english case cerebrovascular (revisi)

8/12/2019 English Case Cerebrovascular (Revisi)

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CASE REPORT

Presentan : dr . Yudi Prasetyono

Moderator : dr . H. Ahmad Asmedi, M.Kes, SpSExaminer : dr. H. Pernodjo Dahlan, SpS (K

dr. H. A!dul "o#ir, SpS

$ommentator : dr. %etty Kurnia&atiMay, ''th))*

Identity :

+ame

AeSex

-upation

Eduation

/eliionAddress

Date o# admissonMedial /eord

: Mr. 0SP

: *1 years: Male

: /etired inspetor o# elementary shool

: $ollee

: 2slam: "ununsari, 0ejiharjo, Karanmojo, "unun Kidul

: '3 April ))*: '.4.*5.43

Anamnesis :

-!tained #rom the patient and his &i#e on April, ) th, ))*

Chief complaint :

6ea7ness o# riht arm and riht le

The present history of illness :

A!out '5 hours !e#ore admission to hospital, &hen he &a7ed up in the mornin

()*.)) a.m., suddenly he omplained &ea7ness on the riht arm and le. He &as una!leto ta7e up a lass &ith riht hand !ut a!le to et up #rom seat, to &al7 assisted !y his &i#e.

He also omplained speeh lisp. Pre8iously, he did not omplain #or headahe. %here &ere

no unonsiousness, nausea or 8omitin, 8ertio, aute !lindness or loss o# partial 8isual

#ield, num!ness or &ithout #eelin a hal# o# the !ody, &et the !ed, sei9ure, #e8er. %hepatient ne8er had head injury !e#ore.

A!out * hours !e#ore admission to hospital, his omplaint &as &orsenin. He &as

una!le to et up #rom seat, so he ould only raise riht arm and le. His #amily !rouhthis to paramedi, and than he re##ered to Dr. Sardjito Hospital.

Durin * days stay in the hospital, the patient &as still onsious and there &as no

#e8er. He did not omplain headahe, 8omitin, and dyspnoe. %he &ea7ness o# rihtextremities &ere not ettin &orse, the patient ould to s&allo& the #ood and a drin7

&ithout ho7e. %he patient &as also o#ten uiet, !ut he ould to ommuniate his

omplaint, and he &as a!le to reoni9e his #amily. %he pro!lem o# hih !lood pressure

'


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&as ontrolled. %he patient ha8e !een also onsulted to internal and ardia departments

#or manaement o# hyperlyemia and ardia pro!lem.

The history of previous illness :

- Patient su##ered #rom hypertention a!out 5 years, he did not ha8e his !lood

pressure ontrolled reularly, and did not ta7e many mediines.- Patient su##ered #rom dia!etes mellitus and already to ta7e li!enlamide (';>?. %hese symptom o# the


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patient lead to 8asular lession, !eause the onset &as sudden. %hese suest to the

dianosis o# stro7e.

STRO"E

Stro7e &as de#ined as rapidly de8elopin linial symptoms and ; or sin o# #oaland sometimes loss o# ere!ral #untion &ith the symptom lastin more than 3 hours or

leadin to death &ith no apparent ause other that o# 8asular (6H- cit Dahlan and

@amsudin, '>>1 Stro7e dianosis &as !ased on linial examination, &hile type o# patholoy &as

!ased on result head $% san or Maneti /esonane 2main (M/2 &hih is still

limited in se8eral hospitals in 2ndonesia. Some sorins suh as "adjah Mada Stro7e

Alorithm an !e used to replae $% san in patholoial dianosis o# stro7e &hoseparameters loss o# onsiousness, headahe, and !a!ins7y sin. (Dahlan and @amsudin,

