indikasi bedah pada stroke
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Surgical Indicationof Stroke
Handoyo PramusintoNeurological Surgery Division
Sardjito Hospital
N Engl J Med, Vol. 344, No. 19 , May 10, 2001
www.nejm.org
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Case Presentation
57 year old female
,
Slurred speech
Collapsed
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Physical Exam
T 99.4 P52 BP 195/99 RR13
Pu ils-2 mm reactive
Neck-no JVD, bruits
CV-bradycardia, no murmurSkin-warm and dry
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Neurological Exam
Neurological exam:
no a reflex withdraws to ain
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GCS
Eyes-1
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Motor-4
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CT Scan
Intracerebral hemorrhage 6
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Blood Clot
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Pathophysiological features
Common site
A. Cerebral lobe
C. Thalamus
D. Brain stem (pons predominantly)
E. Cerebellum
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Intracerebellum hemorrhage10
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Intraventricular hemorrhage
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Subarachnoid hemorrhage
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Key Clinical QuestionsWhich ICH patient require surgery?
o ume o ema oma
Location
Clinical presentation ( GCS, BP )
Facility ( ICU )
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Key ConceptsTwo key concepts:
Intracranial pressure
Elevated when ICP >20 mm Hgere ra per us on pressure
CPP=MAP-ICP
Must maintain ICP > 70 mm Hg
Example: MAP = 100, ICP = 20
CPP in above example = 80 mmHg
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Increased ICP TreatmentIntracranial Pressure (ICP): considered amajor contributor to mortality whenelevated
Controlling ICP is considered essential
Osmotherapy
HyperventilationBarbiturate coma
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OsmotherapyOsmotherapy-Mannitol
Reduces cerebral edema by decreasing
Rebound effect-use less than 5 days
20% solution
0.5-1.0 mg/kg maintain serum osmolarity310-320 mOsm/L
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HOB Elevation
Elevate head of bed-decrease ICP
Mechanical-helps drain blood by gravityDoes not allow blood to pool in cranium,
which may occur if patient is left laying flat
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ICP MonitorsAHA recommends ICP monitors in
patients with a GCS less than 9 and allbe deteriorating due to elevated ICP
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Non-Surgical ICH PtsSmall Hemorrhages (10 cm3)
Minimal neurological deficitsGCS < 4 (excluding cerebellar
hemorrhage with brain stem
compression)
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Key Learning PointsMost ICH patients are non-surgical
Consult your neurosurgeon early
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There are promising new therapiessuch as Factor VII on the horizon
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DiagnosisCT scan infarction or hemorrhage
Location and size of the hematoma
Hydrocephalus
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CT scan demonstrating the R MCA territory infarction
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CT scan on day one, demonstrating evolving R MCAinfarction with mass effect and compression of the
ventricular system.
Clinical examination revealed right midriazis
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CT scan, one day after hemicraniectomy
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CT scan, one month posthemicraniectomy, with resolution of
previous midline shift
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ManagementEvaluation & management inthe ER
Decreased level ofof reflexes the protect airway Intubation !
Urgent CT scan, NS
consultationHyperventilation, intravenousmannitol and intraventricularcatheter for drainage.
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Management
Intensive monitoring ofneurologic &cardiovascular status
the first 24 hrs
GCS, hourly
BP
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Mass effect & intracranialhypertension
Hematoma, edema tissue,
Management
o s ruc ve y rocep a usherniation !
Use of hyperventilation andosmotic agent improved thelong-term outcome
Corticosteroids should beavoid !
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ManagementManagement ofblood pressure
Elevation of blood
pressure expansionof hematoma poor
outcome !
AHA guideline
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ManagementVentricular blood andhydrocephalus
Blood in ventricles obstructive hydrocephalus
high mortality rate !
External drainage
Clots in the catheter andinfection
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ManagementSurgical evacuation
Reduce mass effect, block the release of
neuropathic product from the hematomaurgery or supra en or a emorr age
Hankey et al:
126 not undergo surgery
123 surgical evaculation through an open
craniotomysurgery higher rate of death (83% vs 70%) / 6m
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ManagementCerebellar hematoma
Can be approached with
minor damageecompress on o ra n
stem
Surgical GCS < 14,
volume > 40 ml
Conservative treatment
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