Case Report

Hemorrhagic Stroke

By:
Fitra Rulian Anwar
1608437616

Supervisor:
dr. Enny Lestari, Sp.S

DEPARTMENT OF NEUROLOGY
MEDICAL SCHOOL RIAU UNIVERSITY
RSUD ARIFIN ACHMAD
PEKANBARU
2018
 KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN
FAKULTAS KEDOKTERAN UNIVERSITAS RIAU
SMF/ BAGIAN SARAF
Sekretariat : Gedung Kelas 03, RSUD Arifin Achmad Lantai 04
Jl. Mustika, Telp. 0761-7894000
E-mail : saraffkur@gmail.com
PEKANBARU

I. Patient’s Identity

Name Mrs. LA
Age 23 years old
Gender Female
Address Indragiri Hilir
Religion Islam
Marital’s Status Married
Occupation Housewife

Entry Hospital July, 31st 2018

Medical Record 9927XX

II. ANAMNESIS :
Alloanamnesis with patient’s husband (Aug, 2nd 2018)
Chief Complain
Weakness of right extremities
Present illness history
 Patient presented with muscle weakness on the right side of her body when
she was waking up since 7 days before admitted to Arifin Achmad’s General
Hospital. The weakness equally intense in both upper and lower limbs. Few
hours after present the muscle weakness, patient directly bring by her family
to PH Hospital and treated for 6 days. Apart from that, the patient also
complained of headache 1 week before, nausea, vomiting and speech
difficulties. The patient did not present any other complaint, including loss of
consciousness, injury or seizures.
Past Illness history
 History of hypertention (-)
 History of brain and spine trauma (-)
 History of stroke (-)
 Diabetes Mellitus (-)
 History of seizurres (-)
 History of heart disease (-)

Daily routine history

 Smoke (-)
 Alcohol (-)
 Free drugs injection history (-)
 Long Drug Consumption (-)

History Jobs
 Housewife

The Family Disease History

 No family complain that same complaint
 A history of sudden death (-)
 A history of cancer or tumors (-)
 A history of hypertension (-)
 A history of diabetes mellitus (-)

RESUME ANAMNESIS
Patient Mrs. LA, 23 years old, was admitted to Arifin Achmad’s General
Hospital with her main complaint being muscle weakness in the right side of her
whole body since 7 days ago, speech difficulties, headache, nausea and vomit
were present. No history of seizure and loss of consciousness.
III. Physical Examination

A. Generalized Condition
Blood Presure : 120/80 mmHg
Heart Rate : 90 bpm
Respiratory : Respiratory rate : 22 x/mnt
Temperature : 36,8°C
Weight : 50 kg
Height : 155 cm IMT : 20,83 (Normoweight)

B. NEUROLOGICAL STATUS
1) Consciousness : Composmentis GCS : E4V5M6
2) Cognitive Function : Difficult to assess
3) Neck stiffness : Positive

4) Cranial Nerves
1. N. I (Olfactorius )
Right Left Interpretation
Sense of Smell Normal Normal Normal

2. N.II (Opticus)
Right Left Interpretation
Normal Normal
Visual Acuity

Visual Fields Normal Normal Normal

Colour Recognition Normal Normal

3. N.III (Oculomotor)
Right Left Interpretation
Ptosis - -
Pupil
Shape isochoric isochoric
Side Round Round Normal
Φ3mm Φ3mm
Pupillary reaction to light
direct + +
Indirect + +
4. N. IV (Trochlear)
Right Left Interpretation
Extraocular
(+) (+) Normal
movements

5. N. V (Trigeminal)
Right Left Interpretation
Motoric
Sensory Normal Normal Normal
Corneal reflex

6. N. VI (Abduscens)
Right Left Interpretation
Doll eyes manuver (+) (+)
Strabismus (-) (-) Normal
Deviation (-) (-)

7. N. VII (Facialis)
Interpretati
Right Left
on
Tic (-) (-)
Motor
- Frowning Normal Normal
- Raised eye Normal Normal
brow Normal Normal
- Close eyes Normal Normal
- Corners of Normal
the mouth Normal Normal
- Nasolabial
fold Normal Normal
Sense of Taste Normal Normal
Chvostek Sign (+) (+)