'>>1

Patient aute stro7e 6ith or &ithout

=nonsiousness, headahe,

and 0a!ins7y re#lex

%here are three or t&o o# Yes 2ntraere!ral hemorrhai

these symptoms and sins (+ stro7e

+o

=nonsiousness (+ Yes 2ntraere!ral hemorrhai

headahe ( and stro7e

0a!ins7y re#lex (

+o

=nonsiousness ( Yes 2ntraere!ral hemorrhai

headahe (+ and stro7e

0a!ins7y re#lex (

+o

=nonsiousness ( Yes Aute ishemi stro7e

headahe ( and or in#artion stro7e

0a!ins7y re#lex (+

+o

=nonsiousness ( Yes Aute ishemi stro7e headahe ( and or in#artion stro7e

0a!ins7y re#lex (

Ischemic stro#e or infarction stro#e

Symptoms o# ishemia are onsistent &ith neuroloi dys#untion #rom a sinle

arterial territory or i# impro8ement ours rapidly or early in the linial ourse. 2shemi

ere!ro8asular disorders are lassi#ied aordin to temporal pro#ile, inludin transient

4


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ishemi atta7 (resolution o# symptoms &ithin the #irst 3 hours, re8ersi!le ishemi

neuroloi de#iit (resolution o# symptoms a#ter 3 hours, &ithin 4 &ee7s, proressi8e

ishemi stro7e (proressi8e de#iit, o#ten #or as lon as 3


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$emorrha%ic stro#e

Hemorrhai stro7e ha8e a linial pro#ile that may not !e learly distinuisha!le#rom ishemi sto7e, the onset has sudden. A prominenet derease o# le8el onsiousness

an !e a lue. Headahe, nausea, 8omitin, se8ere hypertention, or other sin o# raised

intraranial pressure also suest a hemorrhai stro7e (6ini7ates, ))'A!out ') o# the stro7e aused !y intraere!ral !leedin and a!out 5 are

su!arahnoid !leedin, &hih is aused !y the smash o# aneurysma, mal8ormation

arterio8enous, anioma a8ernous, aloholism, !lood disrasia, anti7oaulan therapy andaniopati amyloid ( @indsay, '>>?.

&or#in% dia%nosis:

$linial dianosis

%opial dianosis

Etioloial dianosis

: &ea7ness o# riht extremities &ith sudden onset and

&orsen radually, speeh lisp

: DD: le#t anterior &atershed area

le#t internal apsule: DD: launar stro7e

throm!oti stro7e

Physical e'amination :%he patient &as examined in April ) th, ))*

(eneral status

"eneral $ondition

$onsiousness

0lood pressurePulse

/espiratory rate

%emperatureHead

+e7

$hest

Heart@un

A!domen

Extemity

: #air, &ithin normal nutrition

: ompos mentis ("$S :E3,C5 M*

: riht: '*);>) mm H, le#t: '*);>) mm H: riht: 13 x;minute, le#t: 13 x;minute

: ) x;minute

: not #e!rile: onjunti8a not anemis

: !ruit arotis (

: !reath mo8ement riht and le#t is !alane

: irreular rythme (+, murmur (

: sonor, 8esiular, ronhi (

: le8er and splen unpalpa!le, musle riidity (

: uneual pulses (

Psychiatric state :

%he psyhiatri sreenin used =$@A +europsyhiatri 2n8entory

/esult : suest to distur!ane in !eha8ior domain depression and apathy

!eurolo%ical e'amination :

5


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$oniousness

Head eye

+e7

: ompos mentis, "$S : E3,C5 M*: mesoephal

pupil isoor, diameter 4mm;4mm liht re#lex ;, orneal re#lex ;

: ne7 sti##ness (


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Pronounin the linual (


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Pression 6nl 6nl

Ci!ration 6nl 6nl

Position 6nl 6nl

Disrimination 6nl 6nl

Ceetati8e #untion : &ithin normal limit

A!normality mo8ement : (

(ad)ah *ada Stro#e Scale : 3

+arthel inde' : '5

Activities of Daily ,ivin% :'*

Co%nitive function :

Mini Mental State

Examination

-rientation : 1 (orientation o# person and plae &ere

not impaired, !ut orientation o# time &as impaired

/eristration : 4Attention and alulation : 3/eall : (ne& learnin a!ility &as impaired

@anuae : 3, the patient did not do the option o#

sentene ommand, !eause &ea7ness in the rihthand

$onstrution : the imitatin o# piture &as not

examined, !eause o# &ea7ness in the riht handDesposito Attention : it &as impaired, the patient did not do

ompletely to mention the !a7&ard diit seuene

and the !a7&ard month seuene

@anuae : the patient ould spea7 spontaneously, !utit &as not #luentlyJ the mentionin, repetition,

interpretation o# 8er!al lanuae and readin &ere

not impaired, !ut the &ritin o# sentene &as notexamined, !eause o# &ea7ness in the riht hand,

apraxia &as not impaired

Cisuospatial : it &as not impairedCisuoonstrution : it &as not examined, !eause o#

