1.

Patofisiologi Migraine
2. Stroke in young adult
3. Moya-Moya Syndrome
4. Takayasu Syndrome
5. mRS
6. NIHSS
7. Antiplatelet, anticoagulant & fibrinolitik
 Migraine
• Common (prevalence
12%) Migraine
• Manifested by :
– Recurrent headache Classic Migraine
– Usually unilateral (Migraine w/
– Frequently pulsatile aura)
– Often associated with
nausea, vomiting,
Common
photophobia, Migraine
phonophobia (without aura)
Pathophysiology of migraine
Migraine attacks are often reported to have four phases:

• Prodromal or premonitory phase – Symptoms are often subtle and

can occur in the days and hours leading up to a migraine. Symptoms
can include yawning, neck stiffness, thirst, and polyuria.
• Aura phase – In 28% of migraine patients, the prodromal phase will
develop into an aura phase and this can either precede or coexist
with the headache phase. Patients can experience visual and
auditory hallucinations, feelings of physical and mental distortion
and even partial loss of sight.
• Headache phase – Described as a throbbing pressure that
intensifies with increased intracranial pressure leading to nausea,
sensitivity to light, noise and smell.
• Postdromal phase – This phase is characterised by a diverse range
of symptoms, including fatigue and poor concentration as well as
cognitive issues such as poor comprehension skills and lowered
mood levels, even depression.
 Stroke in young adults
• Uncommon, comprising 10-15% of all stroke patients
• Younger than 45 or 49 years
• Large economic impact by leaving victims disabled before
their most productive years  major public health problem
• Most common vascular risk factors dyslipidemia (60%),
smoking (44%), hypertension (39%)
 Uncommon Causes of Stroke in Young Adults
Non-artherosclerotic • Cervicocephalic arterial disease
angiopathies • Moya-moya disease
• Fibromuscular dysplasia
• Reversible cerebral vasoconstriction
Hematologic Condition • Hypercoagulable state due to :
Deficiencies of protein S, protein C / antithrombin; factor V Leiden
mutation
• Antiphosholipid syndrome
• Hyperchromocysteinemia
• Sickle cell disease
• Myeloproliferative disorder
Genetic • Fabry Disease
• CADASIL (Cerebral Autosomal Dominant Arteriopathy w/
subcortical infarcts and leukoencephalopathy)
• MELAS (Mitochondrial encephalopathy w/ lactic acidosis and
stroke-like episodes)
• Marfan Syndrome
Inflammatory & • Vasculitis (sjogren syndrome, Wegener granulomatosis)
Infectious • Temporal arteritis
• Takayasu disease
 Moya moya syndrome
• Definition : rare, progressive cerebrovascular disorder
caused by blocked arteries at the base of the brain area
called the basal ganglia
• Incidence is higher in Asian than Europe/ North America
• Primarily affects children but can also occur in adults
• Peak of incidence among 10 years and 30-40 years
• The first symptom is often stroke, or recurrent TIA,
frequently accompanied by muscular weakness / paralysis
affecting one side of the body
• In children, ischemic symptoms especially TIA, are
predominant (intellectual decline, seizures, and involuntary
movements are also common)
• Etiology is unknown, recent genetic studies identified
RNF213 in the 17q25-ter region as an important
susceptibility gene of MMD among East Asian populations
• Diagnostic method of choice is catheter angiography; MR
angiography and CT angiography are noninvasive diagnostic
methods (steno-occlusive change at the ICA billateraly or
unilateral)
• Treatment  revasularization to the brain by opening
narrowed blood vessels / by bypassing blocked arteries
(children usually respond better than adults)
• Prognosis  without surgery  individuals will experience
mental decline and multiple strokes because of progressive
narrowing of arteries
 Takayasu arteritis
• Takayasu arteritis is a rare, systemic,
inflammatory large-vessel vasculitis of
unknown etiology that most commonly affects
women of childbearing age.
• It is defined as "granulomatous inflammation
of the aorta and its major branches" by the
Chapel Hill Consensus Conference on the
Nomenclature of Systemic Vasculitis.
 Epidemiology & etiology
• Very rare disease of young • causes unknown.
people, initial symptoms • most likely to be the
arising between 5 and 40 consequence of
years of age. environmental factors and a
• 80-90% female susceptible genetic
• more common in patients background.
originating from the Far • One common but unproven
East, Japan and the Asian hypothesis is that it is
sub-continent. precipitated by an infection.
• The inflammation involves
white blood cells invading
the wall of the artery
predisposing to damage and
scarring.
 symptoms
• initial symptoms  non-specific
(malaise , profound fatigue, fever,
night sweats, weight loss, myalgia
(muscle pain), arthralgia (painful
joints), rash)
• Additional symptoms can include
dizziness/light headedness,
shortness of breath, cramping
pain in the arms, legs or chest on
exertion.
• Carotidynia, (pain and tenderness
over the carotid arteries in the
front of the neck) is also found in
approximately 25% of patients.
Diagnosis (American College of
Rheumatology)
Dx criteria :
1. Onset of disease = 40 years
2. Claudication(severe muscle pain
due to cramp, caused by narrowed
blood vessels) of an extremity
3. Reduced brachial artery pulsation
4. Difference in systolic blood
pressure >10 mmHg between the
arms
5. Aortic or subclavian artery bruit
6. Angiographic abnormality
 Diagnosis test
• Blood Tests: no blood test to definitively confirm the
diagnosis. The ESR and CRP can help measure activity of the
illness
• MRI
• Ultrasound – Doppler ultrasound (ultrasound scan) : can
detect and monitor the arterial wall and the degree of
narrowing
• Positron emission tomography (PET scanning): often used
in combination with CT scanning (CT-PET). may identify
early active disease and may on occasion help to
distinguish active disease (which needs further treatment)
from scarring resulting from previous inflammation.
• Computed tomography (CT) angiography
MRI USG