8. N. VIII (Acoustic)
Right Left Interpretation
Normal Normal
Hearing sense Normal
 9. N. IX (Glossopharyngeal)
Right Left Interpretation
Arcus farings Normal Normal
Normal
Gag Reflex Normal Normal

10.N. X (Vagus)
Right Left Interpretation
Arcus farings Normal Normal
Normal
Dysfonia Normal Normal

11.N. XI (Accessory)
Right Left Interpretation
Motoric Normal Normal
Normal
Trophy Normal Normal

12.N. XII (Hypoglossal)

Right Left Interpretation
Motoric Normal Normal
Trophy Normal Normal Normal
Tremor Normal Normal
Disartria Normal Normal

IV. MOTOR SYSTEM

Right Left Interpretation
Upper Extremity
Strength Hemiparesis
Distal 3 5 of the right
Proximal 3 5 upper and
Tone Normal Normal lower
Trophy Eutrophy Eutrophy extremities –
Involuntary movements (-) (-) central
Clonus (-) (-) lesion of the
Lower Extremity motor
Strength pathway
Distal 3 5 (Upper
Proximal 3 5 Motor
Tone Normal Normal Neuron)
Trophy Eutrophy Eutrophy
Involuntary movements (-) (-)
Clonus (-) (-)
 Body
Trophy Eutrophy Eutrophy
Involuntary movements (-) (-) Normal
Abdominal Reflex (+) (+)

V. SENSORY
Right Left Interpretation
Touch
Pain Normal Normal
Temperature
Proprioceptive
 Position
Normal
 Two point
discrimination Normal Normal
 Stereognosis
 Graphestesia
 Vibration

VI. REFLEX
Right Left Interpretation

Physiologic
Biseps + +
Physiologic reflex
Triseps + +
(+)
Patella + +
Achilles + +

Patologic
(-) (-)
Babinski
(-) (-)
Chaddock
(-) (-) Pathologic Reflex (-)
Hoffman Tromer
(-) (-)
Openheim
(-) (-)
Schaefer
VII. COORDINATION
Right Left Interpretation
Point to point movement
Walk heel to toe
Disdiadokonesia difficult difficult
difficult to assess
Gait to assess to assess
Tandem
Romberg

VIII. OTONOM
Urinate : urine catheterized
Defecate : normal

IX. OTHERS EXAMINATION

a. Laseque : -/-
b. Kernig : -/-
c. Patrick : -/-
d. Kontrapatrick : -/-
e. Valsava test : -
f. Brudzinski : -

GAJAH MADA STROKE ALGORITHM

Loss of consciousness (-), headache (+), pathology reflex (-)
Hemorrhagic stroke

SIRIRAJ SCORE
(2.5 x level of consciousness (0)) + (2 x Vomit (1)) + (2 x headache (1)) + (0.1
x diastolic (80)) – (3x atheroma factor (0)) – 12 = 0
Interpretation : -1until 1= Confuse  Suggested to CT- Scan

X. EXAMINATION RESUME
Generalized Condition
Consciousness : Composmentis (E(4)V(5)M(6))
Blood Presure : 120/80 mmHg
Heart Rate : 90 bpm
Respiratory : Respiratory rate : 22 x/mnt

Temperature : 36,8°C
Weight : 50 kg
Height : 155 cm
Cognitive Function :difficult to assess
Meningeal Sign : Neck stiffness (+),Brudzinski I-IV (-)
Cranial Nerve : Normal
Motoric : Right hemiparesis, Central lesion of Upper Motor Neuron
Sensory :Normal

Coordination :difficult to assess

Otonom : Normal
Reflex : Physiologic (+), Patologic (-)
Gajah mada score : Hemorrhagic stroke
Siriraj score : Confuse

XI. WORKING DIAGNOSE

CLINICAL DIAGNOSE :Stroke
TOPICAL DIAGNOSE : Left Carotid system
ETIOLOGICAL DIAGNOSE : Hemorrhagic stroke
DIFFERENTIAL DIAGNOSE : Stroke infarction

