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 % OF CASES
Putamen 30-50

Subcortical Whitematter 30

Thalamus 10-15

Pons 5-12

Cerebellum 9

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 (Wiswanathan A,
et al. Ann Neurol. 2011 Dec;70(6):871-80.)

Lancet Neurol 2005;4:662-72

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