case yuwono
DESCRIPTION
caseTRANSCRIPT
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CVD hemoragik
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Resume
Telah diperiksa seorang laki-laki berusia 32 tahun yang datang dengan keluhan lemah pada tubuh sebelah kiri mendadak yang dialami os 3 hari SMRS, pada saat bangun tidur. Keluhan disertai juga dengan bicara pelo mendadak. Pada saat itu os mengeluhkan nyeri kepala berdenyut di bagian belakang bawah kanan kepala yang hilang timbul. Os juga merasa mual dan muntah. Saat itu tidak ada keluhan kejang, demam, cedera kepala serta penurunan kesadaran.
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• Faktor resiko:– Hipertensi grade I– Merokok
• Status internis:– Hipertensi grade I (TD kanan: 150/70 mmHg, kiri:
150/100 mmHg)
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• Status neurologis:
1. Kesadaran : CM, GCS 15 (E4M6E5)2. TRM: -3. ↑ TIK: -4. Pupil: bulat, isokor φ 3mm, RCL +/+, RCTL +/+5. Nn. Cranialis: parese N VII dan XII sinistra tipe
UMN6. Motorik: hemiparese sinistra dengan derajat
kekuatan otot, 0000
atoni lengan kiri. 1111
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7. Sensorik: baik8. Fs. Cerebellum & koordinasi: kanan baik. Kiri
tidak dapat dinilai9. Fs. Luhur: baik10. Rf. Fisiologis: lengan +/+
tungkai KPR -/+, APR +/+11. Rf. Patologis: -/-
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Diagnosa
• Klinik:– parese N VII dan XII sinistra tipe UMN– Hemiparese sinistra tipe UMN– Hipertensi grade I
• Topik: – korteks dekstra
• Etiologi:– CVD hemoragik tipe perdarahan intracerebral
• Patologi: – perdarahan
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TINJAUAN PUSTAKA
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Stroke
• Manifestasi klinis dari gangguan fungsi otak baik setempat ataupun menyeluruh, yang timbul mendadak dan cepat, berlangsung > 24 jam, tanpa penyebab lain selain gangguan pembuluh darah. (WHO)
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Type stroke
Iskemik Hemoragik
Trombus Emboli Perdarahan subarachnoid
Perdarahan intraserebral
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Faktor resiko
• Usia > 65 th• Hipertensi • Hiperkolestrolemia• Merokok• Diabetes • Minum alkohol• Kontrasepsi oral• Genetik
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PERDARAHAN INTRASEREBRAL
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Pathophysiology
1. Cerebral autoregulation- normotensive individuals lowest MAP: 60mmHg-below symptoms of hypoxia (light-headedness, confusion, dimming of vision)- below 35-40 mmHg somnolence & LOC- MAP 150-200 mmHg hypertensive encephalopaty
- chronic HT: lower limit MAP higher CBF decline – MAP below 120 mmHg
2. Chronic hypertension- promote structural changes in the wall of penetrating arteries intracerebral hemorrhage.- Charcot and Bouchard aneurysm
3. Acute hypertensionsudden increase BP (amphetamine & cocaine abuse)
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Pathology
• The caudate and putaminal branches of the middle cerebral arteries (42%)
• Branches of the basilar artery supporting the pons (16%)• Thalamic branches of the posterior cerebral arteries
(15%)• Branches of the superior cerebellar arteries supplying
the dentate nuclei and the deep white matter of the cerebellum (12%)
• Some white matter branches of the cerebral arteries (10%)
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Penyebab lainnya
• Trauma• Gangguan pembuluh darah – malformasi
arterivenosa, vaskulitis , amiloidosis• Perdarahan Tumor• Kelainan darah (koagulopati)
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Clinical findings
• Ps awake• Headache (50% ps), may severe• BP ↑ after hemorrhage has occurred• Edema surrounding the hemorrhage, minutes
days• Rapid onset
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Diagnosis
• Klinis• Pemeriksaan penunjang– CT scan: hiperdens dalam jar. Hemisfer, dikelilingi
daerah/ cincin hipodens (edema otak) + pendorongan garis tengah (falx cerebri)
– MRI– Pungsi lumbal
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Treatment
• ABC• Surgical– Early in the course, ps still conscious– Superficial hemorrhage
• Medication – Anticoagulant and antithrombotic discontinued– Fresh frozen plasma and vit K– Antihypertensive agent lower BP to diastolic level of 100
mmHg – Diuretic: furosemide (10 mg – 40 mg IV), manitol 20% 0,25-
0,5 kg/BB
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Komplikasi
• Hidrosefalus
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Prognosis
• Ad vitam: dubia ad malam• Ad functionam : dubia ad malam• Ad sanationam : dubia ad malam
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VS
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• Pendarahan ke dalam ruang (ruang subarachnoid) diantara lapisan dalam (pia mater) dan lapisan tengah (arachnoid mater)
SUBARARACHNOID HEMORRAGE
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RISK FACTORS
Disorders associated with weakened blood
vessels, including polycystic kidney
disease , fibromuscular dysplasia, or connective
tissue disorders
High blood pressure
increases the risk of aneurysm
rupture
Smoking and Moderate to heavy alcohol consumption
Past history of
aneurysms
Faktor resiko & etiologi
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Gambaran klinis• Gejala nyeri kepala
mendadak sangat berat disertai fotofobia, mual, muntah dan tanda2 meningismus (kaku kuduk dan tanda kernig)
• Peningkatan tekanan intrakranial dan gangguan kesadaran
• Pada funduskopi : edema papil dan perdarahan retina.
• Tanda neurologis fokal dapat terjadi sebagai akibat dari : – Efek lokalisasi palsu dari
peningkan TIK– Perdarahan intraserebral yg
terjadi bersamaan– Spasme pembuluh darah
akibat efek iritasi darah, bersamaan dengan iskemia
• bradikardi dan hipertensi dengan peningkatan tekanan intrakranial dan demam
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DIAGNOSIS• ANAMNESIS • PEMERIKSAAN FISIK • PEMERIKSAAN PENUNJANG – CT scan– Lumbar puncture
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• Pungsi lumbal – Ditemukan darah pada LCS
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TERAPI
• Aneurisma dapat diterapi dengan operasi pembedahan saraf berupa penutupan leher aneurisma dengan metal clip
• Pembedahan sebaiknya dilakukan dalam 72 jam pertama setelah pendarahan subarachnoid yaitu sebelum periode dengan risiko terbesar terjadinya vasospasme
• Bentuk terapi lain adalah mengisi aneurisma dengan metal koil
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