SUGGESTION EXAMINATION
o Blood routine Hb, Ht, leucocyte, platelets
o Blood chemistryBlood glucose, ureum, creatinin, SGOT, SGPT, total
cholesterol, HDL, LDL, Trygliseride
o Electrolyte
o Head CT Scan without contrast
o Chest X-Ray AP
o ECG
 MANAGEMENT
 General
- Bed rest with head position elevated 300
- Control of vital sign
- Monitoring intracranial pressure
- Oxygen 2-3 L/minute (Nasal Cannula)
- IVFD Ringer Lactate (30cc/kgBW/day)  20 dpm
- Calorie needs 25-30 kkal/kgBW/day: Carbohydrate 30-40% of total
calories, fat 20-35% of total calories, protein 20-30% of total calories
- Consult the patient to physical medicine and rehabilitation (PM&R)

 Special
- Anti-edema : Manitol 125 cc/8 h
- Antifibrinolytic : Tranexamic acid 3x500 mg iv
- Neuroprotector : Citicolin 3x500 mg iv
- Gastric protector : Ranitidin 2x50 mg iv

LABORATORIUM FINDING :
1. Blood Routine (July, 25th 2018)
Hemoglobin : 12,7 gr/dl
Hematocrit : 38 %
Leucocytes : 18.000 /mm3
Platelets : 223.000/mm3

2. Blood Chemistry (July, 25th 2018)

Glucose : 106 mg/dl (<200 mg/dl)

Urea : 32 mg/dl (15 – 41)

Creatinin : 0.4 mg/dl ( 0,55 – 1,30)

SGOT : 23 U/L (15 – 37)

SGPT : 16 U/L (12 – 78)

3. EKG (25th July 2018)

Interpretation :
Sinus Tachycardial, normo axis, heart rate 107 bpm

4. CT Scan (July, 31st 2018)

Interpretation:
Intracerebral and intraventricular haemorrhagic at regio parietal sinistra

FINAL DIAGNOSE
- Hemorrhage stroke
- Intraventricullar hemorrhage

Follow up Aug, 3rd 2018

S : Weakness of right extremities (+)
O :GCS: E4V5M6
Blood Pressure :110/80 mmHg
Heart Rate : 88 bpm
Respiratory Rate : 20x/i
Temperature : 36,7 °C
Cognitive Function :Normal
Meningeal Sign :Negative
Cranial Nerves :light reflect (+/+)
Motoric :Hemiparese dextra
Sensory :Normal
Coordination :Difficult to assess
Autonomy :urinate with urine catheterized
Reflex : Pathologic (-), Physiology (+)

A : Haemorrhagic stroke
P :
 Head up 30o
 O2 3 L/minute
 IVFD RL 20drops/minute
 Manitol 125 cc/8 h iv
 Tranexamat acid 3x500 mg iv
 Ranitidin 2 x 50 mg iv
Follow up Aug, 4th 2018
S : Weakness of right extremities (+)
O :GCS: E4V5M6
Blood Pressure :120/80 mmHg
Heart Rate : 90 bpm
Respiratory Rate : 22x/i
Temperature : 36,9 °C
Cognitive Function :Normal
Meningeal Sign :Negative
Cranial Nerves :light reflect (+/+)
Motoric :Hemiparese dextra
Sensory :Normal
Coordination :Difficult to assess
Autonomy :urinate with urine catheterized
Reflex : Pathologic (-), Physiology (+)

A : Haemorrhagic stroke
P :
 Head up 30o
 O2 3 L/minute
 IVFD RL 20drops/minute
 Manitol 125 cc/8 h iv
 Tranexamat acid 3x500 mg iv
 Ranitidin 2 x 50 mg iv

Follow up Aug, 5th 2018

S : Weakness of right extremities (+)
O :GCS: E4V5M6
Blood Pressure :110/70 mmHg
Heart Rate : 86 bpm
Respiratory Rate : 20x/i
Temperature : 36,5 °C
Cognitive Function :Normal
Meningeal Sign :Negative
Cranial Nerves :light reflect (+/+)
Motoric :Hemiparese dextra
Sensory :Normal
Coordination :Difficult to assess
Autonomy :urinate with urine catheterized
Reflex : Pathologic (-), Physiology (+)

