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intracerebral hemorrhage& subaracnoid.pptx
- 1. Intracerebral Subaraknoid pasien dengan hipertensi dan aterosklerosis serebral ruptur p.darah Haemorrhagi membesar penurunan kesadaran dan abnormalitas tanda vital. Akibat trauma atau hipertensi, tetapi penyebab paling sering adalah kebocoran aneurisme pada area sirkulus Willisi dan malformasi arteri vena kongenital pada otak. Perdarahan sering berulang dan menimbulkan vasospasme hebat. STROKE HEMORAGIK Hunt and Hess grading scale for acute SAH GRADE CHARACTERISTIC 1 Headache 2 Meningeal signs, severe headache, cranial neuropathy 3 Lethargy; inattentiveness, requiring repeated stimulation to remain alert; hemiparesis 4 Stupor; brief arousal only to painful stimulus 5 Coma- no arousal to any stimulus
- 3. Adams and Victors Principles of Neurology, 10th Edition. 2014.
- 4. Klasifikasi • Hypertensive Hemorrhage • Non-Hypertensive Hemorrhage • Trauma • Vascular Malformation • Hemorrhage into Cerebral Infarcts • Amphetamine/Cocaine Abuse • Cerebral Amyloid Angiopathy • Acute Hemorrhagic Leukoencephalitis • Hemorrhage into Tumors • Coagulopathies • Anticoagulation
- 5. Hypertensive Hemorrhage Hipertensi merupakan salah satu penyebab paling sering yang menyebabkan perdarahan intraserebral non-traumatik Patofisiologi Autoregulasi serebral karena adanya perubahan cerebral arterial menyebabkan range autoregulasi tekanan darah meningkat Perubahan dinding arteri llipohyalinosis & false- aneurysm (mikroaneurisma) Charcot & Bouchard aneurysms Predileksi basal ganglia, thalamus, pons, dan subcortical white matter Clinical neurology, 9th Edition. 2015.
- 6. Clinical neurology, 9th Edition. 2015.
- 7. Diagnosis • Anamnesis: riwayat hipertensi, stroke, trauma kepala, penggunaan obat antitrombotik • Tanda & Gejala: • Defisit neurologis fokal • Sakit kepala berat • Muntah • Tekanan darah sistolik >220 mmHg • Penurunan kesadaran
- 8. Manifestasi Klinis Clinical neurology, 9th Edition. 2015.
- 9. Pemeriksaan Penunjang • LED meningkat ringan • PTT, hitung trombosit • CT Scan • Deteksi perdarahan yang berdiameter < 1 cm • Darah segar massa berwarna putih • CT angiography: appearance of contrast within the hemorrhage high rate of hematoma expansion • Mass effect & edema hypodense • MRI • Brainstem hemorrhages & residual hemorrhages (visible long after no longer detectable on CT: after 4-5 weeks) Adams and Victors Principles of Neurology, 10th Edition. 2014.
- 10. Kim & Bae. Management of intracerebral hemorrhage. Journal of Stroke 2017;19(1):28-39
- 11. Tatalaksana Kim & Bae. Management of intracerebral hemorrhage. Journal of Stroke 2017;19(1):28-39
- 12. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. AHA/ASA Guideline, 2015.
- 13. Tatalaksana Bedah Kim & Bae. Management of intracerebral hemorrhage. Journal of Stroke 2017;19(1):28-39
- 15. • Definisi: masuknya darah ke ruang subaraknoid (antara piameter dg memb araknoid) • Etiologi: • Nontrauma: • Aneurisma (tersering) • Angioma • Neoplasma • Cortical thrombosis • Infeksi • Vaskulitis • Trauma: sering krn fraktur basis cranium → aneurisma a. Carotid interna http://www.strokecenter.org/patients/about- stroke/subarachnoid-hemorrhage/ https://emedicine.medscape.com/article/1164 341-overview
- 16. • Faktor risiko pembentukan aneurisma: • Atherosclerosis • Hypertension • Advancing age • Smoking • Hemodynamic stress • Heavy alcohol consumption • Herediter • Patofisiologi: Stres hemodinamik (aliran darah dan turbulensi) → pembentukan pouching kecil → ukuran bertambah besar → tunika media yg elastis digantikan o/ jar ikat → ruptur → ekstravasasi darah → pe↑ tek intrakranial → kompensasi → vasokonstriksi PD kranial & pengeluaran mediator inflamasi → iskemik sekunder → menekan jar otak sekitar → injury → terbentuk massa → menghambat aliran darah dr distal https://emedicine.medscape.com/article/1164341-overview https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5288992/
- 17. • Gejala profromal: muncul 10 – 20 hari sebelumnya, tjd krn adanya kebocoran, emboli atau massa aneurisma yg menekan jar sekitar • Headache (48%) • Dizziness (10%) • Orbital pain (7%) • Diplopia (4%) • Visual loss (4%) • Tanda dan gejala: tergantung dr derajat perdarahan dan lokasi lesi • Sudden and explosive headache (paling sering) • Loss of consciousness: krn penurunan perfusi darah ke otak • Seizure (6-16%) • Jk aneurism terbentuk di: • posterior communicating artery → bisa tjd disfungsi pupil • middle cerebral artery → Motor neurologic deficits (10 – 15%) • ophthalmic artery → monocular vision loss krn penekanan ke optic nerve ipsilateral • Dapat ada gej sakit kepala ringan beberapa minggu sebelumnya krn adanya kebocoran darah ke subarachnoid space • mild to moderate blood pressure (BP) elevation → mjd labil stl tek intrakranial meningkat • Takikardi • Peningkatan suhu jk disertai dg meningits https://emedicine.medscape.com/article/1164341-overview https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5288992/
