Hemorragic Stroke

Case Report
By:
Nur Intan
Supervisor : dr. Enny Lestari, Sp.S
DEPARTMENT OF NEUROLOGY
MEDICAL SCHOOL RIAU UNIVERSITY
RSUD ARIFIN ACHMAD
PEKANBARU
2018
Name Mrs. M
Age 58 years old
Gender female
Address Jl. Cipta Karya , Panam
Religion Islam
Marital’s Status married
Occupation Merchant
Entry Hospital July, 8st 2018
Medical Record 9895XX

Chief Complain
• Weakness on the right extremities since 4 hours before admitted to the hospital
Present Illness History
• Since 4 hours before admitted to the Hospital, the patient complained about weakness on
right extremities, Patient suddenly fell in to the floor while watching TV. Patient also told
to her son that she has a headache before she felt. There was no seizure before, no
history of trauma and no history of convultions.
Past Illness History
• Patient had an uncontrolled hypertention

• History of brain and spine trauma (-)
• History of stroke (-)
• History of heart disease (-)
• Diabetes Mellitus (-)
• History of seizurres (-)
• History of fever (-)
Daily routine history
• Smoke (-)
• Alcohol (-)
• Free drugs injection history (-)
• Long Drug Consumption (-)
The Family Disease History
• No family complain that same complaint

• A history of heart disease(-)
• A history of hypertension (+)
• A history of diabetes mellitus unknown
 Patient Mrs. M, 58 years old, admitted to Hospital with chief
complaint weakness on rigth extremities since 4 hours before admitted
to the hospital. headache was present. No history of injury, fever, and
seizure.
VITAL SIGN NEUROLOGICAL STATUS
• BP : 190/120 mmHg • Consciousness: somnolan

• HR : 88 bpm • GCS : (E3 M6 V afasia)
• RR : 22x/mnt • Noble Function : afasia
•T : 36,4 c global
• Weight : 60 kg • Meningeal Sign :
• Height : 150 cm • Neck Rigidity (-)
• IMT : 26,7 (Overweigth)
1. Cranial nerve I (Olfactory)
Right Left Interpretation

difficult to difficult to
Sense of Smell difficult to assess
assess assess
2. Cranial nerve II (Optic)

Visual Acuity difficult to assess difficult to assess
Visual Fields difficult to assess difficult to assess difficult to assess

Colour Recognition difficult to assess difficult to assess
3. Cranial nerve III (Oculomotor)
Ptosis (-) (-)
Pupil Isokor Isokor
Shape Round Round
Size Φ3 mm Φ3 mm
Normal
Pupillary reactions to light

Direct (+) (+)
Indirect (+) (+)
4. Cranial nerve IV (Trochlear)
Doll eyes manuver (+) (+) Normal
5. Cranial nerve V (Trigeminal)
Motoric
Sensory difficult to assess
assess assess
Corneal reflex
6. Cranial nerve VI (Abducens)
Doll eyes manuver (+) (+)

Strabismus (-) (-) Normal
Deviation (-) (-)
7. Cranial nerve VII (Facial)
Tic (-) (-)

Motor
- Frowning Difficult to asses Difficult to asses
- Raised eye brow Difficult to asses Difficult to asses
- Close eyes Normal Normal
- Corners of the mouth Decrease Normal Parese N. VII
- Nasolabial fold Flatter Normal dextra central
Sense of Taste Difficult to asses Difficult to asses type
Chvostek Sign (-) (-)
8. Cranial nerve VIII (Acoustic)
assess assess
Hearing sense difficult to assess
9. Cranial nerve IX (Glossopharyngeal)
Arcus farings difficult to difficult to

difficult to assess
Gag Reflex assess assess
10. Cranial nerve X (Vagus)

Arcus farings difficult to difficult to
difficult to assess
Dysfonia assess assess
11. Cranial nerve XI (Accessory)