&ea7ness in the riht hand

Memory : diit span &as three (reent memory &asimpaired, reallin o# 5 &ord &as t&o (ne& learnin

a!ility &as impaired, narratin o# urrent pu!li e8ent

&as neati8e

Exeuti8e #untion : it &as impaired, mentionin o#animal name &ithin ' minute &as six, tontinuin the

alternatin piture and the letter


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and exeuti8e #untion

$achins#i score : ''

Supportin% e'amination:

@a!oratory #indin (April, '3th, ))*

H! : '4,3 ;d@ Di##tel : AS% : 4*.4 2=;@

A@ : 1.')) ; mm4 +eutro#il: *?.3 H A@% : 4?. 2=;@AE : 5,13 x ')* ; mm4 @im#osit : ?.' @ 0=+ : ''.> m;d@

Ht : 34,' @ Monosit : 3.* @ $reatinin : '.) m;d@

A% : '3.))) ; mm4 Eosino#il: ).> =ri aid : ,* m;d@

0aso#il : ),) /andom luosa:45 m;d@

+a : '41 mmol ; @ $hol : 4'' m;d@

K : 4.3 mmol ; @ % : ''5 m;d@

$l : ')) mmol ; @ HD@ : 5' m;d@@D@ : > m;d@

@a!oratory #indin

Fast luose : )> m;d@

"luosa hour postprandial : '?1 m;d@

Radiolo%y:

/onten o# thorai ( April, '3 th ))*

/esult: Pulmo : &ithin normal limit, $or: ardiomeali

$ead CT Scan(April, '3th))*

Hipodens lession on le#t su!ortial deep temporal lo!e (diameter mm and le#t

peri8entriular (diameter 5 mm/esult : in#artion on le#t su!ortial deep temporal lo!e and le#t peri8entriular

Electrocardio%raphy

April, '3th ))*:Synus /hytm, Heart /ate ?* x;minute, 8entriular extrasystole #reuent

April, '*th ))*:

Synus /hytm, Heart /ate ? x;minute, 8entriular extrasystole !ieminiApril, )th ))*:

Synus /hytm, Heart /ate 13 x;minute, 8entriular extrasystole rare

Consultations

Cardiolo%y department (April, '3th))*:

/esult: 8entriular extrasystole #reuent

>


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%reatment : oxienation 8ia anule, amiodarone oral 4 x ')) m

E8aluation assessment (April, '*th))*:

/esult: 8entriular extrasystole !iemini%reatment : oxienation 8ia mas7, amiodarone drip 35) m;3 hours

E8aluation assessment (April, )th))*:

/esult: 8entriular extrasystole rare%reatment : oxienation 8ia anule, amiodarone drip 35) m;3 hours

Internal department (April, '3th))*:/esult: dia!etes mellitus type non o!ese

E8aluation assessment (April, 5th))*:

%reatment: reular insulin 4 x 3 2=

*edical reha-ilitation department(April, '*th))*:

/esult: /iht hemiparesis on in#artion stro7e patient

Proram: Exerise proram

Musle strenthenin Mo!ili9ation and AD@ impro8ement

SECO!D DISCSSIO!

%he results o# physial examination, sho&ed onsiousness, riht hemiparesis andriht #aial &ea7ness (paresis o# riht #aial ner8e


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the esta!lished riteria o#unilateral motor and;or sensory sins that in8ol8ed the &hole o#

at least o# the 4 !ody parts (#ae, arm, le &ithout distur!ane o# onsiousness, 8isual

#ields, lanuae, or other ortial#untions. 6e distinuished 3 launar syndromes: puremotorstro7e, sensorimotor stro7e, pure sensory stro7e, and atati hemiparesis;dysarthria

lumsy hand syndrome (De Lon et al., )).