A : Haemorrhagic stroke
P :
 Head up 30o
 O2 3 L/minute
 IVFD RL 20drops/minute
 Manitol 125 cc/8 h iv
 Tranexamat acid 3x500 mg iv
 Ranitidin 2 x 50 mg iv
 DISCUSSION

1. Stroke
1.1. Definitions
Stroke is a collection of symptoms characterized by the development of
clinical manifestations of cerebral function disorders either focal or global (for the
patient in a coma), which happens quickly and more than 24 hours or ended up
with death without being discovered other causes than vascular disorders. This
definition includes stroke due to cerebral infarction (ischemic stroke),
nontraumatic intracerebral hemorrhage, intraventricular hemorrhage and some
cases of subarachnoid hemorrhage.1

1.2. Epidemiology
The increasing age of life expectancy will tend to increase the risk of
vascular disease (coronary heart disease, stroke and peripheral artery disease).
Data in Indonesia showed the tendency of an increase in stroke cases both in
terms of mortality, incidence, and disability. The mortality rate based on age is:
15.9% (age 45-55 years) and 26.8% (age 55-64 years) and 23.5% (age 65 years).
The incidence of stroke amounted to 51.6 / 100,000 population. Sufferers are men
more than women and age profile under 45 years of 11.8%, 54.2% aged 45-64
years, and age over 65 years amounted to 33.5%. Stroke attacking reproductive
age and the elderly that could potentially give rise to new problems in health
development nationally at a later date.2

1.3 Etiology and Classification

Stroke can occur because of some pathological circumstance, such as

emboli, trombus, ruptur of blood vessels, change in the vlood vessels
permeability, increasing the viscocity, or because there is a change in the quality
of blood flowto the brain blood vessels. That pathological condition assosiated
with stroke classification. Stroke is classified into two types of major categories,
non-hemorrhagic stroke and hemorrhagic stroke. Non hemorrhagic stroke more
commonly known as ischemic stroke, which is a common occurrence of all types
of stroke. From the overall incidence of stroke, 80% to 85% is the incidence of
ischemic stroke. Ischemic cerebrovascular disease is basically due to the
occlusion of blood vessels of the brain that cause the cessation of the oxygen and
glucose supply. This stroke is categorized into two groups, namely thrombus
occlusion and embolic occlusion.3,4,5

Hemorrhagic stroke occurs due to intracranial hemorrhage. The incidence

reaches 15% to 20% of the overall incidence of stroke. Most hemorrhage occurs
due to hypertensive. However, other causes may occur such as saccular aneurysm
(Berry) or arteriovenous malformations (MAV) .4,5 The major classifications of
stroke are listed in Table 1.

Table 1. Major classification of stroke5

Ischemia-infarct cerebrum (80- Intracranial hemorrhage (15-20%)

85%)

Thrombus occlusion Intraserebrum hemorrhage

Lakunar Subaraknoid hemorrhage
Embolic occlusion Intraventrikuler hemorrhage
Kardiogenik
Arteri to arteri

1. Ischemic stroke

Ischemic stroke can occur with or without infarct. It is the most

common stroke. Stroke is caused by obstruction in one or more arteries
located in the cerebrum, which led to the cessation of the supply of oxygen
and glucose.4,5

The obstruction that occur can be a clot (thrombus) that are present in
the brain blood vessels as wll as inherited from the distal organ blood vessels
(embolism) which causes blockage in the brain vascularization. The most
common cause of thrombosis in the form of atherosclerosis that is cause
stenosis or narrowing of the blood vessels. While the most common of
embolic stroke is an embolus coming from large blood vessels or heart.5
 The brain gets blood from the heart, blood containing oxygen and
nutrients to the brain. The amount of blood flow to the brain in normal
circumstances usually about 50-60 ml / 100 g of brain tissue / min, mean the
brain needs 20% of the blood pumped from the heart. If the clogged arteries,
brain cells (neurons) can not generate enough energy and the brain stops
working.7,8

