Académique Documents
Professionnel Documents
Culture Documents
ON
dr. Yudityarini SpS
2020
Diarrhoeal diseases
Conditions arising
3
during the perinatal period
Ischemic
1
heart disease
Unipolar
2
major depression
Road
3
traffic accidents
Cerebrovascular
4
disease
5Chronic obstructive
pulmonary disease
Cerebrovascular disease
Lower
6 respiratory infections
Source: CDC/NCHS.
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MENDADAK
Stroke
85%
15%
Primary hemorrhage
Intraparenchymal
Subarachnoid
Ischemic stroke
20%
Atherosclerotic
cardiovascular
disease
Hypoperfusion
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25%
20%
Penetrating
artery disease
(lacunes)
Cardiogenic
embolism
Atrial
fibrilation
Valve
disease
Ventricular
thrombi
Many others
30%
Cryptogenic
stroke
5%
Other, unusual
causes
Prothrombic
states
Dissections
Arteritis
Migrane /
vasospasm
Drug abuse
Many more
Arteriogenic
emboli
5
Anatomi.
Vascularization :
Carotid artery (2)
80% supply for brain
demand.
Vertebral art (2) 20%
brain demand
kolateral formation
Willis circle constant
supply
3
1
CBF
%
50
NORMAL
RANGE
Maintained by autoregulation;
higher CBF in gray matter
80
40
OLIGEMIA
Increased O2 extraction
may maintain normal CMRO2
60
30
40
20
20
0
10
0
ISCHEMIA
100
MILD
? Glycolysis
? Protein synthesis
THRESHOLD OF ELECTRICAL FAILURE
MODERATE
SEVERE
The Penumbra
THRESHOLD OF IONIC FAILURE
Anoxic deporalization
( ECF K+ & ECF Ca++)
E
T
A
L
L
CO
L
A
R
W
O
FL
Normal
Oligemia
Mild Ischemia
The Penumbra
Severe Ischemia
Penumbra (20-50)
Core (0-20)
Functional Disability
24%-53% of stroke
survivors with complete
or partial dependence
Quality of Life
27% decrement in mean
quality of well-being
score at 6 months
Dementia or Cognitive
Decline
34% at 52 weeks
poststroke
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JHN
17
AVM
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18
ANEURYSMA CEREBRAL
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19
AGE
GENDER
HEREDITARY
RACE-ETHNICITY
UMUR
Determinan stroke yang paling kuat adalah umur.
Insiden stroke
JENIS KELAMIN
Perbedaan jenis kelamin dalam insiden dan mortalitas
stroke menunjukkan resiko lebih besar pada laki-laki.
HEREDITAS/ BAWAAN
Stroke
Riwayat keluarga
stroke
Faktor determinan
mortalitas stroke
Hypertension
Smoking
Diabetes
Asymptomatic carotid stenosis
Sickle cell disease
Hyperlipidemia
Atrial fibrillation
ROKOK
Perokok dan peningkatan resiko stroke
Penghentian Rokok
Prospective
Cohort
Study
Penghentian
merokok dapat
resiko stroke
100
81
94
80
% Survival
From Age 35
91
NON- SMOKERS
81
59
59
60
10 years
SMOKERS
40
24
20
26
0
40
50
60
70
Years
80
4
90
2
100
ATHEROSCLEROSI
S
Terbentuknya plaque
(penumpukan substansi
lemak yang mengeras) di
dalam pembuluh darah
Bisa terjadi di seluruh
pembuluh darah
Monocyte
LDL-C
Adhesion Macrophage
molecule
Oxidized
LDL-C
Foam cell
CRP
Smooth muscle
cells
Endothelial
dysfunction
Inflammation
Oxidation
Plaque instability
and thrombus
- Hyperhomocysteinemia
- Protein C deficiency
- Drug abuse
- Protein S deficiency
- Hormone replacement therapy
- Antithrombin III
deficiency
Diagram
hubungan
antara
stadium
dan
pregesifitas
stroke
dan
tindakan
pencegahannya.
