b. MIDDLE CEREBRAL ARTERY c. ANTERIOR CEREBRAL ARTERY

2. VERTEBROBASILER SYSTEM a. VERTEBRAL ARTERY b. BASILER ARTERY c. POSTERIOR CEREBRAL ARTERY

CLINICAL ASSESSMENT

A. HISTORY B. PHYSICAL EXAMINATION

1. GENERAL 2. NEUROLOGIC 3. VASCULAR :

a. Palpation b. Auscultation

4. OPHTHALMOSCOPY

BRAIN INFARCTION

• GENERALLY HAVE ONE OR MORE RISK FACTORS

• HEADACHE AND VOMITING ARE UNUSUAL AT THE

ONSET

• DEFICITS MAY CONTINUE TO WORSENING

• USUALLY FOCAL DEFICIT WITH CAROTID DISTRIBUTION

BRAIN INFARCTION

MECHANISMS OF ISCHEMIC INFARCTION

1. THROMBOTIC– a thrombus is superimposed on an atherosclerotic

plaque– precipitated by an abnormality of blood clotting

2. EMBOLIC– due to occlusion of an artery by an embolus– inadequate collateral blood flow

3. HEMODINAMIC– stenosis or occlusion of the proximal artery– collateral compensatory blood flow inadequate – global cerebral perfusion is decreased (decreased

cardiac output)

CLINICAL CATEGORIES

1. ATHEROTHROMBOTIC

• PADA VASKULER ATEROSKLEROTIK ARTERI EKSTRAKRANIAL DAN INTRAKRANIAL UTAMA

• PATOMEKANISME TERJADI INFARK OTAK :– PLAK MEMBESAR DAN OKLUSI VASKULER,

SERINGNYA DISERTAI (SUPERIMPOSED) TROMBOSIS

– EMBOLIK, DARI LEPASNYA TROMBUS ATAU FRAGMEN PLAK (ARTERY TO ARTERY EMBOLUS)

• RIWAYAT TIA (+) DAN BRUIT SERVIKAL (+)

CLINICAL CATEGORIES (LANJ)

2. CARDIOEMBOLIC

• DEFISIT FOKAL, DAPAT WORSENING STROKE• DIAGNOSA ATAS DASAR DITEMUKAN SUMBER EMBOLI KARDIAL

DAN TRANSKARDIAL : KARDIAL

# FIBRILASI ATRIAL ATAU ATRIAL FLUTTER# INFARK MIOKARD# GAGAL JANTUNG KONGESTIF# KELAINAN KATUP MITRAL DAN AORTIK

TRANSKARDIAL (PARADOXICAL EMBOLIC)# RIGHT TO LEFT CARDIAC SHUNT# SUMBER EMBOLI : TROMBUS VENA PERIFER

• INFARK OTAK MULTIPEL ATAU INFARK SISTEMIK

CLINICAL CATEGORIES (LANJ)

2. CARDIOEMBOLIC

• MANIFESTASI KLINIK ISOLATED :#ISOLATED HEMIANPSOA HOMONIM#ISOLATED APHASIA

• KOMPLIKASI : INFARK BERDARAH• INFARK PADA DAERAH KORTIKAL, DISTRIBUSI CABANG

ARTERI SEREBRI MEDIA

CLINICAL CATEGORIES (LANJ)

3. LACUNAR• LESI PADA PENETRATING ARTERIES• PADA PERCABANGAN BELOKAN 90O :

#ARTERI LENTIKULOSTRIATA#ARTERI BATANG OTAK

• ARTERI PENETRANS MISKIN SISTEM KOLATERAL• OBSTRUKSI VASKULER OK :

#ARTERIAL DISEASE (ANGIOPATHY)#TROMBUS# EMBOLI

CLINICAL CATEGORIES (LANJ)

3. LACUNAR• DIAGNOSIS KLINIK BERDASARKAN :

BRAIN IMAGING (LESI < 1,5 CM) SINDROMA KLINIK (LOKASI ANATOMIK) :

– PURE MOTOR HEMIPARESIS– PURE SENSORY STROKE– ATAXIC HEMIPARESIS– DYSARTHRIA CLUMSY HAND SYNDROME

• SINDROMA DAPAT DENGAN IMAGING NORMAL• SINDROMA DAPAT JUGA KARENA PIS KECIL ATAU

INFARK KORTIKAL

GAMBARAN KLINIK

DITENTUKAN :

LETAK LESI LUAS LESI

GAMBARAN KLINIK

ARTERI KAROTIS INTERNA

OKLUSI DI SERVIKAL GMBR KLINIK TAK KHAS BILA KOLATERAL ADEKUAT ASIMTOMATIK BILA SIMTOMATIK :

• TIA SAMPAI INFARK LUAS MEKANISME

HEMODINAMIK ARTERY-TO-ARTERY EMBOLIC ATEROTROMBOTIK (PROPAGATION TROMBUS SAMPAI A. SEREBRI

MEDIA)

