Case Report - InFARCTION STROKE - Ary Anggi Kristiana

8/19/2019 Case Report - InFARCTION STROKE - Ary Anggi Kristiana

1/23

Case Report

INFARCTION STROKE

By:

Ary Anggi Kristiana

1408465581

Supervisor:

dr. Rii Sui!"dr!# Sp.S

$E%ART&ENT OF NE'RO(O)*

&E$ICA( SC+OO( 'NI,ERSIT* OF RIA'

ARIFIN AC+&A$ )ENERA( +OS%ITA(

%EKANBAR'


2/23

-015

KE&ENTRIAN %EN$I$IKAN $AN KEB'$A*AAN

FAK'(TAS KE$OKTERAN 'NI,ERSITAS RIA'

S&FBA)IAN SARAFSere/!ri!/ : Gedung Kelas 03, RSUD Arifin Achmad Lantai 04Jl. Mustia, !el". 0#$%'(4000)&mail * saraffur+gmail.cm

% E K A N B A R '

I. %ATIENTS I$ENTIT*

-ame Mrs.

Age #4 /ears $ mnths

Gender emale

Address Jalan 1angtuah Gang 1angtuah -. 44 2eanaru

Religin Mslem

Marital Status Married

ccu"atin 1use5ife

Date f Admissin -6emer, 74th 70%8

Medical Recrd (0 '% 99

II. ANA&NESIS

Allanamnesis :-6emer, 78th 70%8;

Cie2 Co3p!i"/

!he 5eaness n the right arm and leg

%rese"/ I"ess +is/ory

Since a da/ efre admissin, the "atient has cm"lained the 5eaness n

her right arm and leg. At first, the "atient has cm"lained the numness

and then 5eaened suddenl/ 5hen she 5e u" n the mrning. She ne6er

cm"lained the numness efre.

urthermre, the "atient


3/23


4/23

3; Ne S/i22"ess * -egati6e

4; Cr!"i! Nerves

%. Cr!"i! "erve I O2!/ory;

Right Left nter"retatinSense f Smell =an


5/23

#. Cr!"i! "erve ,II F!i!;

Right Left nter"retatin

!ic

Mtr Sense f !aste

=h6ste Sign

:&;

-rmal=an


6/23

I,. &OTOR S*STE&


U""er )9tremit/ Strength

Distal

2r9imal

!ne

!r"h/

n6luntar/ m6ements

=lnus

%

%

-rmal

)utr"h/

:&;

:&;

8

8

-rmal

)utr"h/

:&;

:&;

1emi"aresis

:UM- !/"e;

L5er )9tremit/

Strength

Distal2r9imal

!ne

!r"h/

n6luntar/ m6ements

=lnus

%%

)utr"h/

:&;

:&;

88

)utr"h/

:&;

:&;

1emi"aresis:UM- !/"e;

d/

!r"h/

n6luntar/ m6ements

Adminal Refle9

)utr"h/

:&;

:&;

)utr"h/

:&;

:&;

-rmal

,. SENSOR* S*STE&


Light !uch

2ain

!em"erature

=an


7/23

ains/

=haddc

1ffman !rmer

"enheim

Schaefer 2rimiti6e Refle9

2almmental

Snut

:&;

:&;

:&;

:&;

:&;

:&;

:&;

:&;

:&;

:&;

:&;

:&;

:&;

:&;

2athlgic refle9 :&;

- 2rimiti6e Refle9

,II. COOR$INATION


2int t "int m6ements

Eal heel t teGait

!andem

Rmerg

=an

)e"er! S/!/us : 1/"ertensin :%#0>'0 mm1g;

Co9"i/ive Fu"/io" : =gniti6e m"airment

Ne S/i22"ess : -egati6e

Cr!"i! Nerves : D/sarthria

&o/ori : 1emi"aresis :UM- !/"e;


8/23

Se"sory : =an


9/23

I,. (ABORATOR* AN$ RA$IO(O)* FIN$IN)S

1. Bood Rou/i"e Nove37er# -4/ -015;

? 1emglin * %7.7 g>dL

? 1ematcrit * 34 H

? Leuc/te * $.$00>mm3

? !hrmc/te * 74#.000>mm3

nter"retatin* -rmal

-. Bood Ce3is/ry

Nove37er# -4/ -015;