Motoric difficult to difficult to
difficult to assess
Trophy assess assess
12. Cranial nerve XII (Hypoglossal)
Motoric difficult to difficult to
Trophy assess assess difficult to assess
Tremor
Disartria
Upper Extremity
Strength
Distal difficult to difficult to
Proximal assess assess
Tone Normal Normal
Trophy Eutrophy Eutrophy
Involuntary movements (-) (-)
Clonus With fall down test, there is
(-) (-)
lateralization to the right side
Lower Extremity
Strength
Distal difficult to difficult to
Proximal assess assess
Tone Normal Normal
Involuntary movements (-) (-)
Clonus (-) (-)
Body
Involuntary movements - - Normal
Abdominal Reflex - -
Protopatic
Touch difficult to assess difficult to assess
Pain difficult to assess difficult to assess
Temperature difficult to assess difficult to assess
difficult to assess difficult to assess

Proprioceptive difficult to assess
difficult to assess difficult to assess
 Position
 Two point difficult to assess difficult to assess
discrimination difficult to assess difficult to assess
 Stereognosis
 Graphestesia
 Vibration
Physiologic
Biceps (+) (+)
Triceps (+) (+) Physiologic reflex (+)
Knee (+) (+)
Ankle (+) (+)
Pathologic
Babinsky (+) (-)
Chaddock (+) (-)
Hoffman Tromer (+) (-) Pathologic reflex (+) on the rigth
Openheim (-) (-) side
Schaefer (-) (-)
Primitive Reflex
Palmomental (-) (-)
Snout (-) (-)
Interpretation
Right Left
Point to point movement

Walk heel to toe
Disdiadokonesia difficult to difficult to
difficult to assess
Gait assess assess
Tandem
Romberg
Autonomy System Others Examination
Urin catheterized Laseque :-
defecate unknown Kernig :-
Patrick : -/-
Kontrapatrick : -/-
Valsava test :-
Brudzinski :-
GADJAH MADA ALGORITHM
• Loss of consciousness (-), headache (+), pathology
reflex (+)  Hemorrhagic stroke
SIRIRAJ SCORE
• (2.5 x level of consciousness (0)) + (2 x Vomit (0)) + (2 x
headache (1)) + (0.1 x diastolic (120)) – (3x atheroma
factor (0)) – 12 = 2  Hemorrhagic stroke
• Blood Presure :190/120 mmHg
• Heart Rate :88 bpm
• Respiratory : 22 x/mnt
• Temperature : 36,8°C
• Weight : 60 kg
• Height : 150 cm
The •
•
Noble Function
Meningeal Sign
: Afasia global
: Neck stiffness (-)
summary of • Cranial Nerve
type
: N.VII  parese dextra central
physical • Motoric
• Sensory
: Hemiparese dextra
: difficult to assess
examination • Coordination : difficult to assess
• Otonom : difficult to assess

• Physiologic : Normal
• Patologic : positive on the rigth side
• Gadjah mada score : Hemorrhagic stroke
• Siriraj score : Hemorrhagic stroke
CLINICAL DIAGNOSE : Stroke
TOPICAL DIAGNOSE : Carotid system
ETIOLOGICAL DIAGNOSE : Hemorrhagic stroke
DIFFERENTIAL DIAGNOSE : Ischemic stroke

