k20~stroke hemorrhagic

8/17/2019 K20~Stroke Hemorrhagic

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YUNELDI ANWAR Sp.

S (K)DEPARTEMEN

NEUROLOGI FK USU

STROKEHEMORAGIK


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STROKE HEMORAGIK

1. PERDARAHAN INTRA

SEREBRAL

2. PERDARAHAN SUB ARACHNOID


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%"&'rr%"

B$'' $"*+ ,r"!t$- ,nt' #r,npr"n!%-&

HTN &'+t !'&&'n !+"


4/32

S# r!%n',%"&'rr%"

B$'' $"*+ /r'&!"r"#r$ 0"++"$

,nt' +#r!%n',+p!"I/ rt"r,$ +"nn p,n/$An"r-+&+ nAM+


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Etiologi (ICH )H,p"rt"n+,/ ( Pr,&"r )N'n3%,p"rt"n+,/ ( S"*n"r )

3 rptr" n"r-+&4 AM

3 nt,*'$n+, 4t%r''$,t,*

3 n"'p$+& tr&

3 r #+"4,nt'*+,*+, 3 C"r"#r$ 0"n'+ +,n+tr''+,+


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PathogeneseH,p"rt"n+,'n rt"r,$ 5$$ $t"r"

+"&"nt$ $,p'%-$,n'+,+ n t%" /$+"n"r-+& (&,!r'n"r-+&) C%r!'t nB'!%r.

&,!r'n"r-+&+ t' %-p"rt"n+,'n n%-p"rt"n+,0" %"&'rr%" t%",r /r"6"nt$'!$,7t,'n 'n p"n"trt,n +&$$ rt"r,"+ nrt"r,'$"+ '/ t%" #+$ n$, t%$&+p'n+ n +#!'rt,!$ 5%,t" &tt"r

A&-$', ,&pr"nt,'n '/ 0"++"$ 5$$+r"pr"+"nt+ ,8"r"nt &"!%n,+& /'r 0"++"$rptr"


7/32

Gejala klinis.Terjadi waktu aktif dan tiba-tibaNeri ke!ala hebat kesadaran"enurun "untah# kejang#ko"a.

$iwaat hi!ertensi kronis%e&sit neurologis tergantunglokasi dan luas he"ato"

He"ato" di lobus frontalis 'te"!oralis kejang he"i!aresis kontralateral


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G"9$ K$,n,+

W%,t" !"nt"r" r"t,n$ %"&rr%" (R't% Sp't+)

Fr"+% pr"r"t,n$ %"&'rr%"Heada*he a*ute h!ertension n +o"iting

5,t% /'!$ n"r'$',! ":!,t r" t%" !r,n$/"tr" t' ,+t,n,+% %"&'rr%" /r'&,+!%"&,! +tr'*".

Pt&,n$ %"&'rr%" t%" "-"+ r" "0,t" t't%" +," 'pp'+,t" t%" pr$-+,+

T%$&,! %"&'rr%" t%" &'+t !'&&'n '!$r#n'r&$,t- ,+ '5n5r "0,t,'n '/ t%" "-"+

n t%" pp,$+ &- #" nr"!t,0" p'nt,n" %"&'rr%" t%" "-"#$$+ r" :;" n

t%" pp,$+ r" t,n- #t r"!t,0"


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Prosedur diagnostik

S!%"$" /'t'

H" !t +!n4MRI

CT4MR An,'rp%-40"n'rp%-

LP

LAB WBC ESR INRPTTP$t"$"t !'nt

D,,t$ +#+tr!t n,'rp%-


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%I,GN, /,N%ING

Penebab ko"a dan 0 g

lain Infark serebri

Pe*ahna /err aneuris"

(a**ular aneurs")


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P"n'#tn.

