stroke + gbr
TRANSCRIPT
7/23/2019 Stroke + Gbr
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11
CEREBRO VASCULARCEREBRO VASCULAR
DISEASEDISEASE
CVD : adalah berbagai gangguan fungsi otakCVD : adalah berbagai gangguan fungsi otak
akibat roses atologik !askuler"akibat roses atologik !askuler"
# Stroke # Aole$ia# Stroke # Aole$ia# %&DO # &&DO# %&DO # &&DO
'(S'(S
Dr"'uha))ad (usuf*SS
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'(S'(S ++
StrokeStroke
Adalah )anifestasi klinik dari gangguan
fungsi otak* baik fokal )auun global*
,ang berlangsung dengan -eat* ge.ala /
+0 .a) atau )eninggal* tana en,ebab
lain selain gangguan !askuler"
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'(S'(S
RE%ULASI ALIRA2 DARA3 4ERE%ULASI ALIRA2 DARA3 4E
5O6A4 7Cerebral Blood 8lo9 # CB85O6A4 7Cerebral Blood 8lo9 # CB8 Otak )eneri)a darah dari :
5 A"karotis a"karotis interna
a"oftal)ika a"khoroidea ant"
a"serebri ant" a"serebri )edia"
5 A"!ertebralis a"basilaris a"serebri ost"
# siste)a !ertebrobasilaris"
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'(S'(S 00
4edua siste) arteri )e)bentuk4edua siste) arteri )e)bentuk
; Sirkulus <=illisi ; ; Sirkulus <=illisi ;
A" karotis a" serebri ant" a"
ko)unikans ant" A" basilaris a" serebri ost" a"
ko)unikans ost" a" karotis"
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'(S'(S >>
a" 4o)unikans ant"
a" Serebri ant"
a" 4arotis
a" Basilaris
a"Serebri ost"
a" 4o)unikans ost
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'(S'(S ??
&eredaran Darah Otak&eredaran Darah Otak
@ Sirkulasi anterior 7karotid )e)erdarahi :
5 4orteks serebri 7sebagian besar"
5 Subkorteks 79hite )atter"
5 Basal ganglia" 5 4asula interna"
%e.ala stroke karotid :
# Afasia" # 3e)iaresis"
# Araksia" # 3e)isensor, disturban-es" # Agnosia" # %gn"laangan andang"
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'(S'(S
&eredaran Darah Otak&eredaran Darah Otak
@ Sirkulasi osterior 7!ertebro5basiler
)e)erdarahi :
5 Brainste)" 5 6hala)us"
5 Cerebellu)" 5 Sebagian dari lobus < o--iitalis dan te)oralis"
%e.ala stroke !ertebro5basiler :
5 Co)a" 5 Vertigo* nausea* !o)itus" 5 Dro atta-ks" 5 &arese saraf kranial"
5 Ataksia"
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'(S'(S
Regulasi Aliran Darah ke OtakRegulasi Aliran Darah ke Otak
@ Otak beratn,a kira+ 1*> kg # kira+ +5 dari
BB )anusia* relatif )eneri)a ban,ak darah"
@ 'eneri)a 1?5+> darah ,g dio)akan .antung #
> < 1+ -- F )enit# kira+ > --F)enitF1 gr .ar"otak"
@ 'e)akai 7istirahat 5 + O+"
5 glukosa"
4eadaan eredaran darah u)u) sangat
)e)engaruhi fungsi otak"
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'(S'(S GG
8aktor+ ,ang 'engatur CB88aktor+ ,ang 'engatur CB8
@ 8aktor+ ekstrinsik :
tekanan erfusi
CB8 # 555555555555555555555 resistensi !askuler otak
6ekanan erfusi # tekanan darah siste)ik
5 tekanan !ena serebral 7relatif ke-il # > )) 3g tek"erfusi # tek"darah siste)ik"
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'(S'(S 11
8aktor+ Ekstrinsik8aktor+ Ekstrinsik
6ekanan darah siste)ik :
&erubahan tek"darah siste)ik tdk )e)5engaruhi CB8* ke-uali 'AB& turun
kira+ > )) 3g 7kira+ H dari nor)al"
&erubahan -ardia- outut :
&enurunan C"O d" gagal .antung tidak
)e)engaruhi CB8* ke-uali enurunan6D ,g berat"
ok" adan,a autoregulasi serebral"
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'(S'(S 1111
8aktor+ Ekstrinsik8aktor+ Ekstrinsik