When the blood flow to the brain stops within 6 seconds will occur
neuron metabolic disorders, if more than 30 seconds EEG picture will be
horizontally, within 2 minutes there will be termination of brain activity,
within 5 minutes began to brain damage and more than 9 minutes, humans
will die. Ischemic brain occurs when blood flow to the brain is reduced to 25-
30 ml / 100 grams of brain tissue permenit.1

2. Hemorrhagic stroke

Hemorrhagic stroke is a stroke that occurs due to intracerebral

hemorrhage. This can happen if intraserebrum vascular lesions rupture,
causing bleeding in the subarachnoid space and in brain tissue.

Cerebral hemorrhage can cause rapid neurological manifestations in

the brain due to the presence of the pressure on the nerve structure in the
brain. If bleeding occurs slowly, most likely symptoms is a severe headache.5
Some of the etiology that can cause intraserebrum hemorrhage showed in
Table 2 :

Table 2. Intracerebrum hemorrhages etiology2

Some intracerebrum hemorrhages etiology

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

1.4 Risk Factors

According to the American Heart Association (AHA), the risk factors of

stroke are divided into two, that are not modifiable risks factors and modifiable
risk factors. Not modifable risk factors include: age, sex, low birth weight, race or
ethnicity, and genetic factors. Modifiable risk factors include: hypertension,
smoking, diabetes, nutritional imbalance, lack of physical activity, alcohol
consumption, and drug abuse. incidence of stroke can occur with one or more risk
factors (multifactor).3,6

Table 3. Stroke risk factors3,6

Not Modifable Modifable
1. Age 1. Stroke history 10. Smoking
2. Gender 2. Hypertension 11. Alcohol
3. Genetik 3. Heart disease 12. Drug abuse
4. Ras 4. Diabetes melitus 13. Hyperhomosisteinemia
5. Carotic stenosis 14. Antibody anti fosfolipid
6. TIA15. Hyperurisemia
7. Hypercholesterolemia 16. Elevation of hematocrit
8. Oral contraception 17. Elevation of fibrinogen
9. Obesity

1.5 Clinical Manifestation

The differences in clinical manifestation between infarction stroke and

hemorrhage stroke showed in Table 4
Tabel 4. Difference of clinical manifestation between infarction and
haemorrhage stroke5,7

Symptom or Infarction Intracerebral haemorrhage

examination

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

Doing activity/resting Rest, right after Often while doing physical

wake up activity

Headache and vomit Rarely Often or severe

Lost of consciousness at Rarely Often

onset

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

1. Gajah Mada Stroke Algorhytm7

1. Lost of consciousness
2. Headache
Acute stroke
3. Pathology reflex

All criteria or two of the three

Lost of consciousness (+), headache (-), pathology reflex (-) Haemorrhage
Lost of consciousness (-),headache(+),pathology reflex (-)  Haemorrhage
Lost of consciousness (-),headache(-),pathology reflex (+) infarction
Lost of consciousness (-),headache (-),pathology reflex (-) infarction
 2. Siriraj Stroke Score (SSS)7

SSS = 2.5 C + 2 V + 2 H + 0.1 DBP - 3A – 12

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

V = Vomit (none = 0, yes = 1)
H = Headache (none = 0, yes = 1)
DBP = Diastolic blood pressure
A = Ateroma (none = 0, one or more: DM, Angina, vaskular disease = 1)

SSS DIAGNOSE

>1 Hemorrhagic stroke

<-1 Infarction stroke
-1 to 1 Uncertain

1.6 Management

Stroke patients should be handled by a multidisciplinary

team.Management stroke be done by improving the general state of the patient,
treat the risk factors, and prevent complications.2,4,9

1.6.1 Hyperacute stadium

Action at this stadium is done at the Emergency Room, the aim is to
prevent the widespread of brain tissue damaging. At this stage, patients were
given oxygen 2 L / min and 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 (including electrolytes), and if hypoxia, do the blood gas
analysis. Other actions in the Emergency Room are providing mental support to
patients and provide an explanation to the family to remain calm.10
1.6.2 Acute stadium