Prinsi! 1onser+atif Perawatan ko"a

1ontrol hi!ertensi2 T% g tinggi !erdarahan ' ede"a serebri 23,P 4 556 ""Hg "ulai tera!i.3engatasi ede"a serebri 2

"annitol !erati+e


12/32

P"n!"%n "*+pn+,%"&t'&Managemen Tek darah TD sistolik

diturunkan < 140 pada fase akutmengurangi hematom ekspansi

Anti hipertensi pilihan

- Labetolol

- Esmolol

- Niardipin

- !"drala#ine - Nitroprusside


13/32

Mn"&"n ""& t%"rn,+,$epala ditinggikan %0 der&at dengan leher posisi

netral

'smoterapi

- Mannitol (0)

0*(+ , 0*+ grkgbb - .aline h"pertonik Na/l % ) bolus (+0

(o mnt

2arbiturat

- 3entobarbital 10 mgkg - Thiopental 1*+ , %*+ mgkg

!iperentilasi


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Pr'n'+ T%" ICH S!'r"<Pr",!t,'n '/ =>3-+

&'rt$,t-

H"&t'& 0'$&" ? => &$G$+'5 C'& S!$" S!'r" @

In/r t"nt'r,$ $'!t,'n

I,ntr0"ntr,*$r %"&'rr%"A"


15/32

6PE$,TI7Indikasi tindakan o!eratif 2 - !erdarahan intraserebeller 4 8 *"

- !erdarahan lobar 9 dia"eter 4 8 *"9

tanda !eninggian TI1 g *e!at !erburukan klinis di*oba tindakan

o!eratif utk life sa+ing.

::: ebelu" ko"a dala" 9 !u!ildilatasi

"aksi"al


16/32

P"rr%n +# 3r*%n',$P"n-"## - p$,n +"r,n<1. Tr&

2. Sp'ntn

2.1. P"rr%n ,ntr+"r"#r$

rn

+#r*%n', 2.2. Pr,&"r< 3 An"r,+& ( B"rr- )

'r

+!!$r

n"r-+& 3 AM

3 $$.


17/32

H"&'rr%" (Rptr" S!!$r

An"r-+&)

3en"ebab tersering /D* sesudah trombosis* emboli*3.* tetapi paling berbaha"a

.aular aneur"sm disebut &uga 5berr" aneur"sm6

3enon&olan dari dinding arteri sirkulus 7illis atau

abang utaman"a3en"ebabn"a defet pada bagian media dan elastis

dari arteri* bisa &uga ok destruksi lokal membranelastik akibat tekanan hemodinamik "g kuat padabifurkatio dinding intima menon&ol keluar sptkantong 8saular aneur"sm9

:kuran aneur"sm ini antara (mm , % m* rupturebiasan"a pada ukuran 10 mm atau lebih


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L'*+, An"r,+&( S!!$r An"r-+& )Pr'*+,&$ A. K'&n,*n nt"r,'rA+$ Art"r, K'&n,*n P'+t"r,'r

B,/r*t,' A. S"r"#r, &",

B,/r*t,' A. Kr't,+ ,nt"rn "nn A.S"r"#r, &", n +"r"#r, nt"r,'r

> *++ +!!$r ( B"rr-

n"r-+& ) t"rpt p#,n nt"r,'r !,r*$+ '/ 5,$$,+


19/32

Gejala klinis2

S*,t *"p$ - %"#t ('!!,p,t$)&nt%

K"+rn &"nrn *'&

t"rntn $+n- p"rr%nTn2 p"rn+nn &"n,n"$<** **

Fn+*'p,< p"rr%n r"t,nGnn p+,*,+

Kn2 *"9n /'*$ 4 &&


20/32

G"9$ *$,n,+ ;ika perdarahan massie death dalam beberapa menit

atau &am

diagnosa salah satu pen"ebab sudden deathupture aneur"sm sering di&umpai 7aktu beraktiitas

5se=ual interouse6> Mengedan 7aktu 2A2* mengangkatbeban berat* batuk keras dan bersin* dll>

