Presentasi Presentasi Kasus Kasus Diajukan oleh : dr. Noegroho Diajukan oleh : dr. Noegroho Harbani Harbani Moderator : dr. RM. Hermanu Moderator : dr. RM. Hermanu Poespaningrat, SpS Poespaningrat, SpS Penilai : Prof. DR. dr. Hj. Sri Penilai : Prof. DR. dr. Hj. Sri Sutarni , SpS (K) Sutarni , SpS (K) dr. Lukman Hakim , SpS dr. Lukman Hakim , SpS
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Presentasi KasusPresentasi Kasus
Diajukan oleh : dr. Noegroho HarbaniDiajukan oleh : dr. Noegroho Harbani
Moderator : dr. RM. Hermanu Poespaningrat, SpSModerator : dr. RM. Hermanu Poespaningrat, SpS
Penilai : Prof. DR. dr. Hj. Sri Sutarni , SpS (K)Penilai : Prof. DR. dr. Hj. Sri Sutarni , SpS (K)
dr. Lukman Hakim , SpS dr. Lukman Hakim , SpS
Klaten, 29 April 2009Klaten, 29 April 2009
Identitas
Nama : Tn. S
Pekerjaan : Pensiunan PNS
Umur : 67 tahun
Agama : Islam
MR : 605709
Alamat : Balanharjo, Glagah Wangi, Klaten
Pendidikan : D3
Masuk RS : 31 Maret 2009
ANAMNESIS
Allo anamnesis : diperoleh dari penderita dan istri penderita
(2 April 2009)
Keluhan utama :
Kelemahan anggota gerak kiri
Riwayat Penyakit Sekarang
Lebih kurang 2 Jam SMRS mendadak mengeluh anggota gerak kiri terasa lemah dan berat untuk digerakkan.
Untuk jalan terjatuh, disertai nyeri kepala, bicara pelo, mulut perot dan nyeri kepala .
Riwayat Penyakit Sekarang ( lanj..)
Kelemahan antara tangan dan kaki terjadi bersamaan dengan tingkat kelemahan sama
Selama sakit penderita tidak demam, pandangan kabur, pusing berputar, gangguan menelan, kejang, penurunan kesadaran, kesemutan dan gangguan BAB & BAK
ANAMNESIS
Riwayat Penyakit Dahulu
Riwayat hipertensi sejak tahun 1995 tidak terkontrol
Riwayat merokok (-)
Riwayat kencing manis (-)
Riwayat sakit jantung (-)
Riwayat trauma kepala (-)
Riwayat tumor (-)
Riwayat stroke atau sakit serupa (-)
ANAMNESIS (Lanj.)Riwayat Penyakit Keluarga
Tidak ada keluarga yang menderita sakit serupa
Evaluasi sistem
Sistem serebrospinal : kelemahan anggota gerak kiri, pelo, perot, nyeri kepala bersifat akut
Sistem kardiovaskuler : normal
Sistem Respirasi : normal
Sistem gastrointestinal : normal
Sistem muskuloskeletal : normal
Sistem intugumentum : normal
Sistem urogenital : normal
Resume anamnesis
Laki- laki usia 67 tahun, datang dengan keluhan sejak 2 jam sebelum masuk rumah sakit kelemahan anggota gerak kiri, nyeri kepala, pelo, perot. Tidak ada demam, penurunan kesadaran dan kejang. Tidak ada riwayat trauma, tumor, gangguan penglihatan, sakit gigi, dan infeksi telinga. Riwayat hipertensi sejak 1995 tidak terkontrol.
Diagnosis Sementara
Diagnosis klinis : kelemahan anggota gerak kiri, bicara pelo, dan perot disertai nyeri kepala yang bersifat akut.Diagnosis topik :intraserebral hemisperium dextra, subkortikalDiagnosis etiologi :
1. Stroke hemoragik2. Stroke non hemoragik
Pemeriksaan umum
Keadaan umum : sedang,gizi sedang, compos mentisTanda vital : TD 160/100 mmHg, N : 76x/mnt, RR : 20 x/mnt, t : 36,5 oCStatus internus :Jantung : murmur (-), S1, S2 normal Paru : sonor, vesikular, ronkhi (-)Lever : normalLien : tak terabaStatus psikiatrik : kooperatif, normoaktif, orientasi orang, waktu dan tempat baik
Tampak lesi hiperdens di talamus dekstra dan di capsula interna dekstra
Kesan: Intra serebral hemoragi di talamus dan kapsula interna dekstra
Pemeriksaan penunjang
Diagnosis akhir
Diagnosis klinis : hemiparese sinistra cum parese N VII et XII sinistra UMN.
Diagnosis topik : Talamus dan kapsula interna dekstra sesuai dengan vaskularisasi arteri lentrikulostriata cabang arteri serebri media.
Diagnosis etiologis : intraserebral hemoragik
Penatalaksanaan
Umum Airway ,breathing and circulation maintenanceO2 3- L/mntIVFD Ringer asetat 16 tetes/mntCateterFarmakoterapi Anti edema : Manitol 20% 4x125cc inj, tapering offNeuroprotektan : Piracetam inj 3 gr / 6 jam
Citicoline inj 250 mg / 12 jam
Antibiotik : Ceftriaxon 1gr / 12 jam
Prognosis
Death : baik
Disesase : dubia ad bonam
Discomfort : dubia ad bonam
Disability : dubia ad bonam
Dissatisfaction : dubia ad bonma
Destitution : dubia ad malam
Follow up (03/04/2009)S : nyeri kepala (+), sulit tidurO : KU sedang, kes.CM ,GCS E4V5M6, TD 140/90, N 84 x/menit, afebris, RR 20
x/menit, isokor, RC +/+, RK +/+parese N VII & N XII sinistra UMN
- Ekstremitas : G B T K 555 333 RF + RP - +
B T 555 333 + - +
Tn N N Tr E E Cl -- / - N N E E
Sensibilitas : dbnVegetatif : dbn
Tanggal 3/04/09 6/04/09 7/04/09 8/04/09
Keluhan Nyeri kepala +Sulit tidur
Nyeri kepala - Nyeri kepala - Nyeri kepala -
Keadaan umum
Cukup,CME4M6V5
Cukup,CM E4M6V5
Cukup,CM E4M6V5
lCukup,CM E4M6V5
Tanda vital TD : 140/90N: 84,T:37,4
TD : 130/90N: 88,T:36,2
TD : 130/90N: 88,T:36,6
TD : 130/90N: 84,T:36.5
Nn.craniales
Parese NVII&XIIsin UMN
Parese NVII&XIIsin
UMN
Parese NVII&XIIsin
UMN
Parese NVII&XIIsin
UMN
R.fisiologis Meningkat pd ekstremitas kiri
Meningkat pd ekstremitas
kiri
Meningkat pd ekstremitas
kiri
Meningkat pd ekstremitas
kiri
R.patologis Positif pd ekstremitas kiri
Positif pd ekstremitas
kiri
Positif pd ekstremitas
kiri
Positif pd ekstremitas
kiri
clonus - / - - / - - / - - / -
Kekuatan
Follow up
555 333
555 333
555 444
555 444
555 444
555 444
555 444
555 444
Definisi StrokeDefinisi Stroke
Stroke adalah gangguan fungsional otak fokal Stroke adalah gangguan fungsional otak fokal maupun global yang terjadi secara akut, berasal maupun global yang terjadi secara akut, berasal dari gangguan aliran darah otak . Termasuk di dari gangguan aliran darah otak . Termasuk di sini perdarahan subarachnoid, perdarahan sini perdarahan subarachnoid, perdarahan intraserebral dan iskemik atau infark serebri. intraserebral dan iskemik atau infark serebri. Tidak termasuk disini gangguan peredaran Tidak termasuk disini gangguan peredaran darah otak sepintas, tumor otak, infeksi atau darah otak sepintas, tumor otak, infeksi atau stroke sekunder karena trauma (WHO, 1986)stroke sekunder karena trauma (WHO, 1986)
• Stroke penyebab kematian ke-3 di berbagai negara
• Stroke didpt pd semua gol. umur ttp terutama pd usia tua dan meningkat dgn tambahnya umur,
• Stroke adl ggn fungsional otak fokal maupun global akut, > 24 jam akibat ggn ADO
Gangguan aliran sirkulasi darah dapat Gangguan aliran sirkulasi darah dapat berupa :berupa :
Trombus Trombus
EmbolusEmbolus
Komplikasi StrokeKomplikasi Stroke
DemensiaDemensia
DepresiDepresi
KecacatanKecacatan
EpilepsiEpilepsi
KontrakturKontraktur
Peptic ulcerPeptic ulcer
BronchopneumoniaBronchopneumonia
DeckubitusDeckubitus
SeptikemiaSeptikemia
Trombosis vena Trombosis vena profundaprofunda
Emboli pulmoEmboli pulmo
Ggn keseimbangan Ggn keseimbangan cairancairan
31
ANATOMI OTAKANATOMI OTAK
Anatomy – Stroke. Anatomy – Stroke.
