Diskusi Co-Ass Minggu IV 2016
-
Upload
auladi-lubis- -
Category
Documents
-
view
223 -
download
0
Transcript of Diskusi Co-Ass Minggu IV 2016
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 1/37
Fig. 1.4. One of the most importantbooks in the study of apoplexy. Wepfer was city physician
at Schahausen inSwiterland when he carried outmeticulous examinationson the cerebral blood !essels andbrains of patients whohad suered apoplexy
"#S$%S# &O'(SS )#*++% #,
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 2/37
$asus 1
• -n )/ laki'laki/ 0 tahun/ datang ke #+" 2S%3() )edan pada pukul 5. wib dengan lemahlengan dan tungkai kanan yang dialami secaratiba'tiba se6ak 1 6am sebelumnya saat os sedang
menonton -,.• "ari anamnese didapati riwayat nyeri kepala 7'8
sebelumnya/ muntah 7'8/ ke6ang 7'8/ demam 7'8/riwayat benturan di kepala 7'8/ bicara celat 798.
Selama : 1 tahun os menderita darah tinggi/namun os tidak berobat secara teratur.
• $eadaan ini tidak pernah dialami pasiensebelumnya.
;#);#*+(* &O(SS )#*++% #,
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 3/37
"iskusi $asus 1
emiparese "" <<<<<
5;#);#*+(* &O(SS )#*++% #,
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 4/37
$asus 1 = 3em. neurologi
• 3emeriksaan klinis = sensorium &)/
-" 5>11 mmg/ nadi ? x>i reguler/pernafasan x>i/ temp 50/?&.
• Sudut mulut tertarik ke kiri/ mata bisamenutup.
• @engan kanan = tidak ada kontraksi otot
• -ungkai kanan = bisa diangkat dari tempattidur tapi segera ter6atuh kembali
• 2eAeks patologis 7'8
4;#);#*+(* &O(SS )#*++% #,
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 5/37
"iskusi $asus 1
"iagnosa sementara <<
(lasan <<
B;#);#*+(* &O(SS )#*++% #,
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 6/37
)C);C"($(* S# "(* S
SI
• Onset saat istirahat
• %sia lebih tua
• $esadaran umumnyabaik
• -#$ umumnya tdkmeninggi
• $aku kuduk tdkdi6umpai
SH
• Saat aktif
• @ebih muda
• @ebih sering menurun
• @ebih sering meninggi
• ;isa di6umpai
0;#);#*+(* &O(SS )#*++% #,
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 7/37
"iskusi $asus 1
"imana lesi <<
-eritori arteri mana yang
terlibat <<
D;#);#*+(* &O(SS )#*++% #,
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 8/37
;#);#*+(* &O(SS )#*++% #, E
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 9/37
;#);#*+(* &O(SS )#*++% #, ?
The idea of the cortical homunculus
was created by Wilder Penfield.
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 10/37
S#S-C) (2-C2# $(2O-#S
;#);#*+(* &O(SS )#*++% #, 1
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 11/37
;#);#*+(* &O(SS )#*++% #, 11
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 12/37
S#S-C) (2-C2# ,C2-C;2O;(S#@C2
;#);#*+(* &O(SS )#*++% #, 1
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 13/37
&@C OFW#@@#S
;#);#*+(* &O(SS )#*++% #, 15
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 14/37
-homas Willis 7101'10DB8
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 15/37
+C(@( "(* -(*"( $@#*#S;C2"(S(2$(* -C2#-O2# (2-C2# G(*+
-C2@#;(-• (. serebri media =
gangguan motorik dan sensorik kontralateral
7wa6ah/ lengan/ dan lebih ringan pada tungkai8
afasia 7bila lesi di hemisfer dominan8neglect 7bila lesi di hemisfer non dominan8
• (. serebri anterior =
gangguan motorik dan sensorik kontralateral7tungkai dan lebih ringan pada lengan8
;#);#*+(* &O(SS )#*++% #, 1B
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 16/37
+C(@( "(* -(*"( $@#*#S;C2"(S(2$(* -C2#-O2# (2-C2# G(*+
-C2@#;(- 7lan6utan8• (. serebri posterior =
deHsit lapangan pandang kontralateral
afasia dan confusion 7bila pada hemisfer dominan8
• 3enetrating arteries 7lacunar8 =
gangguan motorik atau sensorik kontralateral
7wa6ah/ lengan/ dan tungkai8
;isa di6umpai ataksia atau disartria
;#);#*+(* &O(SS )#*++% #, 10
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 17/37
• (. !ertebralis 7atau a. serebelli posteriorinferior8 =
truncal ataxia/ disartria/ disfagia/ gangguansensorik ipsilateral wa6ah dan gangguan sensorikkontralateral dari leher ke bawah
• (. basilaris =
limb ataxia/ disartria/ disfagia/ gangguan motorikdan sensorik 7bisa bilateral8/ pupil asimetris/discon6ugate gae/ gangguan lapangan pandang/respon melambat
;#);#*+(* &O(SS )#*++% #, 1D
+C(@( "(* -(*"( $@#*#S;C2"(S(2$(* -C2#-O2# (2-C2# G(*+
-C2@#;(- 7lan6utan8
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 18/37
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 19/37
3C2;C"((* S# -rombosisdenganCmboli
-2O);OS#S
• "eHsit neurologik timbul mendadak/ tapiberkembang agak lebih lambat.