Blood routine
Blood chemistry
Chest X-Ray
Head CT Scan without contrast

General Special
• Bed rest with head position

elevated 300 • Neuroprotector : Inj.
• Control of vital sign Citicolin 3 x 500 mg iv..
• Monitoring intracranial • Antiedema :
pressure Manitol 125 cc / 6 hours
• IVFD (30cc/kgBB/day)  RL • Gastricprotector : Inj.
20 gtt/i Ranitidin 2 x 50 mg iv
• Antifibrinolotik
as. Tranexamat 3x1 gr
• Anti hypertensi:
• Amlodipin 1x10
Blood routine
July, 8 2018 Electrolyte
July, 8 2018
• Hemoglobin : 11,5 gr% Na+ : 143 mmol/L
• Leukosit : 12.870 /mm3 K+ : 3,82 mmol/L
• Trombosit : 275.000 /mm3 Ca++ : 0,98 mmol/L
• Hematocrit : 34,9 %
Interpretation:
CTR < 50%
Interpretation:
 Intracerebral haemorrhagic at
regio parietal sinistra
Hemorrhages
stroke
Hypertension
Follow up July,9 2018
S : hemipharese dextra + patiens has not able to A : Haemorrhagic stroke

speak P :
O :GCS: E4M6Vafasia Head up 30o
Blood Pressure :160/100 mmHg IVFD RL 20 drops/minute
Heart Rate : 88 bpm Citicolin 2x250 mg iv
Respiratory Rate : 20x/i Manitol 4x125 cc/h iv
Temperature :36,4°C Tranexamat acid 3x500 mg iv
Cognitive Function : Difficult to assess Ranitidin 2 x 50 mg iv
Meningeal Sign : Negative Amlodipin 1x10 mg
Cranial Nerves : light reflect (+/+), Counsul to neurosurgery
Parese N.VII dextra
Motoric : Hemiparese dextra
Sensory : Difficult to assess
Coordination : Difficult to assess
Cognitive : afasia global
Autonomy :urinate with urine catheterized
Reflex : Pathologic (-), Physiology (+)
Follow up July 10 2018
S : hemiparese dextra + patiens has not able to speak A : Haemorrhagic stroke

P :
O :GCS: E4M6V afasia IVFD RL 20 drops/minute
Blood Pressure :170/100 mmHg Citicolin 2 x 250 mg iv
Heart Rate : 84 bpm Manitol 125 cc/h iv
Respiratory Rate : 28 x/i Tranexamat acid 3xmg iv
Temperature : 37,2 °C Ranitidin 2 x 50 mg iv
Cognitive Function : Difficult to assess Amlodipin 1 x10 mg
Meningeal Sign : Negative
Cranial Nerves : light reflect (+/+), Parese N.VII
dextra
Follow up July, 11st 2018
S : Hemiparese dextra + patiens has not able to A : Haemorrhagic stroke

speak P :
IVFD RL 20 drops/minute
Citicolin 2 x 250 mg iv
O :GCS: E4M6V afasia Manitol 125 cc/h iv
Blood Pressure :150/100 mmHg Tranexamat acid 3x500 mg iv
Heart Rate : 96 bpm Ranitidin 2 x 50 mg iv
Respiratory Rate : 20 x/i Amlodipin 1x 10 mg
Temperature : 36,8°C Neurosurgery : observation
Cognitive Function : Difficult to assess CT-Scan : unconsciousness
Cranial Nerves : light reflect (+/+), Parese
N.VII dextra
Follow up July, 12 2018

speak P :
O :GCS: E4M6V afasia Manitol 125 cc/h iv
Blood Pressure :140/90 mmHg Tranexamat acid 3x500 mg iv
Heart Rate : 96 bpm Ranitidin 2 x 50 mg iv
Respiratory Rate : 20 x/i Amlodipin 1x10 mg
Temperature : 36,8°C
Cognitive Function : Difficult to assess
Cranial Nerves : light reflect (+/+), Parede
N.VII dextra