PART OF BRAIN
CONTROL CENTER OF BRAIN
Functional Areas of the Brain
Back
Mungkin sulit dipercaya bahwa di dalam otak Mungkin sulit dipercaya bahwa di dalam otak tersimpan informasi mengenai segala hal yang tersimpan informasi mengenai segala hal yang
mengatur kelangsungan hidup manusiamengatur kelangsungan hidup manusia
38
Corticospinal TractCorticospinal Tract
39
HomunculusHomunculus
Oleh karena ruptur aneurisma, angioma, lesi aterosklerotik
EpidemilogyEpidemilogy
IncidenceIncidence USAUSA
– ICH represents 10-15 percent of all strokes ICH represents 10-15 percent of all strokes (approximately 70,000 new cases each year)(approximately 70,000 new cases each year)11. .
InternationallyInternationally– Asian countries >> incidence of ICH (30%) Asian countries >> incidence of ICH (30%) 22
It is twice as common as subarachnoid hemorrhage It is twice as common as subarachnoid hemorrhage and carries an equally poor prognosis and carries an equally poor prognosis 33
MortalityMortality– At 7 days: >20%At 7 days: >20%– At 1 month: >40%At 1 month: >40%– At 1 year: 53%At 1 year: 53%– Correlated with volume of ICH (>30 cc)Correlated with volume of ICH (>30 cc)
Functionally indipendenceFunctionally indipendence– At 1 month: 10%At 1 month: 10%– At 6 months: 20%At 6 months: 20%
Clev Clin J Med 2005;4:341-344Clev Clin J Med 2005;4:341-344
Primary and SecondaryPrimary and SecondaryCauses of Intracerebral HemorrhageCauses of Intracerebral Hemorrhage
Hypertrophy media & narrowing lumenHypertrophy media & narrowing lumen
These changes are protectiveThese changes are protective reduction wall tension reduction wall tension & shifting of autoregulation curve to allow & shifting of autoregulation curve to allow compensation at higher BPcompensation at higher BP
Vasc remodeling accompanied by endothelial Vasc remodeling accompanied by endothelial dysfunction dysfunction impaired relaxation impaired relaxation poor poor compensation of hypoperfusion compensation of hypoperfusion reduced collateral reduced collateral flow flow higher susceptibility to ischemic injury higher susceptibility to ischemic injury
Perdarahan pd hipertensi tjd umumnya pd Perdarahan pd hipertensi tjd umumnya pd tempat yg dalam dari otak spt ganglia tempat yg dalam dari otak spt ganglia basalis dan thalamus krn pemb.darah pd basalis dan thalamus krn pemb.darah pd daerah tsb tertutup dari tekanan yg tingggi daerah tsb tertutup dari tekanan yg tingggi dari the circle of willis.dari the circle of willis.Perdarhan ini lebih sedikit pd Perdarhan ini lebih sedikit pd pons,serebelum atau kortek superfisialpons,serebelum atau kortek superfisial
Studi patologi menunjukkan hiperplasia pd Studi patologi menunjukkan hiperplasia pd dinding arteri media shg tjd reaksi proliferasi sel dinding arteri media shg tjd reaksi proliferasi sel otot polos pd awal hipertensi.otot polos pd awal hipertensi.Hal ini akan membentuk arteriosklerosis Hal ini akan membentuk arteriosklerosis hiperplastik.hiperplastik.Kemungkinan sel otot polos mati dan diganti Kemungkinan sel otot polos mati dan diganti jaringan kolagen yg membuat ddg pemb darah jaringan kolagen yg membuat ddg pemb darah rapuh dan bertanggung jawab pada kebocoran rapuh dan bertanggung jawab pada kebocoran lebih lanjut.lebih lanjut.
Pada hipertensi kronik diduga bahwa Pada hipertensi kronik diduga bahwa fibrinoid necrosis mrp prekursor pdarahan.fibrinoid necrosis mrp prekursor pdarahan.
CAA mrp hasil dari penumpukan peptida CAA mrp hasil dari penumpukan peptida amiloid beta yg tdk larut pd ddg amiloid beta yg tdk larut pd ddg arteri ,arteriola,dan kapiler dari arteri ,arteriola,dan kapiler dari leptomeningeal dan kortek.leptomeningeal dan kortek.
Penggantian sel otot polos pd ddg arteri Penggantian sel otot polos pd ddg arteri oleh peningkatan amiloid beta seiring dg oleh peningkatan amiloid beta seiring dg usia membuat daya lentur arteri bkurang.usia membuat daya lentur arteri bkurang.
Pdarahan yg dihub dg CAA,bhub dg Pdarahan yg dihub dg CAA,bhub dg interaksi dari faktor resiko lain yaitu interaksi dari faktor resiko lain yaitu hipertensi.hipertensi.
Komplikasinya antara lain double barrel Komplikasinya antara lain double barrel appearance,necrosis appearance,necrosis fibrinoid,microaneurisma,stenotik fibrinoid,microaneurisma,stenotik lumen,mikrohemoragik dan cortical lumen,mikrohemoragik dan cortical infarction.infarction.
Ruptur aneurysma : 6-12 per 100000/thRuptur aneurysma : 6-12 per 100000/thWanita : pria = 3:2Wanita : pria = 3:2Umur : sering 40-60 th, jarang anakUmur : sering 40-60 th, jarang anak
> 40 th, wanita > pria> 40 th, wanita > pria < 40 th, pria > wanita< 40 th, pria > wanita
Aneurisma adalah keadaan dimana pemb Aneurisma adalah keadaan dimana pemb darah mjd mbesar scr abnormal atau darah mjd mbesar scr abnormal atau mengembang spt balon yg menonjol mengembang spt balon yg menonjol keluar.keluar.
Sering tjd pd arteri dibasis otak(circulus Sering tjd pd arteri dibasis otak(circulus willisi) dan di aorta.willisi) dan di aorta.
Menyebabkan ruptur dan kematianMenyebabkan ruptur dan kematian
Peningkatan tekanan(hipertensi sistemik) Peningkatan tekanan(hipertensi sistemik) dan meningkatnya ukuran aneurisma dan meningkatnya ukuran aneurisma memicu tekanan pd ddg dan memicu tekanan pd ddg dan meningkatkan resiko rupturmeningkatkan resiko ruptur
Mekanisme aneurismaMekanisme aneurisma
Degradasi proteolitik dari ddg jar ikat aortaDegradasi proteolitik dari ddg jar ikat aorta
Inflamasi dan respon imunInflamasi dan respon imun
Stress biokimiawi pd ddgStress biokimiawi pd ddg
Molekuler genetikMolekuler genetik
Aneurisma terbentuk scr perlahan selama Aneurisma terbentuk scr perlahan selama bbrp tahun dan sering tanpa gejalabbrp tahun dan sering tanpa gejala
Jika aneurisma mengembang scr cepat Jika aneurisma mengembang scr cepat maka tjd ruptur /robekan atau kebocoran maka tjd ruptur /robekan atau kebocoran darah disepanjang ddg pemb darah ,gx darah disepanjang ddg pemb darah ,gx dpt muncul tiba-tibadpt muncul tiba-tiba
Adalah kelainan kongenital dimana arteri Adalah kelainan kongenital dimana arteri dan vena langsung dihub oleh satu atau dan vena langsung dihub oleh satu atau lebih fistula,hub langsung ini tanpa lebih fistula,hub langsung ini tanpa perantaraan kapiler.perantaraan kapiler.
Lapisan arteri tdk mpy cukup lap muskulerLapisan arteri tdk mpy cukup lap muskuler
Vena sering dilatasi akibat tekanan aliran Vena sering dilatasi akibat tekanan aliran darah yg tinggi mll fistula.darah yg tinggi mll fistula.
MAV mrp sumber stroke pdarahan dan MAV mrp sumber stroke pdarahan dan umumnya pd usia mudaumumnya pd usia muda
Terapi invasif meliputi embolisasi Terapi invasif meliputi embolisasi endovaskuler,reseksi bedah,dan radiasi endovaskuler,reseksi bedah,dan radiasi fokalfokal
PATOFISIOLOGIPATOFISIOLOGI
Perdarahan
PeningkatanTIK
Influks Ca+
NekrosisNeuron
Iskemiaglobal
Pelepasan agenvasokonstriktor
Efek toksikdarah
Influks Ca+
Vasospsme
Iskemia Fokal
Serotonin, Prostaglandin, darah
Proses Vasospasme Pada PerdarahanProses Vasospasme Pada Perdarahan
Pelepasan zat vasokonstriktor dan komponen darah
Influks Ca+ Sel otot polos pembuluh darah
Vasospasmekuat
Iskemik + defisit neurologik
Lumen vasa darah
Vasospasme
Mediate area are insuficiently supplied with blood, and they die
Proses Aterosklerosis
Dimulai luka sel endotel - permukaan tidak mulus lagi – produksi molekul adesi (ICAM) – peningkatan NO - terjadi ketidak seimbangan (Depolarisasi) - ggn tonus vaskuler - aktivasi monosit menjadi makrofag yg mengambil LDL - foam cell
Foam Cell (sel busa) merupakan komponen penting pembentuk struktur masa plak
Aterotrombosis: Trombus Aterotrombosis: Trombus SuperimposedSuperimposed pada Plak Aterosklerotik pada Plak Aterosklerotik
Adapted from Falk E, et al. Circulation. 1995;92:657-671.