• Onset sewaktu istirahat > bangun tidur.
C);O@# =
• "eHsit neurologik timbul mendadak dan sekaligus
mencapai puncak.• Onset sewaktu aktif.
1?;#);#*+(* &O(SS )#*++% #,
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 20/37
"iskusi $asus 1
3emeriksaan penun6ang <<<
$apan dilakukan <<
;#);#*+(* &O(SS )#*++% #,
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 21/37
$asus 1 = 3em penun6ang
• &- scan kepala = tidak tampak adanyainfark/ hematom maupun lesi lainnyadi otak/
$ok bisa <<<
@angkah selan6utnya <<
1;#);#*+(* &O(SS )#*++% #,
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 22/37
;#);#*+(* &O(SS)#*++% #,
*C%2O2("#O@O+#
• +old standard = &- scan kepala
• $apan dilakukan <<<<<
• -idak ada ketentuan yang pasti• #nfark secara radiologis !isible I 4E 6am
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 23/37
;#);#*+(* &O(SS )#*++% #, 5
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 24/37
;#);#*+(* &O(SS )#*++% #, 4
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 25/37
3C*(-(@($S(*((*
-C2(3# -2O);O@#S#S JJJ
;#);#*+(* &O(SS )#*++% #, B
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 26/37
;#);#*+(* &O(SS )#*++% #, 0
The penumbra is the zone of reversibleischemia around the core of irreversible
infarction.
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 27/37
penumbra core
1 hour 2 hour 3-4hour
4-6hour
Corepenumbra
= ~ 1 :1
~ 2-3 :1
~ 4-5 :1
? 10-20 :1
DS-2O$C #S$C)#$ F$'%S% 1B
S(,C -C 3C*%);2( JJJJ
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 28/37
;#);#*+(* &O(SS )#*++% #, E
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 29/37
;#);#*+(* &O(SS )#*++% #, ?
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 30/37
3enatalaksanaan
• (nti hipertensi <<
• (nti platelet <<
• (nti koagulan <<• &iticholin <<
5;#);#*+(* &O(SS )#*++% #,
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 31/37
1. (cute therapy and optimiation ofneurological status
• )aintenance of cerebral perfusion eu!olemia/ support ;3/ bed Aat
• "o not treat hypertension acutely/ unless =
1. was treated by -3(. end organ damage 7 &F/ )&#/ C/
dissecting aortic aneurysm etc8
5. S;3I mmg or ";3 I 1 mmg
• %se short'acting agent = labetalol/nicardipine
• +oal = ;3 reduction 1'1BK
;#);#*+(* &O(SS )#*++% #, 51
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 32/37
1. (cute therapy and optimiation ofneurological status
• (ntiplatelet = aspirin eecti!e for acutetreatment
• (nticoagulant = not eecti!e for acute
treatment/ only for secondary pre!ention in(F and cardioembolic stroke
*e!er start anticoagulant without brainimaging
• yperglycemia = treat glucose aggressi!ely
• yperthermia = treat aggressi!ely withacetaminophen and cooling blanket
;#);#*+(* &O(SS )#*++% #, 5
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 33/37
. Ctiological work'up for secondarypre!ention
• Screening for arterial stenosis>obstruction )2(/ carotid ultrasound/ -&"/ "S(/ &-(
• &ardiac e!aluation C$+/ echocardiogram
• 2ecurrent stroke risk factors screening =L monitor ;3
L obtain fasting lipid panel
L screen for diabetes
L screen for hyperhomocysteinemia
L smoking cessation
;#);#*+(* &O(SS )#*++% #, 55
5 3 ti f l i l
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 34/37
5. 3re!ention of neurologicaldeterioration or medical
complications
• ",- prophylaxis
• (spiration precautions
• +astrointestinal ulcer prophylaxis• -ake out indwelling urinary catheter
as soon as possible
• )onitor platelet counts if on heparin
;#);#*+(* &O(SS )#*++% #, 54
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 35/37
;#);#*+(* &O(SS )#*++% #, 5B
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 36/37
4. 3re!ention of neurological deterioration ormedical complications = "rug therapy in the Hrst
D hours =
1. (ntiplatelet = L aspirin E1'5B mg O"
L clopidogrel DBmg O"
L aspirin B mg 9 dypiridamole mg O"
. ",- prophylaxis = heparin/ @)W/ compression stocking
5. (nticoagulant for cardioembolic stroke = heparin/coumadin/
*O(& 7dabigatran/ ri!aroxaban8
4. #nsulin to treat hyperglycemia
B. (cetaminophen to treat hypertermia
0. Statins = target @"@ M 1 mgK
D. (ntihypertensi!e = (&C#/ (2;/ diuretics/ beta blockers/
&a'channnel blockers
;#);#*+(* &O(SS )#*++% #, 50
8/18/2019 Diskusi Co-Ass Minggu IV 2016
http://slidepdf.com/reader/full/diskusi-co-ass-minggu-iv-2016 37/37
;#);#*+(* &O(SS )#*++% #, 5D