speak P :
O :GCS: E4M6Vafasia Tranexamat acid 3x500 mg iv
Blood Pressure :140/90 mmHg Ranitidin 2 x 50 mg iv
Heart Rate : 90 bpm Dulcolax sup 1
Respiratory Rate : 20 x/i Lactulac syrup 15 ml
N.VII dextra
speak P :
O :GCS: E3VafasiaM6 Tranexamat acid 3x500 mg iv
Heart Rate : 90 bpm Amlodipin 1 x10 mg
N.VII dextra
speak P :
Heart Rate : 90 bpm Amlodipin 1x10 mg
N.VII dextra
speak P :
Heart Rate : 90 bpm Amlodipin 1x 10 mg
N.VII dextra
speak P :
O :GCS: E4VafsiaM6 Tranexamat acid 3x500 mg iv
Heart Rate : 90 bpm Lactulac syrup 15 ml
Respiratory Rate : 20 x/i
N.VII dextra
speak P :
Heart Rate : 90 bpm Lactulac syrup 15 ml
Respiratory Rate : 20 x/i
N.VII dextra
speak P :
Heart Rate : 90 bpm
Respiratory Rate : 20 x/i The patient plan home
N.VII dextra
 Stroke is a collection of symptoms characterized by the development
of clinical manifestations of cerebral function disorders either focal or
global, which happens quickly and more than 24 hours or ended up
with death without being discovered other causes than vascular
disorders.
 Increasing age  increase risk of vascular disease
 The incidence of stroke  51.6 / 100,000 population
 Mortality rate :
 15.9% (age 45-55 years)
 26.8% (age 55-64 years)
 23.5% (age 65 years)
 emboli
 trombus
 ruptur of blood vessels
 change in the blood vessels permeability
 increasing the viscocity
Non
Hemorrhagic
Hemorrhagic
stroke
stroke
Major classification of stroke

Ischemia-infarct cerebrum (80-85%) Intracranial hemorrhage (15-20%)
Thrombus occlusion Intraserebrum hemorrhage

Lakunar Subaraknoid hemorrhage
Embolic occlusion Intraventrikuler hemorrhage
Kardiogenik
Arteri to arteri
 Most commonly known as ischemic
stroke
 The most common occurrence of
stroke (80% to 85%)
 Caused by obstruction in arteri, lead
to lack of oxygen and glucose supply
 Categrized into:
 Trombus
 Emboli
 Occurs due to intracranial
hemorrhages
 The incidence reaches 15%
to 20%
 Most hemorrhages occurs
due to hypertension.
 The other cause are
anuerysm, arterivenous
malformation, trauma, etc
 Hypertensif intracerebrum hemorrhage
 Subarakhnoid hemorrhage
 Ruptura of the aneurisma sakular (Berry)
 Ruptura of the malformasi arteriovena (MAV)
 Trauma
 Cocain and amfetamin abuse
 Brain tumor
 Hemorrage infarct
 Systemic bleeding diseases including anticoagulant therapy
Not Modifable Modifable
• Age • Stroke history

• Gender • Smoking
• Genetik • Hypertension
• Ras • Alcohol
• Heart disease
• Drug abuse
• Diabetes melitus
• Hyperhomosisteinemia
• Carotic stenosis
• Antibody anti fosfolipid
• TIA
• Hyperurisemia
• Hypercholesterolemia
• Elevation of hematocrit
• Oral contraception
• Elevation of fibrinogen
• Obesity
Symptom or examination Infarction Intracerebral haemorrhage
Prodormal sign TIA (+) 50% TIA (-)

Doing activity/resting Rest, right after wake up Often while doing physical activity
Headache and vomit Rarely Often or severe

Lost of consciousness at onset Rarely Often
Hypertension moderate/ Moderate-severe

normotension
Meningeal sign No Yes
High intracranial pressure Rarely Subhialiod bleeding
symptom
Bloody LCS No Yes
Head CT Scan Hypodensity area Intracranial mass with hyperdensity
area
Angiography Stricture appearance aneurism, AVM, massa intrahemisfer
or vasospasme
Lost of consciousness
Acute stroke  Headache
Pathology reflex
All criteria or two of the three