A small clot may break off from a larger thrombus and be carried to other places in the bloodstream. When the embolus reaches an artery too narrow to pass through and becomes lodged, blood flow distal to the fragment ceases, resulting in infarction of distal brain tissue due to lack of nutrients and oxygen.As a cause of stroke, embolism accounts for approximately 32% of cases.
Cerebral Embolism Formation
Evolution of the atherosclerotic plaqueEvolution of the atherosclerotic plaque
1. Accumulation of lipoprotein in intima1. Accumulation of lipoprotein in intima 2. Oxidative stress2. Oxidative stress3. Cytokine activation3. Cytokine activation 4. Monocyte penetration4. Monocyte penetration5. Macrophage foam cells5. Macrophage foam cells 6. Smooth muscle cell 6. Smooth muscle cell
migrationmigration7. Extracellular matrix accumulation7. Extracellular matrix accumulation 8. Calcification and fibrosis8. Calcification and fibrosis
GP IIb/IIIa InhibitorsGP IIb/IIIa Inhibitors
1. Platelet Adhesion
2. Platelet Activation
Platelet
GP Ib
Plaque rupture Activated Platelet
GP IIb/IIIa 3. Platelet Agregation
ASA, Clopidogrel
ASA, Clopidogrel
ASA, acetylsalicyclic acid.Cannon and Braunwald, Heart Disease. 2001.
TxA2
Fibrinogen
Role of platelet at trombosis
< 20 : aktifitas listrik hilang< 10 : Gangguan homeostasis
CBF: CBF: 50 ml / 100 gr jar50 ml / 100 gr jar otak permenit. otak permenit. Oksigen: Oksigen: 6 ml / 100 gr jar6 ml / 100 gr jar otak per menit otak per menit untuk substansia griseauntuk substansia grisea dan dan 2 ml / 100 gr jar2 ml / 100 gr jar otak per menit untuk substansia alba. otak per menit untuk substansia alba. Kebutuhan oksigenKebutuhan oksigen:: 19-23 ml / 100 gr jar 19-23 ml / 100 gr jar otak per menit. otak per menit. Kebutuhan glukosaKebutuhan glukosa: : 4.5 4.5 - - 7 mg / 100 gr jar7 mg / 100 gr jar otak per menit. otak per menit. OtakOtak: : 20% dari seluruh 20% dari seluruh outputoutput jantung, yaitu jantung, yaitu sekitar 800 ml / menitsekitar 800 ml / menit
Proses IskemiProses Iskemi
SumbatanAliran darah Penurunan CBF
Iskemia
ATP, merubah permeabilitas membran
Influks Ca+
berlebihan
Kerusakanmembran
Nekrosis neuron
Cellular Injury During Ischemia
The Ischaemic Cellular Cascade and Targets for Novel Stroke Therapeutic Agents
Cerebral Ischaemia Reperfusion
Neuron depolarisation
Neuronal death
pH Na+ Cl-
adhesion
Glutamate release VGCC open
Intracellular Ca++
PLA2Activation
mitochondria NOS
Organelledamage
Oxidativestress
Tissueresponse
cytokines
molecules
Leukocyteadhesion
inflammation
(1)
Agents stroke iskemik :1. NMDA & AMPA receptor antagonists, Mg+2. Ca A3. NOS inhibitors4. Anti-oxidants5. Adhesion molecule antibodiesVGCC: Voltage gated calcium channelsPLA2 : Fosfolipase A2
(2)
(3)
(4)
(5)
Gadjah Mada Stroke AlgorithmPatient admitted with sudden onset of stroke
Copied from: Rogers (1996) Textbook of Pediatric Intensive Care p. 646
Brain Blood
CSF MassBone
DISTINGUISHING FEATURES HEMORRHAGIC STROKE VS DISTINGUISHING FEATURES HEMORRHAGIC STROKE VS ISCHEMIC STROKEISCHEMIC STROKE : :
FEATURES SUGGESTING HEMORRHAGIC S.FEATURES SUGGESTING HEMORRHAGIC S. : :• early and prolonged loss of consciousnessearly and prolonged loss of consciousness• prominent headache, nausea and vomitingprominent headache, nausea and vomiting• retinal hemorrhagesretinal hemorrhages• nuchal rigiditynuchal rigidity• focal sign do not fit the anatomic pattern of a single focal sign do not fit the anatomic pattern of a single blood vesselblood vessel
FEATURES SUGGESTING ISCHEMIC STROKE :FEATURES SUGGESTING ISCHEMIC STROKE :• stepwise deterioration or progressive worseningstepwise deterioration or progressive worsening• waxing and waning of findingswaxing and waning of findings• focal neurologic impairments in the pattern of single blood focal neurologic impairments in the pattern of single blood vesselvessel• signs point to a focal cortical or subcortical lessionsigns point to a focal cortical or subcortical lession
(Adams Jr. (Adams Jr. et al., et al., 2002)2002)
SIMPTOMS ICHSIMPTOMS ICH
CLINICAL SIGNS OF INTRACEREBRAL HEMORRHAGE CLINICAL SIGNS OF INTRACEREBRAL HEMORRHAGE (1) (1) (Caplan 1988)(Caplan 1988)
Lesion Pupils/eye movement Motor & sensory deficits
Other
Caudate nucleus
Sometimes ipsilaterally constricted/ conjugate deviation to side of lesion
Contralateral hemiparesis, often transient
Headache, confusion
Putamen (small)
Normal/conjugate deviation to side of lesion
Contralateral hemiparesis & hemisensory loss
Aphasia (if lesion on left side)
Putamen (large)
With herniation, pupil dilated on side of lesion/conjugate deviation to side of lesion
Contralateral hemiparesis & hemisensory loss
Decreased consciousness
Thalamus Constricted poorly reactive to light bilaterally/lids retracted. Eyes down and in. Cannot look up.
Slight contralateral hemiparesis but greater hemisensory loss
Aphasia (if lesion on left side)
CLINICAL SIGNS OF INTRACEREBRAL HEMORRHAGE CLINICAL SIGNS OF INTRACEREBRAL HEMORRHAGE (2) (2) (Caplan 1988)(Caplan 1988)
Lesion Pupils/eye movement Motor & sensory deficits
Other
Occipital lobar white matter
Normal Mild, transient hemiparesis
Contralateral hemianopsia
Pons Constricted reactive to light/no horizontal movements. Vertical movements preserved
Quadriplegia Coma
Cerebellum Constriction on side of lesion/slight deviation to opposite side. Movements to side of lesion impaired or 6th cranial nerve palsy
Ipsilateral limb ataxia. No hemiparesis
Gait ataxia, vomiting
Patogenesis pada hipertensiPatogenesis pada hipertensi
Pembuluh darah px hipertensi mudah Pembuluh darah px hipertensi mudah terlukaterlukaterbentuk trombus dari deposit terbentuk trombus dari deposit lemak,sel darah dan komponen darah lemak,sel darah dan komponen darah lainlainaliran darah kencangaliran darah kencangtrombus terlepas trombus terlepas menyumbat lumen.menyumbat lumen.