? )uose : 155 39d(

? Ureum * 3'.4 mg>dL

? =reatinin * 0.($ mg>dL

? AS! * %(.$ U>L

? AL! * %7 U>L

)lectrlite*

? Sdium * %44.' mml>L

? 2tassium * 7.'( mml>L

? =hlride * %%8.( mml>L

Nove37er# -5/ -015;

? =hr * %$8 mg>dL

? 1DL * 4$.0 mg>dL

? !rigl/ceride * #8 mg>dL

? Uric acid * $.3 mg>dL? LDL =hlesterl * %04 mg>dL

? LD2 * %44 U>L


10/23

@. Ee/ro!rdio9r!py

nter"retatin * s/nus rithm, n anrmal mr"hlg/ 5a6es.

4. Ces/ ?r!y Nove37er# -4/ -015;


11/23

nter"retatin* nrmal

5. +e!d CT S!" i/ou/ o"/r!s/

nter"retatin* infarctin n the left hemis"here cereri


12/23

,. FINA( $IA)NOSIS

- nfarctin stre

FO((O> '%

Nove37er# -6/ -015

S * lethargic, 5eaness f the right e9tremit/, a"hasia, fe6er.

O *

G=S )4M$@a"hasia

ld 2ressure %$0>(0 mm1g

1eart Rate (7 "m

Res"iratr/ Rate 77 t"m

!em"erature 3'.%?=

=gniti6e unctin * =gniti6e m"airment

-ec Stiffness * -egati6e

=ranial -er6es * D/sarthria

Mtric * right e9tremit/ hemi"aresis

Sensr/ * =an


13/23

ld 2ressure %$0>(0 mm1g

1eart Rate '0 "m

Res"iratr/ Rate 77 t"m

!em"erature 3'.0?=

=gniti6e unctin* =gniti6e m"airment

-ec Stiffness * -egati6e

=ranial -er6es * D/sarthria

Mtric * 1emi"aresis

Sensr/ * =an


14/23

Autnm/ * Anrmal urinatin and defecatin

Refle9 * -rmal

A * nfarctin stre

% *

@D RL 70 d"m

=iticlin 3 9 800 mg "er @

As"ilet 7 9 '0 mg "er ral

lic acid 7 9 400 Ig "er ral

Discussion

INFARCTION STROKE

1. $e2i"i/io"

Stroke is a""lied t a sudden fcal neurlgic s/ndrme, s"ecificall/ the

t/"e due t cerer6ascular disease. !he term cerebrovascular disease designates

an/ anrmalit/ f the rain resulting frm a "athlgic "rcess f the ld

6essels. Pathologic process is gi6en an inclusi6e meaning namel/, cclusin f

the lumen / emlus r thrmus, ru"ture f a 6essel, an altered "ermeailit/ f

the 6essel 5all, r increased 6iscsit/ r ther change in the Fualit/ f the ld

fl5ing thrugh the cereral 6essels. !he 6ascular "athlgic "rcess ma/ e

cnsidered nt nl/ in its grsser as"ects emlism, thrmsis, dissectin, r

ru"ture f a 6essel ut als in terms f the mre asic r "rimar/ disrder, i.e.,

athersclersis, h/"ertensi6e arterisclertic change, arteritis, aneur/smal

dilatin, and de6el"mental malfrmatin. )Fual im"rtance attaches t the


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secndar/ "arench/mal changes in the rain resulting frm the 6ascular lesin.