1. Ischemic stroke

General treatment:

Place the patient’s head in 30opositions, head an chest in a field, change

the sleep position every 2 hours. Mobilization began gradually when
hemodynamically stable. Furthermore, free the airway, give oxygen 1-2 liters /
min. If necessary, intubation. Fever overcome with compresses and antipyretic,
then look for the cause, when the bladder is full, emptied (preferably with
intermittent catheters).10

Fluid nutrition with 1500-2000 isotonic cristalloid or colloid and

electrolyte as needed, avoid fluids containing glucose or isotonic saline.Nutrition
orally only if swallowing function well, if there is swallowing disorders or
decreased consciousness, nasogastric tube is recommended.10

Blood glucose levels> 150 mg% should be corrected with continuous

intravenous drip insulin during 2-3 days. Hipoglikemia (blood glucose < 60 mg%
or < 80mg% with symptoms) should be corrected immediatelywith dextrose 40%
iv until return to normal and the cause must be sought.10

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, Mean Arterial Blood
Pressure (MAP) ≥ 130 mmHg (the two measurements with an interval of 30
minutes), or obtained acute myocardial infarction, congestive heart failure as well
as kidney failure. Maximal blood pressure reduction was 20%, and the
recommended drugs are sodium nitroprusside, alpha-beta receptor blockers, ACE
blockers, or antagonists kalsium.10

If hypotension occurs, the systolic pressure ≤ 90 mmHg, diastolic ≤70 mm

Hg, the patient should be given 250 mL of 0.9% NaCl for 1 hour, followed by 500
mL for 4 hours and 500 mL for 8 hours or until hypotension treated. If not
corrected, that is systolic blood pressure still <90 mmHg, dopamine 2-20 mcg / kg
/ minute can be given until the systolic blood pressure ≥110 mmHg.10

If there is seizure, give diazepam 5-20 mg iv slowly for 3 minutes, the

maximum dosage is 100 mg per day, followed by oral administration of
anticonvulsants such as phenytoin, carbamazepine. If the seizure appeared after 2
weeks, given orally long-term anticonvulsant.10

If there is an increased of intracranial pressure, bolus mannitol were given

an of 0.25 to 1 g / kg per 30 minutes intravenously, and if rebound phenomenon
suspected, or general condition deteriorated, followed by 0,25g / kg per 30
minutes every 6 hours for 3-5 days. Monitoring of the osmolarity should be
performed (<320 mmol), alternatively can be administered hypertonic solutions
(NaCl 3%) or furosemid.10

Special treatment:

The goal is to reperfusion by administration of antiplatelet agent such as

aspirin and anticoagulant, or with trombolytic rt-PA (combinant tissue
Plasminogen Activator), and neuroprotective agent, such as citicoline or
piracetam.10

2.Hemorrhage stroke
General treatment:
Patients with hemorrhagic stroke should be treated in the 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.
When there is heart failure, blood pressure should be reduced immediately with
10 mg iv labetalol (administration within 2 minutes) to 20 mg (administration
within 10 minutes) maximum dosage is 300 mg, enalapril iv 0,625-1.25 mg per 6
hours, captopril given three times of 6.25 to 25 mg orally. If there are signs of
increased the intracranial pressure, head position elevated 30o, the position of the
head and chest in one area, mannitol (see treatment of ischemic stroke), and
hyperventilation (pCO2 20-35 mmHg). General management same with ischemic
stroke, stomach ulcers resolved with parenteral H2 antagonists, sucralfate, or
proton pump inhibitors; airway complications prevented with physiotherapy and
treated with broad spectrum antibiotics.10

Special treatment:

Neuroprotective drug can be administered except vasodilator. The surgery

considering with age and location of the bleeding is in patients whose condition
worsened with hemorrhage cerebellar diameter> 3 cm, acute hydrocephalus due to
intraventricular hemorrhage or cerebellum, conducted VP-shunting and
hemorrhage lobar> 60 mL with signs of increased the intracranial pressure and
acute threat herniation.10