Insulin Resistance
FFA production Glucose production
Hyperinsulinemia
Dyslipidemia
T2D
SNS activityAbnormal Na+
handling
HTN
Atherosclerosis
Patogenesis pada DMPatogenesis pada DM
Pembuluh darah px Pembuluh darah px DMDMaterosklerotikaterosklerotikmengganggu autoregulasi mengganggu autoregulasi vaskulervaskulerPasien DMPasien DMautoregulasi menurun sampai 10-autoregulasi menurun sampai 10-15cc/100g/mnt 15cc/100g/mnt penumbrapenumbraPenurunan autoregulasi<10cc/100g/mntPenurunan autoregulasi<10cc/100g/mnt peningkatan Ca ekstrasel dan K peningkatan Ca ekstrasel dan K intraselintraselmerusak retikulum merusak retikulum endoplasmikendoplasmikmitokondria terganggumitokondria tergangguasidosis asidosis dan kematian seldan kematian sel
102
Focal Neurological Impairment (prominent and Focal Neurological Impairment (prominent and suggest location of hemorrhage) #1suggest location of hemorrhage) #1
gaze paresisgaze paresis Homonymous hemianopiaHomonymous hemianopia Aphasia (dominant) or Aphasia (dominant) or
neglect (non dominant)neglect (non dominant)
ThalamusThalamus Contralateral hemiparesisContralateral hemiparesis Contralateral sensory lossContralateral sensory loss Contralateral or ipsilateral Contralateral or ipsilateral
conjugate gaze paresisconjugate gaze paresis Downward deviation of Downward deviation of
eyeseyes Small sleggish pupilsSmall sleggish pupils Aphasia (dominant)Aphasia (dominant)
103
Cerebral hemisphere Cerebral hemisphere lobar white matterlobar white matter
Contralateral Contralateral hemiparesis or sensory hemiparesis or sensory lossloss
paresisparesis Ocular bobbingOcular bobbing Pinpoint pupilsPinpoint pupils Hyperthermia and Hyperthermia and
hyperventilationhyperventilation
Focal Neurological Impairment (prominent and suggest location of hemorrhage) #2
104
CerebellumCerebellum
Truncal or gait ataxiaTruncal or gait ataxia IpsilateralIpsilateral
Limb ataxiaLimb ataxia Facial weakness and sensory lossFacial weakness and sensory loss Conjugate gaze palsyConjugate gaze palsy Abducent nerve palsyAbducent nerve palsy
Skew deviationSkew deviation Small reactive pupilsSmall reactive pupils Later developmen of coma and bilateral weakness; Later developmen of coma and bilateral weakness;
sensory loss possible sensory loss possible
Focal Neurological Impairment (prominent and suggest location of hemorrhage) #3
105
LocationsLocations
The most common locations for hypertensive The most common locations for hypertensive hemorrhage are:hemorrhage are:PutamenPutamenThalamusThalamusLobar white matter of the cerebral hemispheresLobar white matter of the cerebral hemispheresBrain stem (pons in particular)Brain stem (pons in particular)CerebellumCerebellum
These locations reflect the vascular teerritories of short These locations reflect the vascular teerritories of short penetrating branches (arterioles) arising from the major penetrating branches (arterioles) arising from the major intracranial arteries.intracranial arteries.
106
INTRACEREBRAL HEMORRHAGE
107
PenatalaksanaanPenatalaksanaan
108
Hasil optimal terapi Stroke perdarahan Hasil optimal terapi Stroke perdarahan sampai 96 jamsampai 96 jam setelah onset setelah onset
Puncak vasospasme antara hari ke 5-10)Puncak vasospasme antara hari ke 5-10)
109
ManagementManagement In emergency RoomIn emergency Room
– ABC rulesABC rules– BP continuous monitoringBP continuous monitoring– Continuous ECG monitoringContinuous ECG monitoring– O2 pulse oxymetryO2 pulse oxymetry– 2 IV lines (norma saline only)2 IV lines (norma saline only)– Blood (CBC, SMAC, RBS, PTT, INR)Blood (CBC, SMAC, RBS, PTT, INR)– Save 6 ml of bloodSave 6 ml of blood– Facilitate transfer to the operating room or ICUFacilitate transfer to the operating room or ICU
The mainstay of acute treatment (A,B,C)The mainstay of acute treatment (A,B,C)Treatment and stabilisation of general conditionTreatment and stabilisation of general conditionSpecific therapySpecific therapy– Recanalisation of a vessel occlusionRecanalisation of a vessel occlusion– Preventive of mecanism leading to neuronal death Preventive of mecanism leading to neuronal death
in the ischhemic brainin the ischhemic brain
Early secondary preventionEarly secondary preventionEarly rehabilitationEarly rehabilitationProphylaxis and treatment of complicationsProphylaxis and treatment of complications
(Lamsudin, 2004)
111
Blood pressureBlood pressure– There are adequately sized randomized , controlled There are adequately sized randomized , controlled
study guiding BP mangementstudy guiding BP mangement– Elevated BP (sistolic>200mmHg or diastolic Elevated BP (sistolic>200mmHg or diastolic
>110mmHg0 may tolerated in the acute phase>110mmHg0 may tolerated in the acute phase– Avoid and treat hypotension or drastic reduction BPAvoid and treat hypotension or drastic reduction BP– BP may be lowered if cardiac condition require itBP may be lowered if cardiac condition require it
Antihypertensive treatment should await Antihypertensive treatment should await the spontaneous decline in BP (within 1the spontaneous decline in BP (within 1stst to 10to 10thth days). If increased BP persist after days). If increased BP persist after 7-10 days, start treatment.7-10 days, start treatment.
Patients already on antihypertensive Patients already on antihypertensive medication prior to stroke, drugs should medication prior to stroke, drugs should be held or reduced for 7-10 days (except be held or reduced for 7-10 days (except B-blockers, should be gradually over 5-6 B-blockers, should be gradually over 5-6 days)days)
Treat If:Treat If:1.1. BP is > 220/140 or MAP >130 mmHgBP is > 220/140 or MAP >130 mmHg2.2. Malignant or hypertensive encephalopathyMalignant or hypertensive encephalopathy3.3. Acute MIAcute MI4.4. Aortic dissection is suspectedAortic dissection is suspected5.5. BP is >180/100 and patient is for thrombolytic BP is >180/100 and patient is for thrombolytic
therapytherapy6.6. 24 hours following thrombolytic therapy 24 hours following thrombolytic therapy
(>185/110)(>185/110)
Blood Pressure (BP) Management Protocol in Acute Stroke
The Following medications can be used, if needed:The Following medications can be used, if needed: Esmolol bolus (500 ug/kg IV)Esmolol bolus (500 ug/kg IV) Esmolol infusion (50-150 ug/kg/min) IV, (Body weight x 60 mg of Esmolol infusion (50-150 ug/kg/min) IV, (Body weight x 60 mg of
esmolol diluted in 100 ml of saline, in a rate of 5-15 ml/hour)esmolol diluted in 100 ml of saline, in a rate of 5-15 ml/hour) Labetalol infusion (15-35 ug/kg/ml) IV, (Body weight x 6 mg of Labetalol infusion (15-35 ug/kg/ml) IV, (Body weight x 6 mg of
labetalol diluted in 100 ml of saline, in a rate of 15-35 ml/hour)labetalol diluted in 100 ml of saline, in a rate of 15-35 ml/hour) Labetalol 100-200 mg bid-tid. POLabetalol 100-200 mg bid-tid. PO Analaprilat 1,25-5 mg IV, 6 hourlyAnalaprilat 1,25-5 mg IV, 6 hourly Lasix 20-40 mg iv tid-qidLasix 20-40 mg iv tid-qid Nicardipin 5 mg/hour IVNicardipin 5 mg/hour IV Clonidine 150-300 mg iv bolus (maximum of 750 mg per day)Clonidine 150-300 mg iv bolus (maximum of 750 mg per day) Sodium nitroprusside 0,25-0,5 mg/kg/minSodium nitroprusside 0,25-0,5 mg/kg/min
Avoid the use of calcium channel blockers and Avoid the use of calcium channel blockers and sodium nitropusside as possiblesodium nitropusside as possible
Blood Pressure (BP) Management Protocol in Acute Stroke
Lowering of blood pressure Lowering of blood pressure In acute ischemic stroke ,there is one of:In acute ischemic stroke ,there is one of:
with acute infark miocard /heart with acute infark miocard /heart failure or acute kidney failure / failure or acute kidney failure / aorta toracalisaorta toracalis
118
Cushing reflexHaematom as a secondary ICPoxyhemoglobin and bilirubin , causing the intracranial hypertensi and blocking the lcs absorbtionHight catecolamin value
Dapat segera diberikan Dapat segera diberikan walaupun diagnosa belum walaupun diagnosa belum jelasjelas
Dapat mencegah dan Dapat mencegah dan merelaksasi timbulnya merelaksasi timbulnya vasospasmevasospasme
Aman dan dapat diberikan pada Aman dan dapat diberikan pada penderita yang akan dioperasi penderita yang akan dioperasi tanpa meningkatkan risiko tanpa meningkatkan risiko perdarahan ulang perdarahan ulang
Iskemik / Infark( Stroke/Cedera Otak sekunder)
Dapat segera diberikan pada
penderita trauma kepala derajat sedang sampai berat
Dapat mencegah dan mengatasi defisit neurologik iskemik
Dapat menyelamatkan sel neuron penumbra
Mencegah meluasnya infark sel neuron
NON SURGICAL CANDIDATESNON SURGICAL CANDIDATES1. Small hemorrhages (<10 cm3) or minimal neurological deficits.1. Small hemorrhages (<10 cm3) or minimal neurological deficits.2. GCS score 2. GCS score 4. Except for cerebellar hemorrhage with brainstem 4. Except for cerebellar hemorrhage with brainstem
compression for livesaving surgery.compression for livesaving surgery.
SURGICAL CANDIDATESSURGICAL CANDIDATES1. Cerebellar hemorrhage > 3 cm who are neurologically 1. Cerebellar hemorrhage > 3 cm who are neurologically
deteriorating or who have brainstem compression and deteriorating or who have brainstem compression and hydrocepahalus from ventricular obstruction.hydrocepahalus from ventricular obstruction.
2. ICH with structural lesion eg aneurysm, AVM, or cavernous 2. ICH with structural lesion eg aneurysm, AVM, or cavernous angioma.angioma.
3. Young patients with a moderate or large lobar hemorrhage who 3. Young patients with a moderate or large lobar hemorrhage who are clinicallyare clinically deteriorating. deteriorating.