@ &erubahan !iskositas darah :
&erubahan !iskositas darah )e)5
engaruhi CB8* 9alauun tek"erfusi tetakonstan o"k" ter.adi erubahan resistensi5
!askuler serebral 7 st" ane)ia dan
olisite)ia "
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'(S'(S 1+1+
8aktor+ Intrinsik8aktor+ Intrinsik
a"l" Autoregulasi serebral )ekanis)e ,g
)engatur agar aliran darah d"arteriole
teta relatif konstan d"erubahan 6D" CB8 relatif konstan dala) suatu batas
,g -uku lebar autoregulator, lateau"
6ek"erfusi )enaik F )enurun a"Sere5 bral konstriksi F dilatasi"
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'(S'(S 11
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'(S'(S 1010
Autoregulator, &lateau :
Batas ba9ah : kira+ > 5 ? ))3g" atas : kira+ 1> < 1? ))3g"
ika tek"erfusi )ele9ati batas autoregula5
tor, lateau CB8 akan ber7J atau ber75
se-ara asif .ika tekanan erfusi ber7J
atau ber75"
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'(S'(S 1>1>
ika tek"erfusi ber75 sa)ai batas ba9ah
autoregulasi hioerfusi serebral :
ekstraksi oksigen dari darah utk"ko)en5
sasi"
ko)ensasi dile9ati )un-ul ge.ala5
klinis"
ika tek"erfusi ber7J )ele9ati batas atas
CB8 ber7J se-ara asif ge.ala klinis"
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'(S'(S 1?1?
8aktor Resiko8aktor Resiko
@ 5 Usia"
5 Ras"
5 enis kela)in"@ 5 3iertensi" 5 3ierliide)ia"
5 4el" antung" 5 6 I A"
5 Diabetes )ellitus" 5 'erokok" 5 3ierurise)ia"
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'(S'(S 11
4lasifikasi4lasifikasi
4linis:
1" 6 I A # 6ransient is-he)i- atta-ks"
+" Stroke non he)orhagik # Stroke iske)ik :
6hro)bosis serebri"
E)bolia serebri"
" Stroke he)ohragik :
&erdarahan intra5serebral 7&IS"
&erdarahan sub5arakhnoidal 7&SA"
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'(S'(S 11
Stadiu)Stadiu)
@ 6 I A"
@ Stroke in e!olution 7rogressing5stroke"
@ Co)leted stroke : 5 2on5he)oragik" 5 3e)oragik"
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'(S'(S 1G1G
6 I A6 I A
@ Serangan defisit neurologik ,g bersifat
te)orer akibat ggn" eredaran darah
otak* ti)bul )endadak* )enghilang dgn
-eat 7K+0 .a) tana ge.ala sisa"
@ Biasan,a : > < ? )enit F ge.ala )a$"
biasan,a +
@ 6 I A : 5 tie karotid"
5 tie !ertebro5basiler"
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'(S'(S ++
R I 2 DR I 2 D
# Re!ersible Is-he)i- 2eurologi- Defi-it"
# 6 I A * tai / +0 .a)"
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'(S'(S +1+1
%e.ala 6IA 4arotid%e.ala 6IA 4arotid
@ A)aurosis fuga$"
@ 3e)iaresis"
@ 3e)i5hiastesi"@ Afasia"
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'(S'(S ++++
%e.ala 6IA Vertebrobasiler %e.ala 6IA Vertebrobasiler
@ Diloia"
@ D,sarthria"
@ Dro atta-ks"@ 3e)iaresis alternans"
@ 3e)ihiastesi"
@ Ata$ia"@ D,shagia"
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'(S'(S ++
EtiologiEtiologi
1" &en,akit e)buluh darah :
5 &laMue atherosklerotik"
5 Arteriosklerosis" 5 Arteritis* dll"
+" 4elainan darah :
5 3,er-oagulabilit," 5 E)bolis)"
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'(S'(S +0+0
" &enurunan erfusi serebral :
5 Cardia- outut ber75"
5 Steal s,ndro)e"
5 4o)resi e)b"darah ekstra5kranial"
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'(S'(S +>+>
&ROSEDUR DIA%2OS6I4&ROSEDUR DIA%2OS6I4
@ Lab"lengka"
@ EC%"
@ 6hora$ hoto"
@ EE%"
@ C6 S-an"
@ L&"
@ Arteriografi"
@ Dll"
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'(S'(S +?+?