%he small penetratin !ranhes o# the major intraranial arteries ha8e poor ollateralonnetions, o!strution o# !lood #lo& aused !y #i!rin deposition, lipohyalinosis,

miroatheroma, or throm!us leads to in#artion in the limited distri!ution o# one o# these

arteries (6ie!ers et al., '>>?. %here isn a time pro#ile #or appearane o# this lesion a#terthe linial e8ent. =sin $% imain, the lo&est pre8alene o# positi8e imaes ours in

the #irst &ee7 a#ter the e8ent. From reported data, early $% positi8ity #or lesions onruent

&ith a linially de#ined launar in#art ranes #rom ' to 5) o# patients. 2n the #irst

#e& days, M/2 is reported to sho& a reent launar in#art in up to >3 o# patients.Di##usion 6eihted Maneti /esonane 2main (D65 sensiti8e and >3 spei#i #or re8ealin an aute launar in#art (2n9itari and

@amassa, ))4.

%he study to determine the linial presentation and aetioloy o# small su!ortialin#artions as #ound on D6>4.

-n the oniti8e #untion examination, the patient had MMSE examination to result

in distur!ane o# orientation, attention and alulation, as &ell as reistration. 6hile in the

Desposito examination to result in distur!ane o# attention, memory, and exeuti8e#untion. 0ased on result o# this examination, the patient had 8asular oniti8e

impairment.

Su!ortial ishemi 8asular injury and launar in#artions rele8ant to 8asulardementia tend to pre8entially in8ol8e the su!ortial &hite matter o# the #rontal lo!es and

the anterior aspets o# the !asal anlia inludin the audate nuleus and lo!us pallidus.

Patient &ith su!ortial 8asular dementia exhi!it more se8ere impairment o# exeuti8e#untion and less impairment o# memory, partiulary reonition memory ($ummins,

))4.

Final dia%nosis :

$linial dianosis

%opial dianosis

Etioloial dianosis

: launar stro7e syndrome

8asular oniti8e impairment: posterior lim! o# le#t internal apsule

le#t su!ortial deep temporal lo!e, le#t peri8entriular

: hypertension small 8essel disease, dia!etes small 8essel disease, hyperholesterolemia small 8essel disease

*ana%ement

''


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-xyenation is a reat importane durin periods o# aut ere!ral ishemia in order

to pre8ent hypoxia and potential &orsenin o# the neuroloyal injury (Adams, ))4.

+europrotetan drus i8e 8ariety result in stro7e patient. %he +ational "uideline o#Stro7e has not reommended neuroprotetan neither has AHA "uidelines . +e8erthless

2ndonesian +euroloial Assoiation still reommended piraetam and itiholine as

neuroprotetan drus #or stro7e patients (Perdossi, ))3. Piraetam has t&o mehanisms a##eted to neuronal and 8asular le8els (Perdossi,

))3:

a. +euronal le8el: related to phospolipid, ell mem!ran #luidity repaired,neurotransmitter repair, adenylate ylase stimulation.

!. Casular le8el: inrease o# erythroyte de#orma!ility, derease o# platelet anti

areration, miroirulation repaired.

2t is indiated to !e i8en at se8en hours o# stro7e onset. First ' rams o# piraetamper in#ussion o8er ) minute, and then #ollo&ed &ith 4 rams !olus e8ery * hour or '

rams e8ery ' hour until the #ourth day. -n day 5 until the end o# 3 &ee7s, is piraetam

i8en 3,1 ram di8ided 4 times a day orally, and on the &ee7 5 until ' it is i8en ,3

ram t&ie a day ( Perdossi, ))3.A randomi9ed, dou!le? patients at 55 enters.

2nlusion riteria are presentin &ithin ' hrs o# onset o# aute ishemi supratentorialstro7e, disa!lin symptoms (-roo9o sale sore o# G5 and ?) and arousa!le, the aes

o# 3) and 15. Patients reei8ed plae!o or ' piraetam as an initial intra8enous !olus

#ollo&ed !y ' daily #or 3 &ee7s and then 3.1 daily #or 1 &ee7s. %he outomeassesment used -roo9o sale and 0arthel 2ndex. Additional analyses o# patients &ith

moderate and se8ere stro7e &ithin the early treatment roup also sho&ed sini#iant

impro8ement on piraetam in !oth outomes (p).) (De Deyn, '>>?.