!hese are f t5 main t/"es ischemia, 5ith r 5ithut infarctin, and hemrrhage

and unless ne r the ther ccurs, the 6ascular lesin usuall/ remains silent. !he

nl/ e9ce"tins t this statement are the lcal "ressure effects f an aneur/sm,

6ascular headache :migraine, h/"ertensin, tem"ral arteritis;, multi"le small

6essel disease 5ith "rgressi6e ence"hal"ath/ :as in malignant h/"ertensin r

cereral arteritis;, and increased intracranial "ressure :as ccurs in h/"ertensi6e

ence"hal"ath/ and 6enus sinus thrmsis;. Als, "ersistent acute h/"tensin

ma/ cause ischemic necrsis in regins f rain et5een the 6ascular territries f

crtical 6essels, e6en 5ithut 6ascular cclusin.%

Mre than an/ ther rgan, the rain de"ends frm mment t mment n

an adeFuate su""l/ f 9/genated ld. =nstanc/ f the cereral circulatin is

assured / a series f arrece"trs and 6asmtr refle9es under the cntrl f

centers in the l5er rainstem. structin f an arter/ / thrmus r emlus is

the usual cause f fcal ischemic damage, ut failure f the circulatin and

h/"tensin frm cardiac decm"ensatin r shc, if se6ere and "rlnged

enugh, can "rduce fcal as 5ell as diffuse ischemic changes.%

cal cereral ischemia differs fundamentall/ frm glal ischemia. n the

latter state, if aslute, there is n cereral ld fl5 f the entire rain and

irre6ersile destructin f neurns ccurs 5ithin 4 t ' min at nrmal d/

tem"erature. n fcal ischemia, there is nearl/ al5a/s sme degree f circulatin

:6ia cllateral 6essels;, "ermitting t a 6ar/ing e9tent the deli6er/ f 9/genated

ld and glucse.

!he effects f a fcal arterial cclusin n rain tissue als 6ar/ de"ending

n the lcatin f the cclusin in relatin t a6ailale cllateral and anastmticchannels. f the structin lies "r9imal t the circle f Eillis :t5ard the heart;,

the anterir and "sterir cmmunicating arteries f the circle are ften adeFuate

t "re6ent infarctin. n cclusin f the internal cartid arter/ in the nec, there

ma/ e anastmtic fl5 frm the e9ternal cartid arter/ thrugh the "hthalmic

arter/ r 6ia ther smaller e9ternalinternal cnnectins. Eith lcage f the

6erteral arter/, the anastmtic fl5 ma/ e 6ia the dee" cer6ical, th/rcer6ical,

r cci"ital arteries r retrgrade frm the ther 6erteral arter/. f the cclusin


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is in the stem "rtin f ne f the cereral arteries, i.e., distal t the circle f

Eillis, a series f meningeal interarterial anastmses ma/ carr/ sufficient ld

int the cm"rmised territr/ t lessen :rarel/ t "re6ent; ischemic damage.

!here is als a ca"illar/ anastmtic s/stem et5een adacent arterial ranches,

and althugh it ma/ reduce the siBe f the ischemic field, "articularl/ f the

"enetrating arteries, it is usuall/ nt significant in "re6enting infarctin. !hus,

in the e6ent f cclusin f a mar arterial trun, the e9tent f infarctin ranges

frm nne at all t the entire 6ascular territr/ f that 6essel. et5een these t5

e9tremes are all degrees f 6ariatin in the e9tent f infarctin and its degree f

cm"leteness.%

Additinal ischemia-modifying factors determine the e9tent f necrsis.

!he s"eed f cclusin assumes im"rtance gradual narr5ing f a 6essel all5s

time fr cllateral channels t "en. !he le6el f ld "ressure ma/ influence the

result h/"tensin at a critical mment ma/ render anastmtic channels

ineffecti6e. 1/"9ia and h/"erca"nia are "resumed t ha6e deleterius effects.

