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STROKE HEMORAGIK

YUNELDI ANWAR SpS


DEPARTEMEN NEUROLOGI
FK USU
STROKE HEMORAGIK

1. PERDARAHAN INTRA SEREBRAL

2. PERDARAHAN SUB ARACHNOID


Intra Cerebral Hemorrhage
Blood leaks directly into brain parenchyma
15 % of all case stroke
Highest mortality and morbidity
Distribution of ICH

LOCATION % OF CASES
Putamen, basal gaglia 30-50

Subcortical Whitematter 30

Thalamus 10-15

Pons 5-12

Cerebellum 9

2 % primary hemorrhages multiple


The American Academy of Neurology Institute, 2012
Adam and Victors Principles of Neurology, Thnth Edition.
Causes and Types of ICH

Primary (80-90% of cases) : when ICH


originates from spontaneous rupture of
small arteries or arterioles damaged by :
chronic hypertension(elastisitasnya
berkurang) or cerebral amyloid
angiopathy

Secondary : when ICH results from


trauma (capitis), rupture of an aneurysm,
vascular malformation, coagulopathy or
other causes(tumours)
Secondary Causes of ICH
Trauma
AVM
Intracranial aneurysm
Coagulopathy
Haemorrhagic conversion of cerebral infarct
Dural sinus thrombosis
Intracranial neoplasm (Tumour)
Cavernous or venous angioma
Dural AV fistula
Cocaine or sympathomimetic drug exposure
CNS vasculitis
Lancet Neurol 2005;4:662-72
Risk factors
Hypertension
= most commonly risk factors for ICH up to
81% of cases (Furian A,J. Et al. Ann Neurol
1979;5:367) (hiprtensi 1 (140-150))
= Relative risk rate of ICH doubled from stage 1
hypertension to stage 2, and doubled again
from stage 2 to stage 3
= The adjusted risk rate of ICH increased 22% for
every 10 mmhg increment of systolic BP
(Sturgeon JD, et al. Stroke 2007 Oct;38(10)
: 2718-25
RISK FACTORS
Alcohol consumption independently increased
the risk 0f ICH, The risk increased when above 3 drinks
a day (Patra J, et al. BMC Public Health. 2010, May
18;10:258
Smoking Independent risk factors for ICH
(relative risk 2,o6) (Kurt T, et al. Stroke 2003;34:2792.)
The data about cholesterol levels and risk of ICH
includes conflicting studies. Overall, higher cholesterol
levels were associated with a lower risk (Ariesen MJ, et
al. Stroke 34;2060-2065, 2003)
Risk factors (cont.d)

Cerebral amyloid angiopathy (15%


cases)
= Deposition of beta-amyloid protein in media
and adventitia of brain arteries and arterioles
leed to loss of smooth muscle wall, wall thickening
micro aneurysma formation (Wiswanathan A,
et al. Ann Neurol. 2011 Dec;70(6):871-80.)

Lancet Neurol 2005;4:662-72


Pathogenesis
Hypertensive vascular lesion segmental
lipohyalinosis Spontaneous rupture of small
penetrating, deeps artery due to changes in the
vessel wall micro aneurisma (aeurysma
Charcot Bouchart) leading to ( easy to
rupture)direct mechanical effect disruption and
injuryof the brain parenchyma
Haematoma expansion
Edema and secondary neuronal injury in
perihaematomal region surrounding the
haematoma
CT imaging
Gejala klinis.
Terjadi waktu aktif dan tiba-tiba
Nyeri kepala hebat kesadaran menurun muntah,
kejang,koma.
Riwayat hipertensi kronis
Defisit neurologis tergantung lokasi dan luas hematom
Hematom di lobus frontalis & temporalis(iritatif motor
cortex) kejang2 / hemiparesis kontralateral
Sakitnya terusmenerus dengan muntah proyektil(tanpa
perhitungan) Penaikan tekanan intrakranial
Diagnosis
History : trauma, hypertension, prior ischemic stroke,
DM, smoking, alcohol and prescription of recreational
drugs such as cocaine, use antithrombotic, hematologic or
other medical disorders that predispose to bleeding.
Risk factors
Age
Physical examination including BP, cardiac
Laboratory testing : INR (n=2-3), PTT
CT scan features (goldstandard)
Lumbar puncture membedakan perdarahan
intraserebral tidak berwarna
Subarachnoroid warna cairan merah)
Lumbal 2,3/3,4 batas terakhir medulla spinalis lumbal
1kalau di lumbal 1 trauma medulla spinalis.
Further brain imaging (MRI/CTA/angiography)
Mayer SA, Rincon F. 59th AAN 2007
Neuroimaging
CT is the modality of choice
CT and MRI scans show equal ability to identify
the presence of acute ICH, its size and location,
and hematoma enlargement.
MRI was significantly more accurate than CT for
the detection of chronic ICH, an AVM, chronic
microbleeds on gradient echo imaging
suggestive of amyloid angiopathy, or a contrast-
enhancing neoplasm