GAMBARAN KLINIK

GEJALA KLINIK : MONOPARESIS S/D HEMIPARESIS DENGAN / TANPA HEMIANOPSIA DISARTRIA DAN DISFASIA AGNOSIA HEMIHIPESTESI AMAUROSIS FUGAX CERVICAL BRUIT (+) (HIGH-PITCH)

GAMBARAN KLINIK

ARTERI SEREBRI MEDIA LESI PADA BAG. PERTAMA (MI) :

GEJALA KLINIK TERGANTUNG KOLATERAL SIRKULUS WILLISI

(A.SEREBRI ANTERIOR DAN POSTERIOR) ETIOLOGI TERSERING : EMBOLIK GEJALA KLINIK BIASANYA BERAT :

HEMIPLEGIA HEMIHIPESTESIA HEMIANOPSIA HOMONIM CONTALATERAL GAZE PALSY APHASIA (HEMISFER DOMINAN)

GAMBARAN KLINIK

ARTERI SEREBRI MEDIA • LESI PADA BATANG ARTERI (ARTERIAL STEM) : GEJALA KLINIK :

¤ DEFISIT MOTORIK KARENA GIANT LACUNE ¤ TERGANTUNG KOLATERAL DIPERMUKAAN OTAK

• OKLUSI PADA CABANG ¤ PARTIAL SYNDROME (ISOLATED)

GAMBARAN KLINIK

ARTERI SEREBRI ANTERIOR

GEJALA KLINIK : HEMIPARESIS, TERUTAMA TUNGKAI HEMIHIPESTESI APRAKSIA (TERUTAMA GAIT APRAXIA) GANGGUAN FUNGSI LUHUR

GAMBARAN KLINIK

VERTEBROBASILER SYSTEM MENDARAHI :

MEDULA OBLONGATA PONTIS MESENSEFALON TALAMUS LOBUS OKSIPITALIS TEMPOROCCIPITAL JUNCTION PARIETOOCCIPOITAL JUNCTION

GAMBARAN KLINIK

ARTERI VERTEBRALIS OKLUSI A. VERTEBRALIS DAN A. CEREBELARIS INFERIOR

POSTERIOR LATERAL MEDULLARY INFARCTION GEJALA KLINIK:

• VERTIGO • MUAL / MUNTAH • DISFAGIA • ATAKSIA SEREBELARIS IPSILATERAL • IPSILATERAL HORNER’S SYNDROME • PAIN AND TEMPERATUR DISCRIMINATION :

≠ IPSILATERAL PADA WAJAH ≠ KONTRALATERAL PADA TUBUH DAN

EKSTRIMITAS

GAMBARAN KLINIK

ARTERI BASILARIS

• OKLUSI A. BASILARIS : GGN BATANG OTAK BILATERAL • OKLUSI CABANG A. BASILARIS SATU SISI BO :

LOCALIZED SYNDROME (Sindroma Batang Otak)

ALTERNATING • GEJALA UTAMA :

VERTIGO NISTAGMUS

GAMBARAN KLINIK

ARTERI SEREBRI POSTERIOR

OKLUSI SERINGKALI KARENA EMBOLI GEJALA KLINIK :

HOMONYMOUS VISUAL FIELD DEFECT : HEMIANOPSIA QUADRANOPSIA

DISLEKSIA DAN DISKALKULI (HEMISFER DOMINAN) SINDROMA LOBUS PARIETALIS (HEMISFER NON-

DOMINAN) BILATERAL :

BUTA KORTIKAL GANGGUAN TINGKAH LAKU

Effects depend on area(s) of brain affectedEffects depend on area(s) of brain affected

Effects of StrokeEffects of Stroke

Right HemisphereRight Hemisphere

= Left-sided paralysis= Spatial misperception (falling, dropping things)= Reading difficulty= Impulsiveness= Left-sided neglect= Loss of short-term memory

Effects depend on area(s) of brain affectedEffects depend on area(s) of brain affected

Effects of StrokeEffects of Stroke

Left HemisphereLeft Hemisphere

= Right-sided paralysis= Speech/language impairment= Inability to complete tasks without patient instruction= Memory loss

Effects depend on area(s) of brain affectedEffects depend on area(s) of brain affected

Effects of StrokeEffects of Stroke

Brain stemBrain stem

= Disruption of breathing= Loss of consciousness= Variable effects on blood pressure= Disruption of eye movements, swallowing, hearing, speech= Bilateral paralysis likely

Effects depend on area(s) of brain affectedEffects depend on area(s) of brain affected

Effects of StrokeEffects of Stroke

CerebellumCerebellum

= Balance= Coordination= Dizziness, nausea, vomiting= Disruption of some reflexes, especially involving head & neck

Gejala dan Tanda StrokeGejala dan Tanda Stroke

Facial Droop

Pronater Drift