Altered 6iscsit/ and smlalit/ f the ld and h/"ergl/cemia are "tentiall/

im"rtant factrs ut difficult t e6aluate. inall/, anmalies f 6ascular

arrangement :f nec 6essels, circle f Eillis, and surface arteries; and the

e9istence f "re6ius 6ascular cclusins must influence the utcme.%

!he s"ecific neurlgic deficit 6iusl/ relates t the lcatin and siBe f

the infarct r fcus f ischemia. !he territr/ f an/ arter/, large r small, dee" r

su"erficial, ma/ e in6l6ed. Ehen an infarct lies in the territr/ f a cartid

arter/, as 5uld e e9"ected, unilateral signs "redminate* hemi"legia,

hemianesthesia, hemian"ia, a"hasia, and agnsias are the usual cnseFuences. n

the territr/ f the asilar arter/, the signs f infarctin are freFuentl/ ilateral andccur in cnunctin 5ith cranial ner6e "alsies and ther segmental rainstem and

cereellar signs Fuadri"aresis, hemi"aresis, and>r unilateral r ilateral sensr/

im"airment are t/"ical, cu"led 5ith di"l"ia, d/sarthria, and 6ertig in 6arius

cminatins.%

-. Ris 2!/or

Accrding t the American 1eart Assciatin :A1A;, the ris factrs f

stre are di6ided int t5, that are nt mdifiale riss factrs and mdifiale


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ris factrs. -t mdifale ris factrs include* age, se9, l5 irth 5eight, race r

ethnicit/, and genetic factrs. Mdifiale ris factrs include* h/"ertensin,

sming, diaetes, nutritinal imalance, lac f "h/sical acti6it/, alchl

cnsum"tin, and drug ause. ncidence f stre can ccur 5ith ne r mre ris

factrs :multifactr;.%&3

T!7e @. Stre ris factrs%&3

No/ &odi2!7e &odi2!7e

% Age

7 Gender

3 Genetic

4 )thnic

% Stre histr/ %0. Sming

7 1/"ertensin %%. Alchl

3 1eart disease %7. Drug ause

4 Diaetes melitus %3. 1/"erhmsisteinemia

8 =artid stensis %4. Antid/ anti fsfli"id

$ !A %8. 1/"erurisemia# 1/"erchlesterlemia %$. )le6atin f hematcrit

' ral cntrace"tin %#. )le6atin f firingen

( esit/

@. Ci"i! &!"i2es/!/io"

!he s"ecific neurlgic deficit 6iusl/ relates t the lcatin and siBe f

the infarct r fcus f ischemia. !he territr/ f an/ arter/, large r small, dee" r

su"erficial, ma/ e in6l6ed. Ehen an infarct lies in the territr/ f a cartid

arter/, as 5uld e e9"ected, unilateral signs "redminate* hemi"legia,

hemianesthesia, hemian"ia, a"hasia, and agnsias are the usual cnseFuences. n

the territr/ f the asilar arter/, the signs f infarctin are freFuentl/ ilateral and

ccur in cnunctin 5ith cranial ner6e "alsies and ther segmental rainstem and

cereellar signs Fuadri"aresis, hemi"aresis, and>r unilateral r ilateral sensr/

im"airment are t/"ical, cu"led 5ith di"l"ia, d/sarthria, and 6ertig in 6arius

cminatins.%,7

4. &!"!9e3e"/

Stre "atients shuld e handled / a multidisci"linar/ team.

Management stre e dne / im"r6ing the general state f the "atient, treat the

ris factrs, and "re6ent cm"licatins.3&$

4.1 +yper!u/e s/!diu3

Actin at this stadium is dne at the )mergenc/ Rm, the aim is t

"re6ent the 5ides"read f rain tissue damaging. At this stage, "atients 5ere


18/23

gi6en 9/gen 7 L > min and cr/stallid>cllid fluid, a6id administratin f

de9trse. rain =! scan e9aminatin, electrcardigra"h/, chest &ra/, cm"lete

"eri"heral ld and "latelet cunt, "rthrmin time > -R, A2!!, ld

glucse, ld chemistr/ :including electrl/tes;, and if h/"9ia, d the ld gas

anal/sis. ther actins in the )mergenc/ Rm are "r6iding mental su""rt t

"atients and "r6ide an e9"lanatin t the famil/ t remain calm.3&$

4.- Au/e s/!diu3

4.7.% General treatment

2lace the "atient


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mL fr 4 hurs and 800 mL fr ' hurs r until h/"tensin treated. f nt