D DD D
1" Eilesi"
+" Cardia- disorders"
" &ostural h,otension"
0" 3,ogl,-ae)ia"
>" S,n-oe"
?" 'iugraine"
" SOL"
" 4el"sikiatris* dll"
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'(S'(S ++
6herai6herai
1" &engobatan terhada faktor resiko"
+" &e)berian obat+ anti thro)botik :
# &latelet inhibitor :
5 Asirin"
5 6i-loidine"
5 Cloidogrel"
# Anti5-ogulansia : 5 3earin"
5 Cou)adin"
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'(S'(S ++
" Oeratif :
5 Endartere-to),"
5 EC F IC b, ass"
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'(S'(S +G+G
&rognosis&rognosis
@ Ban,ak enderita 6IA dengan 1 atau
beberaa kali serangan sebelu) stroke
tana )en.u)ai dokter"
@ Resiko stroke aling tinggi d" tahun
erta)a stlh" 6IA 715+>"
@ 6ahun berikutn,a >"
@ 6IA faktor resiko )a,or utk" Infark otak*
.uga .antung"
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'(S'(S
S6RO4E 2O2 3E'OR3A%I4S6RO4E 2O2 3E'OR3A%I4
# S6RO4E IS43E'I4# S6RO4E IS43E'I4
# I28AR4 SEREBRI# I28AR4 SEREBRI
Infark serebri ter.adi bila suatu daerah diotak)engala)i iskhe)ia dan nekrosis* akibat 5
berkurangn,a aliran darah keotak sa)ai di5
ba9ah le!el kritis ,ang dibutuhkan untuk ke5hiduan sel"
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'(S'(S 11
EtiologiEtiologi
@ 6hro)bosis serebri"
@ E)bolia serebri"
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'(S'(S ++
6hro)bosis Serebri6hro)bosis Serebri
@ Sebagian besar enderita atherosklerosis
# ,g )e)un,ai faktor resiko ,g )e)er5
-eat atherosklerosis"
&en,ebab lain :
5 Arteritis e)b" darah otak"
5 4elainan darah" 5 &erfusi keotak )enurun kritis"
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'(S'(S
E)bolia SerebriE)bolia Serebri
Su)ber e)boli :
1" 4ardio!askuler :
5 &laMue atherosklerotik d"e)b"darah otak ,g besar"
5 Sisa e)b"darah ,g telah )engala)i
oklusi" 5 6rau)a e)b"darah leher"
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'(S'(S 00
5 'ural thro)bosis o"k" infark )iokard*
arit)ia kordis dan ost oeratif bedah .antung"
5 &en," !al!ula .antung st" en,".antungrhe)atik* rolas )itral !al!e* endokarditis"
5 C3D dgn" R to L shunt"
5 (ang .arang : atrial ),$o)a* -ollagendisease* kardio)ioati dan endo-ardial
fibrosis"
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'(S'(S >>
+" Siste)ik :
5 e)boli sesis dari aru* abdo)en dan
el!is"
5 e)boli le)ak"
5 e)boli udara"
5 sel )etastase"
5 benda asing"
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'(S'(S ??