PET Scan
 Treatment
• improving symptoms and preventing
further damage and/or scarring to
the blood vessels
• active inflammation in the arteries,
treatment is started with steroids
(prednisolone), +
imunosupressant(methotrexate,
azathioprine or mycophenolate)
• persistent or very severe disease
cyclophosphamide
• Surgery : only indicated for the most
severe cases of TA.
• Revascularisation – where a blocked
artery is bypassed, typically with a
vein graft from somewhere else in
your body. Good long-term outcomes
have been seen, with 20 year graft
survival rates >70 per cent in one
study. However, results are variable
and further studies are needed for
more conclusive evidence.
• Percutaneous transluminal
angioplasty (PTA) – aims to open
narrowed arteries by inserting and
inflating a balloon to stretch the
narrowed section. In some cases a
wire mesh (stent) may be required to
keep the artery open.
Modified Rankin Scale (mRS)
National Institutes
of Health Stroke
Scale (NIHSS)

• Rate severity of
ischemic stroke
 NIH Stroke Scale
1a. Level of conciousness
1b. LOC Questions
(month & his/her age)
1c. LOC Commands
(open –close eye & grip-release
non-paretic hand)
2. Best gaze
3. Visual
0 = alert, responsive
1 = not alert, arousable by minor stimulatin
2 = not alert, requires repeated stimulation
3 = coma
0 = answer both question correctly
1 = answer 1 question correctly
2 = answer neither question correctly
0 = performs both task correctly
1 = performs 1 task correctly
2 = performs neither task correctly
0 = normal
1 = partial gaze palsy
2 = forced deviation
0 = no visual loss
1 = partial hemianopia
2 = complete hemianopia
3 = bilateral hemianopia
 NIH Stroke Scale
4. Facial Palsy 0 = normal symmetrical movement
1 = minor paralysis
2 = partial paralysis
3 = complete paralysis

5. Motor Arm 0 = no drift

5a. Left arm 1 = drift
5b. Right Arm 2 = Can’t resist gravity
3 = No effort against gravity
6. Motor Leg 4 = no movement
6a. Left Leg UN (untestable) = amputation / joint fusion
6b. Right Leg
7. Limb ataxia 0 = absent
1 = present in 1 limb
2 = present in 2 limbs
UN = Amputation / joint fusion
8. Sensory 0 = normal
1 = mild-moderate sensory loss
2 = severe – total sensory loss
 NIH Stroke Scale
9. Best Language 0 = no aphasia
1 = mild –moderate aphasia
2 = severe aphasia
3 = mute, global aphasia
10. Dysarthria 0 = normal
1 = mild-moderate dysarthria
2 = severe dysarthria
UN = intubated
11. Extinction and Inattention 0 = no abnormalities
1 = visual, tactile, auditory, apatial /
personal inattention
2 = profound hemi-inattention /
extinction to more than 1 modality
 NIHSS Interpretation
Score Description

0 No Stroke

1 -4 Minor Stroke

5 – 15 Moderate Stroke

15-20 Moderate / Severe Stroke

21 – 42 Severe Stroke
Antiplatelet
Anticoagulant
Fibrinolytics
• Non Fibrin Specific
• Streptokinase
• Urokinase
• Anistreplase

• Fibrin specific
Tissue Plasminogen
Activators (t-PA)
• Alteplase
• Reteplase
• Tenecteplase