Rekomendasi tindakan pembedahan pada perdarahanRekomendasi tindakan pembedahan pada perdarahanintreaserebralintreaserebral
Ismail S, 2008
128
FINAL RESULTS OF THE INTERNATIONAL SURGICAL TRIAL IN ICH FINAL RESULTS OF THE INTERNATIONAL SURGICAL TRIAL IN ICH (ISTICH)(ISTICH)
(Mendelow WSC 2004)(Mendelow WSC 2004)
1033 patients with spontaneous supratentorial ICH 1033 patients with spontaneous supratentorial ICH 107 centers in 27 countries.107 centers in 27 countries.
23.8% favourable outcome in “early conse23.8% favourable outcome in “early conserrvative vative treatment” vs 26.1% in “early surgery” (NS).treatment” vs 26.1% in “early surgery” (NS).
Mortality 63.7 % vs 62.6 % (NS); Rankin score Mortality 63.7 % vs 62.6 % (NS); Rankin score 28.1% vs 32.8% (NS); Barthel 22.6% vs 26.7% 28.1% vs 32.8% (NS); Barthel 22.6% vs 26.7% (NS).(NS).
Superficial location (<1cm from surface) favour Superficial location (<1cm from surface) favour early surgery. early surgery.
129
MannitolMannitol
1.1. Lowering ICP : Lowering ICP : Immediate plasma expansionImmediate plasma expansion : reduce : reduce the hematocrit and blood viscosity (improved the hematocrit and blood viscosity (improved rheology) which increases CBF and Orheology) which increases CBF and O22 delivery. delivery. Osmotic effectOsmotic effect : increased serum tonicity draws : increased serum tonicity draws edema fluid from cerebral parenchyma.edema fluid from cerebral parenchyma.
2.2. Supports the microcirculation by improving blood Supports the microcirculation by improving blood rheologyrheology
3.3. Possible free scavengingPossible free scavenging(Greenberg,2000)(Greenberg,2000)
Rehabilitasi (WHO): Tindakan bertujuan Rehabilitasi (WHO): Tindakan bertujuan mengurangi dampak disabilitas/handicap agar mengurangi dampak disabilitas/handicap agar dapat berintegrasi dg masyarakat.dapat berintegrasi dg masyarakat.
Fisioterapi mrp sub instalasi rehabilitasiFisioterapi mrp sub instalasi rehabilitasitx tx okupasi,ortotik prostetik,terapi wicara,psikologi okupasi,ortotik prostetik,terapi wicara,psikologi dan sosial medikdan sosial medik
TujuanTujuan
Memperbaiki fungsi Memperbaiki fungsi motorik,wicara,kognitif,dan fungsi lain motorik,wicara,kognitif,dan fungsi lain yang tergangguyang terganggu
Readaptasi sosial dan mental untuk Readaptasi sosial dan mental untuk memulihkan hubungan interpersonal dan memulihkan hubungan interpersonal dan aktivitas sosialaktivitas sosial
Dapat melaksanakan aktivitas kehidupan Dapat melaksanakan aktivitas kehidupan sehari-harisehari-hari
lanjutanlanjutan
Prinsip rehabilitasi strokePrinsip rehabilitasi stroke penderita tidak penderita tidak tergantung pada orang laintergantung pada orang lain
Keberhasilan bukan dari banyaknya jiwa Keberhasilan bukan dari banyaknya jiwa yg tertolong tp berapa banyak penderita yg tertolong tp berapa banyak penderita berfx lagi dimasyarakatberfx lagi dimasyarakat
138
RehabilitationRehabilitation
EUSI RecommendationsEUSI Recommendations1. Rehabilitation should be initiated early after 1. Rehabilitation should be initiated early after
stroke stroke (Level I)(Level I)
2. Every patient should have access to evaluation 2. Every patient should have access to evaluation for rehabilitation for rehabilitation (Level III)(Level III)
3. Rehabilitation services should be provided by a 3. Rehabilitation services should be provided by a multidisciplinary team multidisciplinary team (Level III)(Level III)
139
Rehabilitation Program : Rehabilitation Program :
Physical therapy :Physical therapy :•MobilizationMobilization•WalkingWalking•Major motor or sensory impairment of the Major motor or sensory impairment of the
limbslimbs•Prescription of devices, such as a cane or Prescription of devices, such as a cane or
walkerwalker
Occupational Therapy :Occupational Therapy :•Fine movements of the handFine movements of the hand•Arm function Arm function •Utilization of toolsUtilization of tools•Assistive devicesAssistive devices•Ability to function independentlyAbility to function independently
140
Speech TherapySpeech Therapy : :
• Disorders of languageDisorders of language
• Disorders of articulationDisorders of articulation
• Disorders of swallowingDisorders of swallowing
Faktor yang berpengaruh pada Faktor yang berpengaruh pada hasil akhir rehabilitasihasil akhir rehabilitasi
Penyebab strokePenyebab strokeBeratnya strokeBeratnya strokeLokasi strokeLokasi strokeUsia penderitaUsia penderitaMotivasi penderita,kepribadian premorbit dan moodMotivasi penderita,kepribadian premorbit dan moodKeluarga penderitaKeluarga penderitaSistem sosio ekonomi penderita dan keluargaSistem sosio ekonomi penderita dan keluargaDefisit neurologi yang khususDefisit neurologi yang khususWaktu,awal,lamanya dan intensitas pemberian terapi Waktu,awal,lamanya dan intensitas pemberian terapi rehabilitasirehabilitasiTim rehabilitasiTim rehabilitasi
142
Komplikasi StrokeKomplikasi Stroke
DemensiaDemensia
DepresiDepresi
KecacatanKecacatan
EpilepsiEpilepsi
KontrakturKontraktur
Peptic ulcerPeptic ulcer
BronchopneumoniaBronchopneumonia
DekubitusDekubitus
SeptikemiaSeptikemia
Trombosis vena Trombosis vena profundaprofunda
Emboli pulmoEmboli pulmo
Ggn keseimbangan Ggn keseimbangan cairancairan
143
Risk of Stroke RecurrenceRisk of Stroke Recurrence(percentage experiencing (percentage experiencing stroke)stroke)
Largest branch of Internal Largest branch of Internal Carotid.Carotid.
Supplies portion of frontal Supplies portion of frontal lobe and lateral surface of lobe and lateral surface of Temporal and Parietal Temporal and Parietal lobes.lobes.
Primary Motor and Sensory Primary Motor and Sensory areas for face, throat , hand areas for face, throat , hand and arm.and arm.
Dominant hemisphere, Dominant hemisphere, supplies area controlling supplies area controlling speech.speech.
Is the Artery most often Is the Artery most often occluded in stroke.occluded in stroke.
146
The MCA proceeds laterally into the lateral sulcus The MCA proceeds laterally into the lateral sulcus and spreads to supply virtually the entire lateral and spreads to supply virtually the entire lateral surface of the cerebral hemiphere, where most of surface of the cerebral hemiphere, where most of the precentral and postcentral gyri are located.the precentral and postcentral gyri are located.
Included in this region are the motor speech of Included in this region are the motor speech of area Broca and the sensory language area of area Broca and the sensory language area of Wernickle.Wernickle.
MCA also supply the putamen, part of the caudate MCA also supply the putamen, part of the caudate nucleus, the outer globus pallidus, the posterior nucleus, the outer globus pallidus, the posterior limb of the internal capsule and the corona limb of the internal capsule and the corona radiata.radiata.
Characterized by weakness of the Characterized by weakness of the contralateral face with hemianopsia and a contralateral face with hemianopsia and a preference of the eyes and head toward preference of the eyes and head toward the side of the involved hemisperethe side of the involved hemispere
Aphasia in dominant hemisphere injuryAphasia in dominant hemisphere injury HemineglectHemineglect Involvement restricted to branches of the Involvement restricted to branches of the
MCA may produces fragment of this MCA may produces fragment of this syndrome sparing of leg strenghsyndrome sparing of leg strengh
Weakness - upper and lower extremity (C)Weakness - upper and lower extremity (C) Weakness - face - lower half (C)Weakness - face - lower half (C) Hemisensory loss - upper and lower extremity (C)Hemisensory loss - upper and lower extremity (C) Sensory loss - face - all modalities (C)Sensory loss - face - all modalities (C) Aphasia – receptive (D)Aphasia – receptive (D) Aphasia – expressive (D)Aphasia – expressive (D) Hemineglect (ND)Hemineglect (ND) Lateral gaze weakness (C)Lateral gaze weakness (C) Gaze preference (C)Gaze preference (C) Visual loss - homonymous hemianopia (C)Visual loss - homonymous hemianopia (C)
(AHA Stroke Center, 2004)
149
Stroke SyndromesStroke SyndromesMiddle cerebral artery – superior divisionMiddle cerebral artery – superior division
Weakness - upper and lower extremity (C)Weakness - upper and lower extremity (C) Weakness - face - lower half (C)Weakness - face - lower half (C) Hemisensory loss - upper and lower extremity (C)Hemisensory loss - upper and lower extremity (C) Sensory loss - face - all modalities (C)Sensory loss - face - all modalities (C) Hemineglect (ND)Hemineglect (ND) Aphasia – expressive (D)Aphasia – expressive (D)
(AHA Stroke Center, 2004)
150
Visual loss - homonymous hemianopia Visual loss - homonymous hemianopia (C)(C)
Visual loss - upper quadrant anopsia Visual loss - upper quadrant anopsia (C)(C)
The ACA follow the corpus callosum The ACA follow the corpus callosum supplying the anterior four fifths of supplying the anterior four fifths of the corpus callosum and medial the corpus callosum and medial aspect of the frontal and parietal aspect of the frontal and parietal lobes. Deep branches, arising near lobes. Deep branches, arising near the circle of Willis, supply the anterior the circle of Willis, supply the anterior limb of the internal capsule, the limb of the internal capsule, the inferior head of caudate nucleus and inferior head of caudate nucleus and the anterior part of the globus the anterior part of the globus pallidus.pallidus.