%e.ala 4linik%e.ala 4linik
@ 6ergantung lokasi dan luasn,a infark"
@ Sindro)a klinik sesuai dg"e)b"darah
daerah infark :
5 3e)iaresis" 5 3e)ihiastesi"
5 Disfasia5afasia" 5 %gn"englihatan"
5 Diloia" 5 8asialis arese" 5 Dll"
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'(S'(S
6hro)bosis Serebri6hro)bosis Serebri
@ Defisit neurologik ti)bul )endadak* tai
berke)bang agak lebih la)bat"
@ Onset se9aktu istirahat F bangun tidur"
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'(S'(S
E)bolia SerebriE)bolia Serebri
@ Defisit neurologik ti)bul )endadak dan
sekaligus )en-aai un-ak"
@ Onset se9aktu aktif"
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'(S'(S GG
&engobatan&engobatan
&rinsi :
)e)erbaiki CB8 )en-egah erluasan
Infark"
# &engobatan u)u)"
# &engobatan sesifik"
# Rehabilitasi"
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'(S'(S 00
&engobatan U)u)&engobatan U)u)
@ 8ungsi aru F .alan nafas"
@ antung N tekanan darah"
@ Cairan N elektrolit"
@ 4adar glukosa N te)eratur"
@ 'akanan"
@ 'en-egah F engobatan ko)likasi a"l" :
5 ede)a serebri" 5 seiure" 5 neu)onia"
5 U6I" 5 e)boli aru F DV6* dll"
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'(S'(S 0101
&engobatan U)u) 7Lan.utan&engobatan U)u) 7Lan.utan
@ 8isioterai N See-h thera,"
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'(S'(S 0+0+
r CBF(ml/100g / menit)
JARINGAN OTAK
STRATEGI TERAPI Neurorote!"iReer#u"i
Norm$lNorm$l
G$nggu$n met$%& Glu!o"$
(Gli!oli"i" $n$ero%i!)
G$nggu$n met$%& Glu!o"$
(Gli!oli"i" $n$ero%i!)'$!to$"io"i"'$!to$"io"i"
G$nggu$n Bio!imi$i
("inte"$ rotein)
G$nggu$n Bio!imi$i
("inte"$ rotein)
G$nggu$n met$%& Ener"iG$nggu$n met$%& Ener"i
G$nggu$n #ung"ion$l
(eol$ri"$"i mem%r$n)
G$nggu$n #ung"ion$l
(eol$ri"$"i mem%r$n)
Keru"$!$n *i"tologi"
(P$nne!ro"i")
Neuron+ gli$+ Enotel
Keru"$!$n *i"tologi"
(P$nne!ro"i")
Neuron+ gli$+ Enotel
,Energ- F$ilure.,Energ- F$ilure.
,Eletri$l
F$ilure.
,Eletri$l
F$ilure.
,Ion Pum F$ilure.Glut$m$te Rele$"e +
C$ in#lu+
Free r$i$l"+ "t
,Ion Pum F$ilure.Glut$m$te Rele$"e +
C$ in#lu+
Free r$i$l"+ "t
0230
4
50
1
10
026
KASKADE ISKEMIK KASKADE ISKEMIK
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'(S'(S 00
&engobatan Sesifik&engobatan Sesifik
Strateg, :
# Reerfusion )e)ulihkan aliran darah
kedaerah iskhe)ik"
# 2eurorote-tion )elindungi .aringan
otak terhada kerusakan akibat iskhe)i"
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'(S'(S 0000
;CorePIskhe)ia
&enu)bra
Lu$ur, erfusion
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'(S'(S 0>0>
enum%r$
core
1 7our 5 7our 426 7our 623 7our
Core
enum%r$8 9 1 : 1 9 524 : 1 9 62 : 1 ; 10250 : 1
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'(S'(S 0?0?