Lost of consciousness (+), headache (-), pathology reflex (-)
Haemorrhage stroke
Lost of consciousness (-),headache(+),pathology reflex (-)
Lost of consciousness (-),headache(-),pathology reflex (+) infarction
Lost of consciousness (-),headache (-),pathology reflex (-) infarction
SSS = 2.5 C + 2 V + 2 H + 0.1 DBP - 3A – 12
C = Consciousness (composmentis = 0, somnolen = 1, sopor/koma = 2)

SSS DIAGNOSE
V = Vomit (none = 0, yes = 1)
>1 Hemorrhagic stroke
H = Headache (none = 0, yes = 1)
DBP = Diastolic blood pressure
<-1 Infarction stroke
A = Ateroma (none = 0, one or more: DM, Angina, vaskular disease = 1)
-1 to 1 Uncertain
Hiperacute
Stadium
Subacute Acute
Stadium Stadium
Hyperacute stadium
• Doing at the Emergency Room
• To prevent the widespread of brain tissue dammaging
• Oxygen 2l/i
• Crystalloid/colloid fluid, avoid administration of dextrose
• Brain CT scan examination, electrocardiography, chest X-ray,
complete peripheral blood and platelet count, prothrombin
time / INR, APTT, blood glucose, blood chemistry
 Ischemic stroke
 General treatment
 Special treatment
 Hemorrhagic stroke
 General treatment
 Special treatment
 General treatment
 Head position 30o
 Make the air way clear, oxygen 1-2 l/i
 Fever overcome with compresses and antipyretic
 Fluid nutrition with 1500-2000 isotonic cristalloid or colloid and
electrolyte as needed
 Blood glucose levels > 150 mg% should be corrected
 Headache, nausea, and vomiting treated according to the symptoms
 Blood preassure doesn’t need taken down immediately, except when
the systolic pressure ≥ 220 mmHg and diastolic pressure ≥120 mmHg
 If there is an increased of intracranial pressure, bolus mannitol were
given an of 0.25 to 1 g / kg intravenously
 Special treatment:
 Antiplatelet agent such as aspirin and anticoagulant
 Trombolytic rt-PA (combinant tissue Plasminogen Activator)
 Neuroprotective agent, such as sitikolin or piracetam
 General treatment:
 Treated in ICU if the hematoma volume> 30 mL,
intraventricular hemorrhage with hydrocephalus, and
clinical situation tends to be worsen.
 Blood pressure should be reduced until premorbid blood
pressure or 15-20% when the systolic pressure> 180 mmHg,
diastolic> 120 mmHg, MAP> 130 mmHg, and hematoma
volume increases.
 Head elevation 30o
 Mannitol
 Special treatment
 Neuroprotective agent
 Surgery
 Continuing the appropriate treatment of acute conditions before
 The management of complications
 Restoration / rehabilitation (as needed of patients), which is
physiotherapy, speech therapy, cognitive therapy, and occupational
therapy
 Secondary Prevention
 Family education
• Cerebral edema
• Hemorrhagic transformation
Neurological • Seizures
• Recurrent stroke
complications
• Increased the blood pressure

Non • Hiperglkemia
• Cardio-respiratory disorder
neurological • Stress ulcer
• Depression
complications • Decubitus ulcer
 Deaths due to stroke was 41.4% from 100,000 population
 42% disability caused by stroke is permanent
 In 2010, stroke accounted for 7% of all causes of mortality in men and
10% of all causes of death among women
 recurrent stroke within five years was 26.4% and in ten years was
39.2%.
 (70-94%) with acute stroke  experienced an blood pressure> 140
mmHg
 in Indonesia  hypertension in patients with acute stroke is about
73.9%.
 AHA / ASA 2007 and ESO 2009  recommend to decrease the high
blood pressure in acute stroke must be done carefully with notice to
some conditions below
From history taking
Loss of consciousness No history of injury,
headache
fever, and seizure
Stroke
It is consistent with the WHO definition that clinical symptoms of stroke
is cerebral disorders, either focal or global attack in 24 hours or more,
no illness is found other than vascular disorders
pathological reflex
positive
physiological
reflex positive carotid system
Hemiparese
dextra and parese
N.VII dextra
Loss of
Hypertension
consciousness
Gajah Mada
Stroke
headache
Algorythm &
Hemorrhages Siriraj Score
Stroke
Hemorrhagic
stroke Non- Hemorrhagic
stroke
CT Scan as the Gold