0-30
th
Foam
Cells
30-50 th
Fatty Intermediate
Streak
Lesion
> 50
th
Atheroma FibrousComplicated
Lesion/Rupture
Plaque
Physician's
M 109/427
Ischemic stroke
11.4
10.6
1.2 (0.7-2.0)
Health Study, USA
(Verhoef 1994)
North Karelia
M/F 265/269
Fatal/nonfatal
M 9.9 M 9.8 M 1.05 (0.56-1.95)
Project, Finland
MI, stroke
F 9.6 F 9.3
F 1.22 (0.6-2.78)
(Alfthan 1994)
--------------------------------------------------------------------------------------------------
Pencegahan
Stroke
primer
sekund
er
PENCEGAHAN
PRIMER
Aktivitas Fisik
PENCEGAHAN
SEKUNDER
GOAL
RECOMMENDATIONS
Hypertension
Smoking
Cessation
Diabetes
Glucose control;
Treat HT
Atrial fibrillation
< 65 y, no risk factors
< 65 y, with risk factors
65-75 y, no risk factors
65-75 y, with risk factors
> 75 y, with/without risk
Aspirin
Warfarin (INR 2.5; range 2.0-3.0)
Aspirin or warfarin
Warfarin (INR 2.5; range 2.0-3.0)
Warfarin (INR 2.5; range 2.0-3.0)
GOAL
-
EAT = endarterectomy
Lipid
Initial evaluation (no CHD)
TC < 200 mg% & HDL 35 mg%
TC < 200 mg% & HDL <35 mg%
TC 200-239 mg% & HDL 35
& < 2 CHD risk factors
TC 200-239 mg% and HDL < 35
or < 2 CHD risk factors
TC 240 mg%
LDL evaluation
No CHD & <2 CHD risk factors
No CHD but CHD risk factors
Definite CHD /other atherosclerotic disease
Gen. Educ.
RECOMMENDATIONS
CEA with >60-<100% carotid stenosis, performed by
surgeon with <3% morbidity /mortality.
Patient selection guided by comorbid conditions, life
expectancy, patient preference, & other individual
factors.
Asymptomatic stenosis evaluated for other treatable
causes of stroke.
LDL<160
LDL<130
LDL<100
GOAL
RECOMMENDATIONS
Obesity
Prevent abdominal
obesity
Physical inactivity
Poor diet/nutrition
Alcohol abuse
Moderation
Drug abuse
Cessation
GOAL
RECOMMENDATIONS
Hyperhomocysteinemia
Hypercoagulability:
Antiphospholipid antibody
Factor V Leiden
Prothrombin 20210 mutation
Protein C & S deficiency
Antithrombin III deficiency
Decrease coagulability
Oral contraceptive
< 50 g estradiol
Inflammatory processes
TREATMENT OF HHCy
(HYPERHOMOCYSTEINAEMIA)
Irrespective of its cause, > 90% of
patients respond to multivitamin
treatment within 2-6 weeks (Level IV,
Grade C).
Stop alkohol
stop merokok
jauhi lingkungan perokok
produk nikotin / obat oral
Olah raga
alkohol
merokok
Faktanya
70 % perokok ingin
berhenti merokok tetapi.
HANYA 5%-10% yang
dapat melakukannya
tanpa bantuan
1.
2.
3.
Hughes JR. New treatments for smoking cessation. CA Cancer J Clin. 2000;50:143-151
FoulisJ, Burke M, Steinberg M, William JM, Ziedonis DM. Advances in pharmacotherapy for tobacco dependence. Expert Opin
Emerg Drugs. 2004;9:39-53
Department of Health. Smoking kills: a White Paper on Tobacco. London, England: Stationery Office; 1998
73
CAS
CEA
Pendekatan Intervensional
SEMOGA
BERMANFAAT
DEFINITION OF TIA
(TIA WORKING GROUP)*
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79