Mayer SA, Rincon F. 59th AAN 2007


Bernstein RA. Current Diagnosis & Treatment Neurology. 2007
DIAGNOSA BANDING

Penyebab koma dan SOL(lesi desak otak


baik samping kanan, kiri dll cth tumor
abses dll) yg lain
Infark serebri
Pecahnya Berry aneurism.
Early Management
Airway
Blood pressure
Oxygenation (suction)
Hyperventilation
Foleys catheter
NG tube
Position : head up (ditinggikan 20-300) difleksikan
Specific treatment
Medical treatment
Surgical treatment
Interventional Radiology
Radiation
Whole brain (keseluruhan otak)
Radiosurgery (radionuklir)
Pengobatan.
Prinsip konservatif
Perawatan koma
Kontrol hipertensi: TD yg tinggi
dibiarkansaja perdarahan & edema serebri
: MAP(mengukurnya dengan 2diastol +1
sistol bagi 3) >110 mmHg mulai terapi.
Mengatasi edema serebri : mannitol
(osmolaritas 295 305 m osm/l)
Hypereventilasi P co2 25 30 mm hg Dikotrol
terus takutnya nanti Pintracranial tinggi
Pencegahan ekspansi hematom
Managemen Tek darah TD sistolik
diturunkan < 140 mm Hg pada fase akut
mengurangi hematom ekspansi
Anti hipertensi pilihan
- Labetolol
- Esmolol
- Nicardipin
- Hydralazine
- Nitroprusside
Managemen edema atau herniasi
Kepala ditinggikan 30 derjat dengan leher posisi
netral (ekstensi sikit kepala supaya lapang)
Osmoterapi
- Mannitol 20% 0,25 0,5 gr/kgbb
- Saline hypertonik NaCl 3 % bolus IV
250 cc/20 menit
Barbiturat
- Pentobarbital 10 mg/kg
- Thiopental 1,5 3,5 mg/kg
Hiperventilasi
Prognosis
The ICH Score: Prediction of
30-days mortality

Hematoma volume > 30 ml


Glasgow Coma Scale Score < 8
Infra tentorial location/supra
Iintraventrikular hemorrhage
Age
Calculating the ICH Score
Glasgow Coma Scale (GCS) Score
3 4 (sopor/koma) 2
5 12 1
13 15 0
ICH Volume (cc) dari CT-scan
> 30 1
< 30 0
Intraventricular Hemorrhage (IVH)
Yes 1
No 0
Infratentorial Origin of ICH
Yes 1
N0 0
Age (years) > 80 1
< 80 0
Total Score 0 - 6
0PERATIF
Indikasi tindakan operatif :
- perdarahan intraserebeller > 3 cm
- perdarahan lobar + diameter > 3 cm +
tanda2 peninggian TIK yg cepat /
perburukan klinis dicoba tindakan
operatif utk life saving.
!!! Sebelum koma dalam + pupil dilatasi
maksimal
Perdarahan subarachnoid
Penyebab yg paling sering:
1. Trauma
2. Spontan
2.1. Perdarahan intraserebral ruang
subarakhnoid
2.2. Primer:
- ruptured saccular aneurysmm
- bleeding AVM
- Ruptured mycotic aneurysm
Subarachoid hemorrhage
Subarachnoid
Blood leaks from
cerebral vessel into
subarachnoid space
If arterial, sudden and
painful
Tepat lewatnya CSF
Aneurysms and AVMs
Penyebab lain (jarang)
Tumor otak primer atau metastase
Blood dyscarias?
Herpes simplek ensefalitis, brain abcess,
acute hemorrhagic leukoencephalitis
Hipertensi
Vasculitis, primary angiitis of the CNS
Ruptured of an arteriosclerotic vessel
Subdural hematoma with ruptured into
the subarachnoid space
Gejala klinis:
Sakit kepala yg hebat (occipital, cervical),
mual,muntah, fotopobia
Kesadaran menurun koma, tergantung
luasnya perdarahan
Tanda2 perangsangan meningeal: kaku
kuduk
Funduskopi: perdarahan retina, papil edema
Gangguan psikis
Kadang2 kejang fokal / umum
Skala Botterell dan Hunt & Hess