Much rarerMuch rarer The classic presentation is proximal arm/leg The classic presentation is proximal arm/leg
weakness with present of distal strength, the weakness with present of distal strength, the so-called “man in a barrel”so-called “man in a barrel”
ACA occlusions cause contralateral motor and ACA occlusions cause contralateral motor and somatosensory deficits, primarily of the lower somatosensory deficits, primarily of the lower extremities.extremities.
In addition, apraxia, mental and personal In addition, apraxia, mental and personal changes, primitiv reflexes and bowel and changes, primitiv reflexes and bowel and bladder incontinence often ptresentbladder incontinence often ptresent
Involves the brainstem, cerebellum, thalamus Involves the brainstem, cerebellum, thalamus & occipital lobes& occipital lobes
Present with bilateral limb weakness or sensory Present with bilateral limb weakness or sensory disturbances, cranial nerve defisit, ataxia, disturbances, cranial nerve defisit, ataxia, nausea, and vomiting or comanausea, and vomiting or coma
occlusion of the basilar artery trunk : Present occlusion of the basilar artery trunk : Present with hemianopia, memory disturbance, mild with hemianopia, memory disturbance, mild personality disturbancepersonality disturbance
Rarely; bilateral thalamus : a state of Rarely; bilateral thalamus : a state of decreased responsiveness and apathy without decreased responsiveness and apathy without motor, sensory or visual impairmentmotor, sensory or visual impairment
156
AFASIAAFASIA
157
AFASIAAFASIAAfasia adalah:Afasia adalah:
gangguan kemampuan berbahasa gangguan kemampuan berbahasa seseorang yang disebabkan oleh seseorang yang disebabkan oleh kerusakan otak akibat suatu kerusakan otak akibat suatu stroke(gangguan peredaran darah di otak)stroke(gangguan peredaran darah di otak)(Dharmaperwira prins,1993)(Dharmaperwira prins,1993)
158
Penyebab AfasiaPenyebab AfasiaGPDO(gangguan peredaran darah di GPDO(gangguan peredaran darah di otak),(trombosis,emboli,perdarahan otak)otak),(trombosis,emboli,perdarahan otak)
Lokasi lesi: bagian posterior fasikulus Lokasi lesi: bagian posterior fasikulus arkuatus hemisfer kiriarkuatus hemisfer kiri
Gangguan pada arteri parietalis posteriorGangguan pada arteri parietalis posterior
164
Afasia GlobalAfasia GlobalLokasi lesi: daerah fronto temporoparietal Lokasi lesi: daerah fronto temporoparietal perisylvis di hemisfer kiriperisylvis di hemisfer kiri
Semua aspek bahasa & bicara tergangguSemua aspek bahasa & bicara terganggu
Sumbatan pada bagian depan arteri Sumbatan pada bagian depan arteri serebri media,bisa juga karena hematom serebri media,bisa juga karena hematom yang luasyang luas
Nama lain: sindrom isolasi anterior,afasia Nama lain: sindrom isolasi anterior,afasia dinamisdinamis
Lokasi lesi:frontal hemisfer kiriLokasi lesi:frontal hemisfer kiri
Gangguan pada arteri orbitofrontolateral dan Gangguan pada arteri orbitofrontolateral dan cabang terminal arteri serebri anteriorcabang terminal arteri serebri anterior
Kerusakan di area border zone parietalis Kerusakan di area border zone parietalis temporalis oleh arteri serebri media dan temporalis oleh arteri serebri media dan arteri serebri posteriorarteri serebri posterior
• Damage to Broca’s area alone is not enough to produce Broca’s aphasia
• Usually involves Broca’s area + surrounding areas including M1 & insula.
Wernicke’s Aphasia
• Damage to Wernicke’s area alone is not enough to produce Wernicke’s aphasia
• Usually involves Wernicke’s area + surrounding areas including MTG & angular gyrus.
Conduction Aphasia
• Damage to the arcuate fasciculus has not been associated with conduction aphasia
• Usually two lesion patterns: posterior STG (wernicke’s areas) and/or SMG
Common area?
Transcortical Sensory Aphasia
• Variable lesion patterns, mostly posterior to Wernicke’s area
• Deficit tends to be transient evolving into anomic aphasia
Common area?
Transcortical Motor Aphasia
• Damage often anterior and/or superior to Broca’s area
Global Aphasia
• Tend to be large “peri-Sylvian” lesions• But smaller lesions can also cause global aphasia
Tx. APHASIATx. APHASIAPiracetam had a potential effect on cognitive Piracetam had a potential effect on cognitive functions functions used in the treatment of aphasia (4.8 g daily used in the treatment of aphasia (4.8 g daily over 6 to12 weeks) but the mechanism over 6 to12 weeks) but the mechanism remained a matter of speculation.remained a matter of speculation.
Piracetam as an Piracetam as an adjuvant to speech therapyadjuvant to speech therapy improves recoveryimproves recovery of various language functions, of various language functions, and this effect is accompanied by a significant and this effect is accompanied by a significant increase of task-related flow activation in eloquent increase of task-related flow activation in eloquent areas of the left hemisphere. areas of the left hemisphere.
(Kessler (Kessler et al.,et al., 2000) 2000)
179
Speech Tx and AphasiaSpeech Tx and Aphasia
The efficacy of The efficacy of speech therapyspeech therapy is is still controversialstill controversial, , with several randomized controlled trials yielding no with several randomized controlled trials yielding no difference in outcome between treated and nontreated difference in outcome between treated and nontreated groups. groups.
(Ferro (Ferro et al. cit et al. cit Kessler Kessler et alet al., 2000) ., 2000)
On the other hand, most author assume a beneficial On the other hand, most author assume a beneficial specific effect of speech therapy particularly when it is specific effect of speech therapy particularly when it is intense and starts earlyintense and starts early. .
(Musso (Musso et al.et al., 1999), 1999)
RECOVERY FROM APHASIARECOVERY FROM APHASIA
Two mechanismsTwo mechanisms for recovery from aphasia, for recovery from aphasia, repair of damaged repair of damaged language networkslanguage networks and and activation of compensatory areas. activation of compensatory areas.
Recovery must involve regions Recovery must involve regions outside the morphologically damaged outside the morphologically damaged areaarea that regain or take over language functions lost in acute stroke. that regain or take over language functions lost in acute stroke.
The The restoration of left hemisphere language networksrestoration of left hemisphere language networks is associated is associated with better recovery and inversely related to activity in the with better recovery and inversely related to activity in the compensated compensated
or recruited areas of the right hemisphere. or recruited areas of the right hemisphere.
(Cao (Cao et alet al., 1999 and Kessler ., 1999 and Kessler et al.,et al., 2000) 2000)
PROGNOSISPROGNOSIS
Most of the Most of the spontaneous recoveryspontaneous recovery in linguistic function in linguistic function occurs in the occurs in the first weeksfirst weeks after stroke and is after stroke and is completed by completed by
the end of the first yearthe end of the first year, although reports exist of , although reports exist of improvements occurring as a result of improvements occurring as a result of long-term therapylong-term therapy of of
patients with chronic aphasia patients with chronic aphasia
(Pulvermuller (Pulvermuller et alet al., 2001).., 2001).