$itiholine treatment &ill impro8e ere!ral #untion passin throuh some &ays as#ollo& (Adi!hlata et al., ))':

a. 2nrease phosphatydil holine to ma7e mem!rane repair

!. 2nhi!it #ree #atty aid and #ree radial. 2nrease aetylholine neurotransmitter prodution &hih has theurapeti e##et as

lon as ishemi

d. As lutation resoures &hih 7ind o# primary endoeni antioxidant in the !rainFor ishemi stro7e, itiholoine should !e i8en on #irst 3 hour sine stro7e atta7

at dose 5)


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myoardial in#artion, or 8asular death. %he o8erall sa#ety pro#ile o# lopidorel is at

least as ood as that o# medium


14/20

ASAN uidelines G4)) m;d@ (@inds!er and /oine, ))4. 2nsulin in#usion has an

e##et that is opposite to that o# hyperlyemia. 2t not only lo&ers !lood luose le8els !ut

also exerts an antioxidant and anti


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e. %o repair li#e uality o# the patient

/eha!ilitation is needed to ain #untional reo8ery throuh relearnin proess.

0e#ore mo!ili9in and ati8e exerisin the patient is i8en positionon to reo8ery his!ody #untion and to protet spastisity (Aliyah, et a.,))'.

%he patient had i8en therapies:(eneral:

Air&ay, 0reathin and irulation maintenane:

- 4 @;min2CFD /iner aetat ) tt per min

Pharmacotherapy

Piraetam inj 3 x 4 ram

$itiholin inj x 5)) m$lopidorel ' x ?5 m

Sim8astatine ' x ') m

Amiodarone drip 35) m ; 3 hours

Plannin therapy #or 8asular oniti8e impairment: donepe9il ' x 5 mDiet: diet DM '>)) 7alori

Physiotherapy

Pro%nosis

%he study &as to in8estiate the lon>*.

%he results o# study a!out #untional outome in patients &ith launar in#artion &as

moderate or se8ere hemiparesis ' month a#ter stro7e onset as the stronest preditor o#physial dependene or death at 4 years (p),))', #ollo&ed !y &hite matter

hyperintensities on M/2 (p),))'. /eurrent stro7e inreased disa!ility and handiap !ut

&as not a statistially sini#iant independent ris7 #ator (Samuelsson et al., '>>*.%he ohort study in pure motori stro7eJ ae, male sex and nonuse o# aetylsaliyli

aid &ere stastitially sini#iant #or independent determinants o# death. 6hile,

hypertension and dia!etes mellitus&ere stastitially sini#iant #or independent ris7 #atoro# reurrent stro7e (Staa# et al., ))'.

%he study a!out t&o type o# launar in#arts per#ormed a #ollo&


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mortality, reurrent stro7e,and o8erall #untional outome in launar stro7e patients &ith

' silent launar lesions is more un#a8ora!le than in patients &ithout suh lesions. %hese

#indins sustain the idea o# launarstro7e entities (De Lon et al., )).

%he patient had many pro!lems inludin hypertension, dia!etes mellitus,

dyslipidemia, 8entriular extrasystole, !arthel index '5, and three launar lesion in thehead $% san #indin &ith symptom pure motori.

0ased on these study, so the pronosis #or this patient are:

DeathDisease

Disom#ort

Dissatis#ationDissa!ility

Distitution

: du!ia ad malam: du!ia ad malam

: du!ia ad malam

: du!ia ad malam: du!ia ad malam

: du!ia ad malam

Follo. up

Follo. up April/ 00th/ 0112 April/ 03th0112 April/ 04th 0112

"eneral ondition

"$S

Cital sin

Fair, E 3C5M *

0PQ'?);'))

PQ11x, //Q )x

tempQnot #e!rile

Fair, E 3C5M *

0PQ'3);>)

PQ11x, //Q )x

tempQ not #e!rile

Fair, E 3C5M *

0PQ'3);>),

PQ11x, //Q )x

tempQ not #e!rile

+.ranialis Paresis +.C22, I22 dextra

=M+

Paresis +.C22, I22

dextra =M+

Paresis +.C22, I22 dextra

=M+

E7stremity :

Mo8ement

@imited Free @imited Free @imited Free

@imited Free @imited Free @imited Free

Strenth 4;4;4 5;5;5 4;4;4 5;5;5 4;4;4 5;5;5

4;4;4 5;5;5 4;4;4 5;5;5 4;4;4 5;5;5

E$"