- 18. • Pemeriksaan penunjang: • Lab: • CBC: evaluation of possible infection or hematologic abnormality • PT & aPTT: evaluation of possible coagulopathy • Blood typing: prepare for possible intraoperative transfusions • Cardiac enzymes: possible myocardial ischemia • Radiologi: • CT scan: first choice (paling sensitif), dapat mendeteksi perdarahan yg baru terjadi • Cerebral angiography • CTA (CT angiography) • MRI: • performed if no lesion is found on angiography • Not sensitive for SAH within the first 48 hours • monitoring the status of small, unruptured aneurysms • Pungsi lumbar: • Jk gejala klinis menunjukkan SAH tapi hasil imaging negatif • Paling baik dilakukan 12 jam stl munculnya gejala • Melihat adanya eritrosit dan cek xantochromia (CSF berwarna kuning/pink stl sentrifugasi ak. Pecahnya eritrosit shg pigmen heme dikeluarkan) https://emedicine.medscape.com/article/1164 341-overview
- 19. CT scan: • Grade 1 - No subarachnoid blood seen on CT scan • Grade 2 - Diffuse or vertical layers of SAH less than 1 mm thick • Grade 3 - Diffuse clot and/or vertical layer greater than 1 mm thick • Grade 4 - Intracerebral or intraventricular clot with diffuse or no subarachnoid blood https://emedicine.medscape.com/article/1164 341-overview
- 20. Tatalaksana • Monitoring: • Cardiac monitoring • Pulse oximetry • Blood pressure • Urine output dg foley catheter • Terapi: • Hipovolemik: isotonic crystalloid for volume replacement • Bari antihipertensi jk MAP >130mmHg • Peningkatan tek intrakranial (ICP): • Osmotic agents (manitol) • Loop diuretic https://emedicine.medscape.com/article/1164341-overview https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5288992/
- 21. Tatalaksana • Vasospasm: • Nimodipine: • Calcium channel blocker • Menghambat vasospasme: menghambat Ca masuk ke sel otot polos & mencegah pelepasan substansi dr platelet dan sel endotel • Bersifat neuroprotektif: menghambat masuknya Ca ke neuron yg rusak • Dapat mencegah dan mjd terapi pada delayed ischaemic • Dosis 60mg tiap 4 jam selama 3 minggu • Magnesium: calcium antagonis • Statin: meningkatkan pembentukan NO → vasodilator • Surgery: pemasangan clip pd aneurisma yg ruptur http://www.strokecenter.org/patients/about- stroke/subarachnoid-hemorrhage/ https://emedicine.medscape.com/article/1164341-overview https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5288992/
- 22. Prognosis • The Hunt and Hess grading system is as follows: • Grade 0 - Unruptured aneurysm • Grade I - Asymptomatic or mild headache and slight nuchal rigidity • Grade Ia - Fixed neurological deficit without acute meningeal/brain reaction • Grade II - Cranial nerve palsy, moderate to severe headache, nuchal rigidity • Grade III - Mild focal deficit, lethargy, or confusion • Grade IV - Stupor, moderate to severe hemiparesis, early decerebrate rigidity • Grade V - Deep coma, decerebrate rigidity, moribund appearance • Semakin rendah grading, prognosis semakin baik • Grade I – III prognosis cukup baik, bisa segera dioperasi • Grade IV – V prognosis buruk, harus stabilisasi kondisi sampai min grade III utk bisa dioperasi https://emedicine.medscape.com/article/1164 341-overview
- 23. • DD: • Aseptic Meningitis • Cluster Headache • Encephalitis • First Adult Seizure • Hypertensive Emergencies in Emergency Medicine • Intracranial Hemorrhage • Ischemic Stroke in Emergency Medicine • Meningitis • Migraine Headache • Transient Ischemic Attack • Komplikasi: • Hydrocephalus • Rebleeding • Vasospasm • Seizures • Cardiac dysfunction https://emedicine.medscape.com/article/1164 341-overview
Editor's Notes
- Cerebellar hemorrhage—Neurologic deterioration, brainstem compression, and hydrocephalus are indications for decompressive posterior fossa surgery, which may avert a fatal outcome. Results are best in conscious patients. Lobar hemorrhage—Surgical evacuation can also be useful for lobar hematomas, especially those larger than 30 mL in volume and located within approximately 1 cm of the brain surface. Patients with good neurologic function who begin to deteriorate are optimal candidates. Prognosis is related to the level of consciousness before surgery. Deep hemorrhage—Surgery is not beneficial for pontine or deep cerebral hypertensive hemorrhage.
- PD otak rentan thd perubahan TD krn tunika adventisia tipis dan tdk ada tunika elastika eksterna → mudah terbentuk pouching aneurisma (berry/saccular aneurism) Aneurism sering terbentuk pd a carotid interna, branching a cerebral pd circulus Willis Jk tek darah sangat tinggi → ruptur → darah yg keluar ke ruang subaraknoid >> → kerusakan jaringan >> Risiko ruptur jk aneurisme >5mm
- Mean arterial pressure (MAP)