crrected, that is s/stlic ld "ressure still (0 mm1g, d"amine 7&70 mcg > g

> minute can e gi6en until the s/stlic ld "ressure N%%0 mm1g. 3&$

f there is seiBure, gi6e diaBe"am 8&70 mg i6 sl5l/ fr 3 minutes, the

ma9imum dsage is %00 mg "er da/, fll5ed / ral administratin f

anticn6ulsants such as "hen/tin, caramaBe"ine. f the seiBure a""eared after 7

5ees, gi6en rall/ lng&term anticn6ulsant. 3&$

f there is an increased f intracranial "ressure, lus mannitl 5ere gi6en

an f 0.78 t % g > g "er 30 minutes intra6enusl/, and if reund "henmenn

sus"ected, r general cnditin deterirated, fll5ed / 0,78g > g "er 30

minutes e6er/ $ hurs fr 3&8 da/s. Mnitring f the smlarit/ shuld e

"erfrmed :370 mml;, alternati6el/ can e administered h/"ertnic slutins

:-a=l 3H; r fursemid. 3&$

4.7.7 S"ecial treatment

!he gal is t re"erfusin / administratin f anti"latelet agent such as

as"irin and anticagulant, r 5ith trml/tic rt&2A :cminant tissue

2lasmingen Acti6atr;, and neur"rtecti6e agent, such as citicline r

"iracetam. 3&$

4.@ Su7!u/e S/!diu3

Medical measures ma/ include cgniti6e thera"/, eha6ir, s5all5ing,

s"eech thera"/, and ladder training :including "h/sical thera"/;. Gi6en the lng

curse f the disease, it taes a s"ecial intensi6e treatment f "st&stre in the

hs"ital 5ith the gal f inde"endence f the "atient, understand, cm"rehend and

im"lement "rimar/ and secndar/ "re6entin "rgrams.

$

Suacute "hase treatment*$

- =ntinuing the a""r"riate treatment f acute cnditins efre- !he management f cm"licatins- Restratin > rehailitatin :as needed f "atients;, 5hich is

"h/sithera"/, s"eech thera"/, cgniti6e thera"/, and ccu"atinal

thera"/

- Secndar/ 2re6entin- amil/ educatin and discharge "lanning


20/23

T+E BASIC OF $IA)NOSIS

1. B!si i"i! di!9"osis

rm the histr/ taing, a #4 /ears ld 5man had a sudden 5eaness n

the right arm and leg :1emi"aresis;. And her s"eech ecame slurred and

nnfluent. She als can


21/23

!he gld standard e9aminatin fr diagnsing the nn hemrrhagic r

hemrrhagic stre is =! Scan. !he cnsideratin f the hemrrhagic stre

ecause f it almst has the same manifestatin, lie the immediate nset, the

"atient 5as nt in se6ere acti6it/, and there is neurlgical deficit.

5. B!si seo"d!ry di!9"osis

rm the "h/sical e9aminatin the ld "ressure is %#0>'0 mm1g. !his

is a""r"riated 5ith J-= ' criteria that fr "atient


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REFFERENCE

% R""er A1, r5n R1. Adams and @ictrK U-R. 2eanaru. 700#.

3 Earl5 =, 6an Gin J, Dennis M, Eardla5 J, amfrd J, 1ane/ G. Stre

2ractical Management. 3th )d. 700'. lac5ell 2ulishing. ".3(&40.

4 Guideline Stre !ahun 70%%. 2di Stre. 2erhim"unan Dter S"esialis

Saraf ndnesia :2)RDSS;. Jaarta. 70%%.

8 25ers EJ. A1A>ASA Guideline 70%8 A1A>ASA cused U"date f the

70%3 Guidelines fr the )arl/ Management f 2atients Eith Acute schemic

Stre Regarding )nd6ascular !reatment. A1A urnals. 70%84$*000&000.

$ Set/"rant . Stre* Geala dan 2enatalasanaan. =DK %'8>@l.3'

n.4>Mei&Juni 70%% hal.74#&780.


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Case Report - InFARCTION STROKE - Ary Anggi Kristiana

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Transcript of Case Report - InFARCTION STROKE - Ary Anggi Kristiana