6erai 6hro)bolitik6erai 6hro)bolitik
@ 'elarutkan -lot dan )e)ulihkan sirkulasi
li)itasi kerusakan otak erbaikan
out-o)e"
@ rt5&A 7re-o)binant tissue las)inogen
a-ti!ator"
@ Onset K ? .a) 7theraeuti-59indo9"
@ rt5&A .a)* dilaorkan erbaikan
out-o)e 5 rotokol ,g ketat"
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'(S'(S 00
Antikoagulansia Antikoagulansia
@ Untuk e)bolia serebri )en-egah
e)bolisasi ulang"
@ a"l" hearin* 9arfarin"
@ 3arus enga9asan e)"lab ,g ketat"
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'(S'(S 00
2eurorote-tion2eurorote-tion
@ %luta)at antagonist"
@ Cal-iu) -hannel blo-ker"
@8ree radi-al s-a!enger"
@ %ABA antagonist"
@ Oioid antagonist"
@ 2a5-hannel blo-ker"@ CD&5-holine* dll"
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'(S'(S 0G0G
&engobatan &ost Stroke&engobatan &ost Stroke
@ 4ontrol faktor resiko"
@ &e)berian obat+ anti5thro)botik :
5 Asirin"
5 6i-loidine"
5 Cloidogrel"
@ &e)berian antikoagulansia :
5 =arfarin"
@ 8isioterai F rehabilitasi"
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'(S'(S >>
S6RO4E 3E'OR3A%I4S6RO4E 3E'OR3A%I4
@ &erdarahan intraserebral 7 &IS "
@&erdarahan subarakhnoidal 7 &SA "
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'(S'(S >1>1
@@ &erdarahan Intraserebral&erdarahan Intraserebral
@ 6er.adin,a erdarahan sontan ke dala)
substansi otak"
@ &ri)er /K sekunder 7trau)a"
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'(S'(S >+>+
EtiologiEtiologi
@ 3iertensif"
@ 2on5hiertensif :
5 Cerebral a),loid angioath, 7CAA"
5 Antikoagulansia F thro)bolitik"
5 2eolas)a"
5 Drug abuse"
5 Aneuris)a F AV'"
5 Idioatik" 5 Dll"
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'(S'(S >>
&IS 3iertensif &IS 3iertensif
@ &enderita hiertensi kronis :
arteriosklerotik e)b"darah ke-il
erubahan+ d"ddg" e)b"darah
aneuris)a 7#Char-ot Bou-hartaneur,s) e-ah &IS"
@ Lokasi:
5 6ala)us" 5 4asula interna"
5 Basal ganglia" 5 Lobar* dll"
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'(S'(S >0>0
%e.ala 4linis%e.ala 4linis
@ 6er.adi 9aktu aktif"@ 2,eri keala hebat kesadaran )enurun
ko)a"
@ Ri9a,at hiertensi kronis"
@ Defisit neurologis tergantung lokasi dan
luas he)ato)"
@ 3e)ato) di lobus frontalis N te)oralis
ke.ang+ F he)iaresis kontralateral"
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'(S'(S >>>>
%e.ala 4linis 7Lan.utan%e.ala 4linis 7Lan.utan
@ &enderita ,g sela)at erbaikan
kesadaran dl)" beberaa hari"
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'(S'(S >?>?