182
Faktor –Faktor PrognosisFaktor –Faktor Prognosis
Luas cederaLuas cedera
Letak cederaLetak cedera
Keparahan afasiaKeparahan afasia
UmurUmur
Intelegensi dan PendidikanIntelegensi dan Pendidikan
LateralisasiLateralisasi
KepribadianKepribadian
183
TADIRTADIR
TES AFASIATES AFASIA
UNTUKUNTUK
DIAGNOSISDIAGNOSIS
INFORMASIINFORMASI
REHABILITASIREHABILITASI
184
Tujuan TADIRTujuan TADIR
Membuat diagnosis afasia /bukan afasiaMembuat diagnosis afasia /bukan afasia
Membuat diagnosis sindrom afasia manaMembuat diagnosis sindrom afasia mana
Memberi informasi kepada pasien, Memberi informasi kepada pasien, lingkungannya dan orang ketiga lainlingkungannya dan orang ketiga lain
Menjadi titik tolak untuk penangananMenjadi titik tolak untuk penanganan
We found 22 subjects (36 %) We found 22 subjects (36 %) with with hyperhomocysteinemia, hyperhomocysteinemia, which is mild which is mild hyperhomocysteinemia (21 hyperhomocysteinemia (21 subject /34,4 %) subject /34,4 %)
There were 22 patients (36 There were 22 patients (36 %) with %) with hyperhomocysteinemia, and hyperhomocysteinemia, and most of them had mild most of them had mild hyperhomocysteinemia (hyperhomocysteinemia ( 15 – 30 15 – 30 mol/L) (21 patients mol/L) (21 patients or 34,4 %) with or 34,4 %) with meanmean homocysteine 19,60 homocysteine 19,60 3,08. 3,08.
TheThe prevalence of prevalence of hyperhomcysteinemia is still hyperhomcysteinemia is still high in vascular dementiahigh in vascular dementia
Result of studies on Homocysteine in Indonesia
N Mean tHcy (mmol/L)
Tugasworo 30 Stroke 14.34±5.45(33% Hyper Hcy)
Meta-analyses of 27 clinical studies Elevation in risk associated with
5 µM increment in tHcy
Cerebrovasc.dis. M/F1.9
(1.6-2.3)(11 studies)
Boushey et al, JAMA 1995
Stroke Stroke increases the increases the
risk of risk of subsequent hip subsequent hip fracture by 2 to fracture by 2 to
4 times.4 times.
Increased fracture risk is a Increased fracture risk is a recognized complication recognized complication followingfollowing strokestroke. Bone loss . Bone loss following a hemiplegic following a hemiplegic strokestroke has been proposed has been proposed
as a major risk factor for as a major risk factor for post-post-strokestroke hip fracture, hip fracture, with awith a recent focus on the recent focus on the development of novel development of novel therapeutic measurestherapeutic measures to to prevent bone loss and prevent bone loss and fractures after fractures after strokestroke. We . We brieflybriefly review the literature review the literature on the epidemiology and on the epidemiology and pathophysiologypathophysiology of bone of bone loss and hip fracture after loss and hip fracture after strokestroke, and then critically, and then critically
review recent studies on review recent studies on preventive strategies.preventive strategies.
Hip fractures after stroke and their preventionP.K. Myint1,2, K.E.S. Poole3 and E.A. Warburton1
Increased Increased Osteoclast Activity Osteoclast Activity in the Presence of in the Presence of Increased Increased Homocysteine Homocysteine ConcentrationsConcentrations
may be an may be an independent risk independent risk factor for osteoporotic factor for osteoporotic fractures and fractures and therefore may also therefore may also adversely affect bone adversely affect bone metabolism.metabolism.Markus Herrmann,1 Thomas Widmann,2 Graziana Markus Herrmann,1 Thomas Widmann,2 Graziana
Colaianni,3 Silvia Colucci,3 Colaianni,3 Silvia Colucci,3 Alberta Zallone,3 and Alberta Zallone,3 and Wolfgang Herrmann1*Wolfgang Herrmann1*Clinical Chemistry 51, No. 12, Clinical Chemistry 51, No. 12, 200200
Increased plasma homocysteine (Hcys)
Several studies found that Several studies found that cobalamin and cobalamin and
folate status are related to folate status are related to bone mineral density (BMD) bone mineral density (BMD)
and fracture riskand fracture risk
Markus Herrmann,1 Thomas Widmann,2 Graziana Markus Herrmann,1 Thomas Widmann,2 Graziana Colaianni,3 Silvia Colucci,3 Colaianni,3 Silvia Colucci,3 Alberta Zallone,3 and Alberta Zallone,3 and Wolfgang Herrmann1*Wolfgang Herrmann1*Clinical Chemistry 51, No. 12, 200Clinical Chemistry 51, No. 12, 200
In a 2-year prospective, placebo-controlled, double-blind trial, Sato et al. (29 ) observed a strong reductionin fracture incidence in stroke patients who received high doses of folate and vitamin B12.
In addition, low cobalamin status has been shown to reduce osteoblast activity Nothing is known, however, about osteoclast (OC) function in the presence of increased HCY or low B vitamin concentrations.
It has been suggested that disturbed crosslinking of collagen fibrils and reduced fibrillin-1 and -2 deposition lead to a disturbed architecture of bone matrix in homocystinuric patients.
> The impact of intermolecular collagen cross-links in bone has been adduced, in part, from studies of lathyrism The sweet pea (Lathyrus odoratus) compound -aminopropionitrile irreversibly inhibits lysyl oxidase and blocks initial collagen cross-link formation. This effect could lead to reduced bone quality and might be an alternative explanation for an increased fracture risk in hyperhomocysteinemic patients.
SEDIAAN
active form CH3 (methyl - )
Jenis Vitamin B12 dan manfaatnya
B12
TIDAK AKTIF
AKTIF
CN
Co Vitamin B komplekB1, B6, B12
Vit B kompleksB1, B6, B12
OH
Co
OHOH
CH2
Co
Dalam Liver
Hycobal
Dalam Serum
CH3
Co
Memperbaiki neuropatimelalui sintesis asam nukleat,protein dan fosfolipid
CH3
Co
Neuropatiperifer
Neuropatiperifer
Memperbaiki anemiamelalui sintesis heme
Anemia dan neuropati akibat defisiensi dan Metabolisme abnormal vit. B1 B6 B12
Anemia dan neuropati akibat defisiensi dan Metabolisme abnormal vit. B1 B6 B12
Anemia dan neuropati akibat defisiensi dan Metabolisme abnormal vit. B1 B6 B12
Anemia dan neuropati akibat defisiensi dan Metabolisme abnormal vit. B1 B6 B12
Memperbaiki Defisiensi cobalamin
Memperbaiki Defisiensi cobalamin
Kadar Homosistein me
Faktor Risiko gangguan Serebrovaskuler
koroner, peny. Pembuluh darah tepiTrombosis vena
KADAR DALAM
SERUM & LCS
highly concentration in CSF and serum
ditransportasikan dengan kadar yang ditransportasikan dengan kadar yang tinggi tinggi
ke dalam organel sel – sel sarafke dalam organel sel – sel saraf
A double-blind, randomized A double-blind, randomized controlled study of 628controlled study of 628
consecutive patients aged 65 consecutive patients aged 65 years or older with residual years or older with residual hemiplegia at least 1 yearhemiplegia at least 1 year
following first ischemic stroke, following first ischemic stroke, who were recruited from a who were recruited from a single Japanese hospital fromsingle Japanese hospital from
April 1, 2000, to May 31, April 1, 2000, to May 31, 2001. Patients were assigned 2001. Patients were assigned to daily oral treatment with to daily oral treatment with 5mg of folate and 1500 μg of 5mg of folate and 1500 μg of mecobalamin, or double mecobalamin, or double placebo; 559 completed theplacebo; 559 completed the
2-year follow-up.2-year follow-up.
Yoshihiro Sato, MDYoshihiro Sato, MD
Yoshiaki Honda, MDYoshiaki Honda, MD
Jun Iwamoto, MDJun Iwamoto, MD
Tomohiro Kanoko, PhDTomohiro Kanoko, PhD
Kei Satoh, MDKei Satoh, MD
In this Japanese population with a In this Japanese population with a high baseline fracture risk, high baseline fracture risk, combinedcombined
treatment with folate treatment with folate and vitamin B12 is and vitamin B12 is safe and effective in safe and effective in reducing the risk of a reducing the risk of a hip fracture in elderly hip fracture in elderly patients following patients following stroke.stroke.