Ann"r,+& p +,n+ !0"rn'++ t

nt"r'$t"r$ +"r"#r, &", n"eri sampai ke orbitaAn"r,+& p p'+t"r',n/"r,'r t nt"r',n/"r,'r

rt"r, +"r"#"$$, n"eri pada unilateral oksipital atauerial

Aneurisma pada posterior ommuniating,internal arotid

&untion or at the posterior ommuniating,posteriorerebral &untion prt,$ '!$'&'t'r p$+- 5,t%,$t" pp,$


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Gr" PSA S*$B'tt"r"$$ n Hnt H"++

G r" I. A+,&pt'&t,* t +*,t *"p$n

** ** r,nn

Gr" II. S*,t *"p$ ** **+"n

+&p, #"rt tnp "9$

n"r'$',* /'*$Gr" III. Dr'5+,n"++ !'n/+" n ":+,t

n"r'$',* /'*$ r,nn


22/32

Gr" I. Stp'r t +"&,*'&"9$

p"r&$n "+"r"#r+,n n.

""tt,/

Gr" . *'& $& n"+"r"#r+,


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Prosedur diagnostik

0P

;-ra tl.tengkorak

CT *an

,rteriogra&


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DIAGNOSA BANDING

M,r,n"

In/"*+, +,+t"&,*

M"n,n,t,+ 4 "n+"/$,t,+H,p"rt"n+,/ "n+"/$'pt,

Art%r,t,+ !"r0,!$,+

In/r* +"r"#r,


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1o"!likasi

P"rr%n $n

+'+p+&"

H,r'+"/$+ *t


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Pengobatan1esadaran "enurun !erawatanko"aPerawatan u"u"

/edrest total (lk. 8 "inggu)Pengobatan si"to"atik utk. akitke!ala gelisahEde"a serebri2 "annitol

n"&"n && p


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n"&"n && p /+" A*t

B" r"+t p""r,n !,rn p"rt%n*n 0'$&"n'r&$

P"r5tn && p+,"n "nn *"+rn &"nrn

Gn*n p"n!%r

C !%nn"$ #*'*"r nt* &"n!"% 0+'+p+&"$-" ,+!%"&,! +tr'*"

O#t, %,p"rt"n+, SBP 1> &&% t *rn

S*,t *"p$ '#t p"n%,$n n-"r,

C"% +,+t"&,* 0"n'+ tr''+,+ +t'!*,n p

**,P""r,n nt, *'n0$+, nt* p"n!"%n t,*

,n9r*n #r ,#"r,*n 9,* ,9&p, *"9n


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Pengobatan (lanj)

Tindakan o!eratif *li!!ing

untuk "en*egah re-bleeding#

setelah !rosedur diagnostik(arteriogra&) aneuris"a

E"ndo+as*ular *oiling

Prognosa2

3ortalitas "asih tinggi.


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PIS H,p"rt"n+,/.

P"n"r,t %,p"rt"n+, *r'n,+<rt"r,'+*$"r't,* p".r% *"!,$

p"r#%n2 p..p".r% n"r,+& (C%r!'tB'!%rt n"r-+& ) p"!%PIS

L'*+,<

3 t$&+ 3 *p+$ ,nt"rn 3 #+$ n$, 3 $'#r $$.


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OPERATIE

PERDARAHAN SEREBELLUM

Diameter < ( m * pasien sadar* tidakada perburukan

klinis* operasi 8-9

Diameter 4 m * dengan perburukan

klinis dandisertai hidrosefalus segera lakukan

operasi

C $ $ t, t% ICH S


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C$!$t,n t%" ICH S!'r"G$+'5 C'& S!$" (GCS) S!'r"

= 2

12 1 1= 1 >

ICH '$&" (!!)

? => 1

@ => >Intr0"ntr,!$r H"&'rr%" (IH)

Y"+ 1

N' >

In/rt"nt'r,$ Or,,n '/ ICH Y"+ 1

N> >

A" (-"r+) ? > 1

< ?0 0Total Score 0 - 6

k20~stroke hemorrhagic

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