At subarachnoid hemorrhage, calcium antagonists (nifedipin) can be used

or surgery (ligation, embolization, extirpation, or gamma knife) if the cause is an
aneurysm or arteriovenous malformation.10

1.6.3 Subacute Stadium

Medical measures may include cognitive therapy, behavior, swallowing,

speech therapy, and bladder training (including physical therapy). Given the long
course of the disease, it takes a special intensive treatment of post-stroke in the
hospital with the goal of independence of the patient, understand, comprehend and
implement primary and secondary prevention programs.10

Subacute phase treatment:10

- 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 and discharge planning
1.7 Complication
Some complications can occure and need to be monitored.
a. Neurological complication:4
- Cerebral edema
- Hemorrhagic transformation
- Seizures
- Recurrent stroke
b. Non neurological complication:4
- Increased the blood pressure
- Hiperglkemia
- Cardio-respiratory disorder
- Stress ulcer
- Depression
- Decubitus ulcer, etc

1.8 Prognosis

Stroke can cause a variety of morbidity, mortality, and recurrence in the

future. Deaths due to stroke was 41.4% from 100,000 population. A third of
patients who have had a stroke, 5-14% will suffer recurrent stroke within a span
of five years.Statistical stroke data by the Stroke Association UK shows that 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.
Recurrence of stroke increases with the time. The possibility of recurrent stroke
within five years was 26.4% and in ten years was 39.2%.3,6,11

2.Hypertension

Most patients (70-94%) with acute stroke, experienced an increase in

systolic blood pressure> 140 mmHg. Study in Indonesia found the incidence of
hypertension in patients with acute stroke is about 73.9%. By 22,5- 27.6% of them
experienced an increase in systolic blood pressure> 180 mmHg.
 Reduce the high blood pressure in acute stroke is not recommended as a
routine treatment, because it is likely to worsen the neurological status. In most
patients, the blood pressure will go down by itself within the first 24 hours after
onset of stroke. Various Guideline (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.

a. In patients with acute ischemic stroke, blood pressure is lowered by about

15% (systolic or diastolic) in the first 24 hours after onset ifthe systolic blood
pressure> 220 mmHg or diastolic blood pressure > 120 mmHg. In patients
with acute ischemic stroke who will be given thrombolytic therapy (rtPA),
blood pressure must be reduced to <185 mmHg for sistolic and<110 mmHg
for diastolic. Furthermore, blood pressure should be monitored until
<180/105mmHg for 24 hours after administration of rtPA. Antihypertensive
drugs used are labetalol, nitropaste, nitroprusside, nicardipine, or intravenous
diltiazem.
b. In patient with acute intracerebral hemorrhage, if systolic blood pressure >
200 mmHg or MAP > 150 mmHg, the blood pressure reduce by using
intravenous antihypertensive drugs with blood pressure monitoring every 5
minutes.
c. If the systolic > 180 mmHg or MAP > 130 mmHg accompanied with
symptoms and signs of high intracranial pressure, the blood pressure reduced
by using intravenous antihypertensive drugs continuously or intermittently by
monitoring the cerebral perfussion pressure ≥ 60 mmHg.
d. If the systolic > 180 mmHg or MAP> 130 mmHg without symptoms and signs
of increased intracranial pressure, blood pressure is reduced carefully with the
use of intravenous antihypertensivedrugs continuously or intermittently, and
monitoring the blood pressure every 15 minutes until the MAP 110 mmHg or
blood pressure 160 / 90 mmHg. In INTERACT study 2010, reduce the blood
pressure until 140 mmHg is still allowed.
e. In patient with intracerebral hemorrhages with systolic blood dpressure 150-
220 mmHg, reducing the blood pressure quickly until 140 mmHg is secure
enough. After craniotomy, the target of MAP is 100 mmHg.
f. Pain management is important to help reducing the blood pressure in patient
with intracerebral hemorrhage stroke.
g. Betablockers (labetalol, esmolol) and calcium channel blocker (nicardipine,
diltiazem) intravenously can be used.
h. Hydralazine and nitroprusside should not be used because it resulted in an
increase in intracranial pressure, although not an absolute contraindication.
i. In the subarachnoid hemorrhage aneurysmal, blood pressure should be
monitored and controlled with monitoring of cerebral perfusion pressure to
prevent the risk of ischemic stroke after subarachnoid hemorrhages and
rebleeding. To prevent recurrent subarachnoid hemorrhage in patients with
acute stroke, the blood pressure until 140-160 mmHg. While the systolic 160-
180 mmHg is often used as a target in preventing the risk of vasospasm, but it
is individualized, depending on the patient's age and cardiovascular
comorbidities.
j. Calcium channel blocker (nifedipine) has been recognized in a variety of
management of subarachnoid hemorrhages because it can improve the
patient's functional output when cerebral vasospasm has occurred. It is linked
to the neuroprotective effects of nimodipine.
k. Decrease in blood pressure in acute stroke should be considered to be lower
than the target above on certain conditions that threaten other organs target,
such as aortic dissection, acute myocardial infarction, pulmonary edema, acute
renal failure and hypertensive encephalopathy. The reduction target is 15-25%
in the first hour, and the blood pressure 160/90 mmHg in the first 6 hours.
 THE BASIC OF DIAGNOSE