Amelioration by Amelioration by mecobalamin of subclinical mecobalamin of subclinical
carpal tunnel syndrome carpal tunnel syndrome involving unaffected limbs in involving unaffected limbs in
stroke patientsstroke patientsThe purpose of this study was to evaluate the effects of the The purpose of this study was to evaluate the effects of the orally administered orally administered mecobalaminmecobalamin, an analogue of vitamin B12, , an analogue of vitamin B12, for carpal tunnel syndrome (CTS) in the nonparetic side in for carpal tunnel syndrome (CTS) in the nonparetic side in patients following patients following strokestroke. In a randomized open label and . In a randomized open label and prospective study of prospective study of strokestroke patients, 67 received of 1500 mug patients, 67 received of 1500 mug mecobalaminmecobalamin daily for 2 years, and the remaining 68 daily for 2 years, and the remaining 68 (untreated group) did not. At baseline, sensory nerve conduction (untreated group) did not. At baseline, sensory nerve conduction velocity, motor nerve conduction velocity, sensory nerve action velocity, motor nerve conduction velocity, sensory nerve action potentials (SNAP) at the wrist, palm-to-wrist distal sensory potentials (SNAP) at the wrist, palm-to-wrist distal sensory latency, palm-to-wrist SNAP, motor nerve conduction velocity latency, palm-to-wrist SNAP, motor nerve conduction velocity compound motor action potentials, and distal motor latency of compound motor action potentials, and distal motor latency of median nerve were significantly more abnormal on the median nerve were significantly more abnormal on the nonparetic side than on the hemiparetic side or in controls. nonparetic side than on the hemiparetic side or in controls. Before the treatment 21 patients (31%) of untreated and 20 Before the treatment 21 patients (31%) of untreated and 20 patients (30%) of treated group met electrophysiologic criteria patients (30%) of treated group met electrophysiologic criteria for CTS. Sensory impairment of the nonparetic side had for CTS. Sensory impairment of the nonparetic side had lessened in the treated group. After 2 years, all lessened in the treated group. After 2 years, all electrophysiologic indices of nonparetic side were significantly electrophysiologic indices of nonparetic side were significantly improved in the treated group compared with those in the improved in the treated group compared with those in the untreated group. The improvement from baseline of untreated group. The improvement from baseline of electrophysiologic parameters in sensory nerve in the treated electrophysiologic parameters in sensory nerve in the treated group was greater than the improvement measured in motor group was greater than the improvement measured in motor nerve. There were no side effects. Oral nerve. There were no side effects. Oral mecobalaminmecobalamin treatment is a safe and potentially beneficial treatment is a safe and potentially beneficial therapytherapy for CTS in for CTS in strokestroke patients. patients.
Department of Neurology, Mitate Hospital, 3237 Department of Neurology, Mitate Hospital, 3237 Yugeta, Tagawa 826-0041, Japan. y-Yugeta, Tagawa 826-0041, Japan. [email protected]@ktarn.or.jp
overuse of the non paretic hand and wrist of the nonparetic side following stroke result in significantly more abnormal on the nonparetic side than on the hemiparetic side in terms of electrophysiologic indices of median nerve function.
An active form of cobalaminAn active form of cobalamin
Participates in transmethylationParticipates in transmethylation
Improves synthesis of proteins, nucleicImproves synthesis of proteins, nucleic
acids and phospholipids which are needed acids and phospholipids which are needed in in
the repair of damaged nerves.the repair of damaged nerves.
Farmakokinetik
1. AbsorpsiB12 yang terdapat dalam makanan akan berikatan dengan Faktor Intrinsik(FI) dalam lambung dan diabsorpsi oleh usus. B12 tidak dapat diabsorpsi tanpa FI. Sehingga pada pasien lanjut usia, yang terinfeksi Helicobacter pylori atau gangguan gastrointestinal lainnya beresiko mengalami defisiensi B12. Bahkan pada pasien yang diangkat lambungnya (seperti pada ulkus dan kanker) maka absorpsi B12 dari makanan adalah nol.
Tetapi, jika B12 diberikan dalam dosis farmakologi(yang berarti dipakai sebagai obat dalam bentuk tablet atau kapsul), maka FI tidak dibutuhkan untuk absorpsinya
2. DistribusiSetelah vitamin B12 diabsorpsi oleh aliran darah, vitamin B12 berikatan dengan transcobalamin II (pembawa protein). Kompleks B12-transcobalamin II ditransportasikan ke dalam sel kemudian dihidrolisa. Nasib B12 selanjutnya adalah berperan dalam proses transmetilasi atau disimpan sebagai adenosilcobalamin.
Hidroksocobalamin akan menghasilkan bentuk antibodi dari transcobalamin II-B12 kompleks (menginaktifkan kompleks). Sehingga penggunaan hidroksocobalamin tidak direkomendasikan.
Methylcobalamin merupakan sediaan yang sudah dalam bentuk aktif untuk perbaikan kerusakan saraf (neuropati)
Cyanocobalamin di dalam liver tidak diubah menjadi methylcobalamin sehingga tidak dapat dimanfaatkan untuk proses perbaikan kerusakan saraf (Ide H, 1987)
3. EkskresiKarena Methycobal sifatnya larut dalam air, maka ia diekskresikan melalui urin.
4. Waktu yang dibutuhkan untuk mencapai kadar puncak dalam serum plasma darah:Oral (kapsul) : 1 jamInjeksi: Intra Muskular = 3 – 5 jam; Intra Vena = 3 menit
5. Konsentrasi dalam darah setelah pemakaian jangka panjangOral (kapsul) : 2 – 2,7 kali normalInjeksi :
- Intra Muskular : 15 – 30 kali normal- Intra vena : 15 – 30 kali normal
PREVALEPREVALENSINSI
DEFISIENSI COBALAMINDEFISIENSI COBALAMIN
USA : 300.000 – 3 JutaUSA : 300.000 – 3 Juta EROPA & INDIA : 1.6 – 10 % EROPA & INDIA : 1.6 – 10 %
POPULASIPOPULASI INDONESIA : ?INDONESIA : ?
BANYAK BANYAK
UMUR: 40 – 70 Th.UMUR: 40 – 70 Th.
DEFISIENSI COBALAMINDEFISIENSI COBALAMIN
USA : 300.000 – 3 JutaUSA : 300.000 – 3 Juta EROPA & INDIA : 1.6 – 10 % EROPA & INDIA : 1.6 – 10 %
•inform them of the risks and to recommend a healthy lifestyle. •A healthy lifestyle not only will lower tHcy levels but, more importantly, will promote health irrespective of whether homocysteine is a cause or a marker of disease.
change in lifestyle will also change the tHcy levels
Raised tHcy levels are related to a poor lifestyle
Green T.J., McMahon, J.A., Skeaff, C.M., Williams, S.M., and Whiting S.J. Am J Clin Nutr 2007;85:460–4.
Total Homocysteine concentrations are strongly dependent on
folate and vitamin B-12 status,
results of randomized controlled trials show that supplementation with folic acid and
vitamins B-12 and B-6 is an effective way of lowering homocysteine.
Green T.J., McMahon, J.A., Skeaff, C.M., Williams, S.M., and Whiting S.J. Am J Clin Nutr 2007;85:460–4.
MECOBALAMINMECOBALAMIN
Vitamin B12 (cobalamin) is an essential cofactor for methionine synthase and N5-
methyltetrahydrofolate serves as the methyl donor.
there are close relationships between plasma homocysteine and cobalamin and folate.
•A close association between plasma homocysteine and risk of ischemi stroke has been reported and plasma homocysteine levels are higher in patients with ischemic stroke in both acute and convalescent phases.
• In patients with homocysteinuria, a rare autosomal recessive biochemical abnormality, there is an increased prevalence of skeletal abnormalities, including osteoporosis, a primary risk factor for hip fracture. Thus, elevated plasma homocysteine concentrations may be associated with osteoporosis and increase the risk of a hip fracture.
• An increased homocysteine level appears to be a strong and independent risk factor for an osteoporotic fracture of the bones, including the hip, in older men and women.
Homocysteine before and after treatment of 8 weeks
8.8
11.1 11.2 11.5
8.89.9
8.77.1
02468
101214
Control Methycobal Folic asid Methycobal +Folic acid
Pre Post Methycobal:1500ug/ day Folic acid:5mg/ day
n 72 63 6464
umol/ l
Hyperhomocysteinemia in Patients with ConvalescentStage Ischemic Stroke: Effect of Combined Therapy with Folic
Acid and Methycobal
Y. Sato. Journal of the Neurological Sciences.2002 202, 65-68
Methycobal gro group CH3B12 1500µg/day up CH3B12 1500µg/day
Methycobal acts as a cofactor in the remethylation of homocysteine.
Role of Methycobal
METHYLENE-TETRAHYDROFOLATE
METHYLTETRA-HYDROFOLATE
Methyl-cobalamin
THF
MethionineMethionine
Methionine synthase
Re-methylation
HomocysteineHomocysteine
AdoMetAdoMet
AdoHcyAdoHcy
Homocysteine is essential in the bodyHomocysteine is essential in the body
Homocysteine participates in three processes: In the transsulfuration pathway to synthesize
cystathionine, cysteine and glutathione. The Catabolism of betaine and choline The recycling of the intracellular folate.
Homocysteine controls growth and support bone and tissue formation.
Why Homocysteine is HarmfulWhy Homocysteine is Harmful
Elevated Elevated HomocysteineHomocysteine
Elevated Elevated HomocysteineHomocysteine
Atherosclerosis and thrombosisMyocardial Infarction
StrokePheripheral vascular
Disease
Birth defects like neural
tube defects
Homocysteine Homocysteine Thiolactone
Protein damage, loss of function, Formation of extensively modified protein
Venous thrombosisVenous
thromboembolism
When associated withDiabetes it increasesthe risk of angiopathy
Alzheimer’s DiseaseOther types of cognitive Loss due to disturbed
transmethylation
Stroke
definisialgoritmafaktor resikoanatomi otak
Stroke perdarahanetiologi
hipertensianeurismaA-V malformasi
patofisiologisimtomtanda klinisdiagnosis lokasi perdarahantatalaksanakontrol tekanan darahPrognosisRehabilitasiKomplikasi