STROKE HEMORAGIK

YUNELDI ANWAR SpS DEPARTEMEN NEUROLOGI FK USU

STROKE HEMORAGIK
1. PERDARAHAN INTRA SEREBRAL

2. PERDARAHAN SUB ARACHNOID

Hemorrhagic Stroke
Intracerebral Blood leaks directly into brain

parenchyma HTN most common cause

Hemorrhagic Stroke
Subarachnoid Blood leaks from

cerebral vessel into subarachnoid space If arterial, sudden and painful Aneurysms and AVMs

Distribution of ICH
LOCATION Putamen Subcortical Whitematter Thalamus Pons % OF CASES
30-50 30 10-15 5-12

Cerebellum

The American Academy of Neurology Institute, 2012.

Types of ICH
Primary (80-90% of cases) : when ICH originates from spontaneous rupture of small arteries or arterioles damaged by : chronic hypertension or cerebral amyloid angiopathy Secondary : when ICH results from trauma, rupture of an aneurysm, vascular malformation, coagulopathy or other causes

Etiologi:
Hipertensif Non-hipertensif

- cerebral amyloid angiopathy (CAA) - antikoagulansia / thrombolitik - neoplasma - drug abuse - aneurisma / AVM - idiopatik - dll.

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.

 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 Lancet Neurol 2005;4:662-72 (Wiswanathan A,

Gejala klinis.
Terjadi waktu aktif

Nyeri kepala hebat

kesadaran

menurun koma. Riwayat hipertensi kronis Defisit neurologis tergantung lokasi dan luas hematom Hematom di lobus frontalis & temporalis kejang2 / hemiparesis kontralateral

Diagnosis
History : trauma, hypertension, prior ischemic

stroke, DM, smoking, alcohol and prescription, over-the-counter, or recreational drugs such as cocaine; use antithrombotic, hematologic or other medical disorders that predispose to bleeding, such as severe liver disease. Risk factors Age Physical examination including BP, cardiac Laboratory testing : INR, PTT, urine tox screen, CBC, ECG CT scan features Further brain imaging (MRI/CTA/angiography)
Mayer SA, Rincon F. 59th AAN 2007

Prosedur diagnostik
X-foto tl. Tengkorak
Head ct scan LP Arteriografi MRA

KOMPLIKASI
HIDROSEFALUS

HERNIASI

- Cinguli - Uncal herniasi - Transtentorial herniasi

DIAGNOSA BANDING
Penyebab koma dan SOL yg lain Infark serebri Pecahnya Berry aneurism.

Pengobatan.
Prinsip konservatif
Perawatan koma Kontrol hipertensi:

TD yg tinggi perdarahan & edema serebri : MAP 110 mmHg mulai terapi. Mengatasi edema serebri : mannitol

Early Management
Airway Blood pressure Oxygenation Hyperventilation Foleys catheter NG tube Position : head up

The ICH Score: Prediction of 30-days mortality

Hematoma volume > 30 ml Glasgow Coma Scale Score < 8 Infra tentorial location Iintraventrikular hemorrhage
Age

Calculating the ICH Score

Glasgow Coma Scale (GCS) 34 5 12 13 15 ICH Volume (cc) > 30 < 30 Intraventricular Hemorrhage (IVH) Yes No Infratentorial Origin of ICH Yes N0 Age (years) > 80 Score 2 1 0 1 0 1 0 1 0 Total Score 0 - 6 1

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 sub arakhnoidal

Penyebab yg paling sering: 1. Trauma 2. Spontan 2.1. Perdarahan intraserebral ruang subarakhnoid 2.2. Primer: - Aneurisma ( Berry ) - AVM - dll.

Gejala klinis:
Sakit kepala yg hebat (occipital),

muntah Kesadaran menurun koma, tergantung luasnya perdarahan Tanda2 perangsangan meningeal: kaku kuduk Funduskopi: perdarahan retina 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, confuse dan defisit

Grade IV. Stupor atau semikoma, gejala permulaan deserebrasi dan ggn. Vegetatif Grade V. koma dalam dan deserebrasi

Prosedur diagnostik
LP
X-ray tl.tengkorak CT Scan Arteriografi

DIAGNOSA BANDING
Migraine
Infeksi sistemik Meningitis / ensefalitis

Hipertensif ensefalopati
Arthritis cervicalis Infark serebri

Komplikasi
Perdarahan ulang
Vasospasme Hidrosefalus akut

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

Pengobatan (lanj)
Tindakan operatif:

untuk mencegah re-bleeding, setelah prosedur diagnostik (arteriografi) Prognosa: Mortalitas masih tinggi.