@a!oratorium

%herapy

Centriular extrasystole

(, synus rythme

- 4 @;min

2CFD /iner aetate )

tt per min

Piraetam inj 3 x 4 ram

$itioline inj x 5)) m

$lopidorel ' x ?5 m@osartan ' x 5) m


Amiodarone drip stop

Diet DM '>)) 7alori

Physiotherapy


(, synus rythme

Fast 0" : )5 h PP 0" : ?1

Al!umin : .51

- 4 @;min

2CFD /iner aetate )

tt per min

Piraetam inj 3 x 4 r

$itioline inj x5)) m

$lopidorel ' x ?5 m@osartan ' x 5) m


/eular 2nsulin 4x3 2=

Al!umin in#use

Diet DM '>)) 7alori

Physiotherapy


(, synus rythme

h PP 0" : '?*

Al!umin : 4.)1

%o stop o# -, 2CFD

Piraetam oral 4x1)) m

$itioline oral x5)) m

$lopidorel ' x ?5 m

@osartan ' x 5) m

Sim8astatine ' x ') m/eular 2nsulin 4x3 2=

Patient dishare #rom

hospital, &ith edua tion:

ontrol to stro7e unit,

memory, endrine and

physiotherapy lini

'*


17/20

REFERE!CES

Adi!hlata, /.M., Hather, 0.S., Dempsey, /.L., ))', E##ets o# $itiholine on

Phospholipid and "lutation @e8els in %ansient $ere!ral 2shaemia, Stroke 32:2376-2381

Anonim, '>>?, Amiodarone,Medicine Net. Com.

Aliyah, A., Kus&ara, E.F., @imoa, 6uysan, "., '>>4, "anuan Peredaran Darah -ta7

dalam Harsono (ed: Kapita Selekta Neurologi, "adjah Mada =ni8ersity,

Yoya7arta

0arlay, @., ))5, Statins May /edue Stro7e /is7, $ontinuin medial Eduation,

Medcape Medical Ne!

0ena8ente, -., ))4, Seondary Pre8ention o# Small Su!ortial Stro7es (SPS4 %rial,

=ni8ersity o# %exas Health Siene $enter, San Antonio, %exas,National "i#rar$o% Medicine

0la7, S., /oman, ".$., "eldmaher, DS., Sallo&ay, S., He7er, L., 0urns, A., Perdomo,$., Kumar, D., Pratt, /., %he Donepe9il 4)? Casular Dementia Study "roup,

))4, E##iay and tolera!ility o# Donepe9il in Casular dementia, "lenpointe

$entre 6est, %eane7, Amerian Hearth Assoiation, Stroke,

&ttp:''!!!.trokea&a.org

$AP/2E Steerin $ommittee, '>>>, A randomised, !linded, trial o# lopidorel 8ersus

aspirin in patients at ris7 o# ishaemi e8ents ($AP/2E,"ancet 3(8)*+38:132*-3*, +ational @i!rary o# Mediine and the +ational 2nstitutes o# Hearth, &&&.

pu!med. "o8

$ummins, L.@., Cinters, H., Felix, L., ))4, &e Neurop$c&iatr$ o% l/&eimer0 ieae

and elated ementia, Martin Dunit9, %aylor and Franis "roup pl, +e& Fetter

@ane, @ondon, =nited Kindom.

Dahlan, P., @amsudin, /., '>>1, iagnoi eni 4atologi Stroke 5ntuk Kepentingan

4enanganan Stroke $ang aional, Manajemen Stro7e Muta7hir, Suplemen

0KM I2C

Da8alos, A., $astillo, L., Sa!in, L.A., Saades, L.L., Meradal. L., @ope9, S., $o!o, E.,

6arah, S., Sherman, D., $lar7, 6.+., @o9ano, /., )), -ral $itioline in Aute2shemi Stro7e, Amerian Stro7e Assoiation, Stroke 33: 28+-287

'?


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De Lon, "., Kessels F., @odder, L., )), %&o %ypes o# @aunar 2n#arts, Department o#

+euroloy, =ni8ersity Hospital Maastriht, Maastriht, +etherlands, Stroke 33:

2+72

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