G rade I. Asimptomatik atau sakit kepala dan


kaku kuduk ringan
Grade II. Sakit kepala, kaku kuduk sedang
sampai berat tanpa gejala
neurologik fokal
Grade III. Drowsiness(ngacau),
confuse(bingung) dan defisit
neurologik fokal ringan
Grade IV. Stupor atau semikoma, gejala
permulaan deserebrasi dan ggn.
Vegetatif

Grade V. koma dalam dan deserebrasi


Prosedur diagnostik

LP (lumbalpungsi)
X-ray tl.tengkorak
CT Scan
Arteriografi
CT angiography
TCD (aliran darah di pembuluh darah
otak)
DIAGNOSA BANDING

Migraine
Infeksi sistemik
Meningitis / ensefalitis
Hipertensif ensefalopati
Arthritis cervicalis
Intracerebral hemorrhage
Komplikasi
Perdarahan ulang
Vasospasme and delayed cerebral
ischemic
o Hidrosefalus akut
Subdural hematoma (tinggi Pint.cra.)
Inapropriate secretion of ADH
Pengobatan
Kesadaran menurun perawatan koma
Perawatan umum
Bedrest total (lk. 3 minggu)
Pengobatan simtomatik utk. Sakit
kepala / gelisah
Edema serebri: mannitol
Untuk mencegah vasospasme :
calsium entry blocker
nimodipine(hanya satu-satunya)
Pengobatan (lanj)
Tindakan operatif clipping
untuk mencegah re-bleeding, setelah prosedur
diagnostik (arteriografi) aneurisma
Emndovascular coiling (masukkan coiling di
aneurismanya)

Prognosa:
Mortalitas masih tinggi. (grade 4-5)
Komplikasi
Vasospasma arteri dijumpai pada 30% kasus, dapat
juga dijumpai setelah 4 12 hari ruptur dan dapat
menetap beberapa hari minggu
Rebleeding pada 24 jam pertama, 20% pada 14 hari
berikutnya penyebab kematian (60% kasus)
Intracerebral hematoma
Subdural hematoma
Acute hydrocephalus
Inappropriate secretion of antidiuretic hormone
SAH yang berat atau komplikasi operasi
Prosedur diagnostik
Schedule foto
Head ct scan/MRI
CT/MR Angiography/venography
LP
Digital substract angiography
Etiologi:
Hipertensif ( Primer )
- Cerebral amyloid angiopathy (CAA)
Non-hipertensif ( Sekunder )
- rupture aneurysma/ AVM
- antikoagulansia / thrombolitik
- neoplasma, trauma
- drug abuse/intoksikasi
- Cerebral venous sinus trombosis
PIS Hipertensif.
Penderita hipertensi kronis:
arteriosklerotik pemb.darah kecil
perubahan2 pd.ddg. pemb.darah
aneurisma (Charcot Bouchart aneurysm )
pecah PIS
Lokasi:
- talamus - kapsula interna
- basal ganglia - lobar dll.
Clinical Manifestations
Rapid onset of focal neurological deficit with
clinical signs of high ICP :
- abrupt change in level of consciousness
- headache
- vomiting
> 90% have acute hypertension exceeding
160/100 mm Hg, with or w.o. history of
hypertension
Dysautonomia : central fever, hyperventilation,
hyperglycemia, tachycarida or bradycardia.

Lancet Neurol 2005;4:662-72


Clinical Manifestations (cont.d)
50% cases originates in the basal ganglia, 1/3
in cerebral hemisphere, 1/6 in brainstem of
cerebellum
40% accompanied by IVH acute
hydrocephalus, high ICP, less chance of good
outcome
Rapid progression to coma with motor
posturing massive supratentorial
haemmorrhage, brainstem or diencephalon
bleeding or acute obstructive hydrocephalus
due to IVH.