1. Basic Diagnose
1.1 Basic clinical diagnose

From the history taking, the patient had a sudden muscle weakness on the
right side of her body when she was waking up since 7 days before admitted to
Arifin Achmad’s General Hospital. The weakness equally intense in both upper
and lower limbs. The patient complained of headache 1 week before, nausea,
vomiting and speech difficulties. The right corner of patient’s mouth was flatter 4
days before admitted to Arifin Achmad Hospital. The patient did not present any
other complaint, including loss of consciousness, injury or seizures.
From physical examination we’re found hemiparesis on both right
extremities. It consistent with the WHO definition that clinical symptoms of
stroke is cerebral disorders, either focal or global attack in 24 hours.

1.2 Basic topic diagnose

Carotid system considered in this patient because there are hemiparese

with cranial nerve disorders on the same side. The left carotid system considered
because a lession in one side of carotid system will lead to contralateral
neurological deficit and the neurological deficit is in the same side with the
paralysis of arms and legs. From the physical examinationthere is hemiparese
dextra.

3.3 Basic etiological diagnose

Basic etiological diagnose of this patient is leads to hemorrhagic stroke,
because on this patient there is sudden weakness of right extremities, headache,
nausea and vomit. It is also supported by Gajah Mada Algorithm that give the
impression of the hemorrhagic stroke.

3.4 Basic differential diagnose

The gold standard examination for diagnosing the hemorrhagic or non

hemorrhagic stroke is CT Scan. The consideration of the non hemorrhagic
 stroke because of it almost has the same manifestation, like the immediate
onset, the patient was not in severe activity and there is neuroogical deficit.

3.6 Basic final diagnose

The final diagnose of this patient is hemorrhagic stroke with intracerebral

hemorrhage. This diagnosed is considered by anamnesis, physical examination
and workup examination. From anamnesis we found sudden weakness of the right
extremity that occured when she wake up, speech difficulties, headache, nausea
and vomit. No history of seizure, trauma or loss of conciousness. From physical
examination we’re found hemiparesis on both right extremities. From head CT-
Scan we can see there is intracerebral hemorrhage and intraventricular hemorrage.

Basic supporting examination

a. Laboratory :to find the risk factor for stroke and general condition of
patient.
b. Head CT-scan :to know the final pathology diagnose from the location
and the wide of the lesion.
c. Chest X ray :to find wether the patient had cardiomegaly or not as the
result of heart disease.

2. Basic treatment
a. Bed rest with head position elevated 20-300 to maintance the adequate
circulation to the brain.
b. IVFD (30cc/kgbb/day) RL 20 gtt/i to maintance the euvolemik
condition and glucose level needed.
c. Inj tranexamic acid 3x 500 to control the bleeding
d. Inj citicoline 2 x 500 mg the neuroprotector
e. Manitol infusion 125cc/8 hours is to maintain intra cranial pressure.
f. Inj Ranitidin 2x 50 mg to protector of the gastric.
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