Standard
Physical
Diagnose
• Headache examinations • head CT-Scan
• Uncontrolled • BP 190/120 there is • Hemorrhage
hypertension mmHg intracerebral stroke
hemorrhage.
• Hemiparese • Hypertension
dextra Supporting
Anamnesis
examination
Laboratory
• To find the risk factor for stroke and general condition of patient.
Head CT-scan
• to know the final pathology diagnose from the location and the wide of the
lesion
Chest X ray
• to find wether the patient had cardiomegaly or not as the result of heart disease
Treatment
• Bed rest with head position elevated 20-300 to maintance the

adequate circulation to the brain.
• IVFD (30cc/kgbb/day) RL 20 gtt/i to maintance the euvolemik
condition and glucose level needed.
• Inj tranexamic acid 3x 500 to control the bleeding
• Inj citicoline 2 x 500 mg the neuroprotector
• Manitol infusion 125cc/6 H to decrease the cerebral edema
• Inj Ranitidin 2 x 50 mg to protector of the gastric.

Hemorragic Stroke

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Case Report

Supervisor : dr. Enny Lestari, Sp.S

Address Jl. Cipta Karya , Panam

Marital’s Status married

Entry Hospital July, 8st 2018

Medical Record 9895XX

Present Illness History

• Patient had an uncontrolled hypertention

Daily routine history

The Family Disease History

• No family complain that same complaint

• BP : 190/120 mmHg • Consciousness: somnolan

Right Left Interpretation

2. Cranial nerve II (Optic)

Right Left Interpretation

Visual Fields difficult to assess difficult to assess difficult to assess

Pupillary reactions to light

Right Left Interpretation

Doll eyes manuver (+) (+) Normal

5. Cranial nerve V (Trigeminal)

Right Left Interpretation

6. Cranial nerve VI (Abducens)

Right Left Interpretation

Doll eyes manuver (+) (+)

Right Left Interpretation

Tic (-) (-)

8. Cranial nerve VIII (Acoustic)

Right Left Interpretation

Right Left Interpretation

Arcus farings difficult to difficult to

10. Cranial nerve X (Vagus)

11. Cranial nerve XI (Accessory)

difficult to assess difficult to assess

Point to point movement

Urin catheterized Laseque :-

defecate unknown Kernig :-

examination • Coordination : difficult to assess

• Otonom : difficult to assess

TOPICAL DIAGNOSE : Carotid system

ETIOLOGICAL DIAGNOSE : Hemorrhagic stroke

DIFFERENTIAL DIAGNOSE : Ischemic stroke

Head CT Scan without contrast

• Bed rest with head position

S : hemipharese dextra + patiens has not able to A : Haemorrhagic stroke

S : hemiparese dextra + patiens has not able to speak A : Haemorrhagic stroke

S : Hemiparese dextra + patiens has not able to A : Haemorrhagic stroke

S : Hemiparese dextra + patiens has not able to A : Haemorrhagic stroke

S : Hemiparese dextra + patiens has not able to A : Haemorrhagic stroke

Major classification of stroke

Thrombus occlusion Intraserebrum hemorrhage

• Age • Stroke history

Prodormal sign TIA (+) 50% TIA (-)

Headache and vomit Rarely Often or severe

Hypertension moderate/ Moderate-severe

All criteria or two of the three

C = Consciousness (composmentis = 0, somnolen = 1, sopor/koma = 2)

• Increased the blood pressure

CT Scan as the Gold

• Bed rest with head position elevated 20-300 to maintance the

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