&rosedur Diagnostik&rosedur Diagnostik
@ Q5foto tulang tengkorak"
@ 3ead C6 S-an"
@L&"@ Arteriografi"
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'(S'(S >>
DDDD
@ &en,ebab ko)a dan SOL ,g lain"
@ Infark serebri"
@ &e-ahn,a Berr, aneuris)"
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'(S'(S >>
&engobatan&engobatan
@ &rinsi konser!atif"
@ &era9atan ko)a"
@ 4ontrol hiertensi : 6D ,g tinggi
erdarahan N ede)a serebri : 'A& 11
))3g )ulai terai"
@ 'engatasi ede)a serebri : 'annitol"
7/23/2019 Stroke + Gbr
http://slidepdf.com/reader/full/stroke-gbr 59/69
'(S'(S >G>G
&engobatan 7Lan.utan&engobatan 7Lan.utan
@ Indikasi tindakan oeratif :
5 &erdarahan intraserebeller / -)"
5 &erdarahan lobar J dia)eter / -) J
tanda+ eninggian 6I4 ,g -eat F
erburukan klinis di-oba tindakan
oeratif utk life sa!ing"
Sebelu) ko)a dala) J uil dilatasi
)aksi)al"
7/23/2019 Stroke + Gbr
http://slidepdf.com/reader/full/stroke-gbr 60/69
'(S'(S ??
@@ &erdarahan Sub5arakhnoidal&erdarahan Sub5arakhnoidal
&en,ebab ,g aling sering :
1" 6rau)a"
+" Sontan :
+"1" &erdarahan intraserebral ruang
subarakhnoid"
+"+" &ri)er : 5 Aneuris)a 7 Berr, "
5 AV'"
5 dll"
7/23/2019 Stroke + Gbr
http://slidepdf.com/reader/full/stroke-gbr 61/69
'(S'(S ?1?1
%e.ala 4linis%e.ala 4linis
@ Sakit keala ,g hebat 7o--iital* )untah"
@ 4esadaran )enurun ko)a* tergantung
luasn,a erdarahan"
@ 6anda+ erangsangan )eningeal : kaku
kuduk
@ 8unduskoi : erdarahan retina"
@ %angguan sikis"
@ 4adang+ ke.ang fokal F u)u)"
7/23/2019 Stroke + Gbr
http://slidepdf.com/reader/full/stroke-gbr 62/69
'(S'(S ?+?+
&rosedur Diagnostik&rosedur Diagnostik
@ L&"
@ Q5ra, tl"tengkorak"
@ C6 S-an"
@ Arteriografi"
7/23/2019 Stroke + Gbr
http://slidepdf.com/reader/full/stroke-gbr 63/69
'(S'(S ??
DDDD
@ 'igraine"
@ Infeksi siste)ik"
@ 'eningitis F ensefalitis"
@ 3iertensif ensefaloati"
@ Arthritis serfikalis"
@ Infark serebri"
7/23/2019 Stroke + Gbr
http://slidepdf.com/reader/full/stroke-gbr 64/69
'(S'(S ?0?0
&engobatan&engobatan
@ 4esadaran )enurun era9atan ko)a"
@ &era9atan u)u)"
@ Bedrest total 7lk )inggu"
@ &engobatan si)to)atik utk" sakit keala F
gelisah"
@ Ede)a serebri : 'annitol"
@ Untuk )en-egah !asosas)e :
Calsiu) entr, blo-ker ;2i)odiineP
7/23/2019 Stroke + Gbr
http://slidepdf.com/reader/full/stroke-gbr 65/69
'(S'(S ?>?>
&engobatan 7Lan.utan&engobatan 7Lan.utan
@ 6indakan oeratif :
untuk )en-egah re5bleeding* setelah
rosedur diagnostik 7arteriografi"
&rognosa&rognosa
'ortalitas )asih tinggi"
7/23/2019 Stroke + Gbr
http://slidepdf.com/reader/full/stroke-gbr 66/69
'(S'(S ????
7/23/2019 Stroke + Gbr
http://slidepdf.com/reader/full/stroke-gbr 67/69
'(S'(S ??
7/23/2019 Stroke + Gbr
http://slidepdf.com/reader/full/stroke-gbr 68/69
'(S'(S ??
7/23/2019 Stroke + Gbr
http://slidepdf.com/reader/full/stroke-gbr 69/69