CASE REPORT

INTRACEREBRAL HEMORRHAGE
Co- Assistant Department of Neurology dr.
Mintohardjo Navy Hospital
Rizki Widya Kirana (030.12.236)
Trisakti University

Introduction
STRO
KE
Any

abnormality

the
the

brain

from
from

a
a

is applied to a sudden focal neurologic syndrome,

specifically the type caused by cerebrovascular disease

of
of

resulting

Embolus

Thrombus

pathologic
pathologic

process of
of the
the blood
blood
vessels
vessels

occlusion
occlusion of
of
the lumen
lumen

rupture of a
vessel

altered
altered permeability
permeability of
of the vessel
vessel
wall
increased
increased viscosity
Other
Other change
change in
in the
the quality
quality of
of
the
the blood
blood flowing
flowing through
through the
the
cerebral
cerebral vessels
vessels

Subarachnoid
Subarachnoid
hemorrhage
hemorrhage

Hemoragi
c stroke

Intracerebral
hemorrhage
hemorrhage
Hypertension
Hypertension
(80%)

Primer
hemorrhage
Primer
hemorrhage
from
from blood vessel on
brain
brain parenchym,
parenchym, not
caused
caused by
by trauma
trauma

Rupture
Rupture of
of
blood
blood vessels
vessels

Epidemiology
Age <45 Years

54,
54,
2%
2%

45-64 Years
>65 Years

11,
11,
8%
8%

33,
5%

Patient Identity
Name
: Mr. NS
Age
: 71 Yo
Gender
: Male
Marital Status
: Married
Religion
: Moslem
Education
: Marine Occupation
: Teacher
Address
: Grogol
Date of hospital admission : 24 June16

Anamnesis (Alloanamnesis)
Chief complaint

Weakness left side of the body

Other complaint

Slurred speech
Impair of conciussness (somnolence)

History of Present Illness

Patient come to emergency room with weakness left
side of the body 15 hours before hospital admission. A
moment ago patient get headache and feel week on
half of his body. Patient took a bath at 02.00 Am.
Patient fell in the bathroom with position back side of
head hit the bathroom floor. Patient was asking for
help, he called his wife. After that patient complained
headache, syncope (-), fever (-), nausea (-), vomit (-),
stuffy (-). Gradually, beside the weakness on left side
of the body, it Followed by slurred speech when he
talked to his wife. Then patient always fell a sleep, but
he still could answered the questions that have been
given.

Past Medical History

Tingling (+)
Cramp (+)
Hypertension uncontrolled (+)
History of diabetes melitus type II(-)
History of surgery (-)
History of accident (-)
This is the first thing happen to him, he hadnt been the

same symptomps before

Family Medical History

His brother and his wife suffer from stroke a long time ago
No history of DM and hypertension in his family

Social Economic and Personal Life

Patient is a former marine of navy, now he is teaching in voyage

school
Husband, and father of one son
Smoker, coffee and tea addict

Objective
Conciousness

E33M66V44 (somnolence)

Generalis Sign
Head
Bruised

Vital Sign
Blood pressure
: 170/100
mmHg
(hypertension grade II)
Heart rate
: 66 bpm
(normal)
Respiratory rate: 16 bpm
(normal)
Temperature : 36C
(normal)

Eye
+
Nose

Thoraks
Lung
-/-,

Normocephali,

(-), lesion (-)

: Isocor, DLR +/+, ILR +/
: Nasal respiratory
Movement (-)
: VS +/+, Rh -/-, Wh

Schlem +/+
Cor
: BJI dan BJ II reguler, M-,
GAbdomen
: BS +, Pain -/-/-/Ekstremity : Warm ekstremity+/+/
+
+, Oedem -/-/-/-

Neurological Examination
Nuchal Rigidity (-)

Laseque (-)/ (-)

Brudzinski I (-)

Kernig (-)/ (-)

Meningeal Sign

Brudzinski II (-)/(-)
Motoric Aphasia (-)
Aphasia

Sensoric
(-)

Aphasia

Disatria (+)

Cranial Nerves
N. I

Not checked

N. II

Not checked

N. III

Ptosis (), good eye movement, pupil isocoria, direct light

reflex +/+,
indirect rightreflex +/+, nistagmus (not checked)

N. IV

Good eye movement

N. V

Good mouth opening and biting, face sensibility (+)

N. VI

Good eye movement

N. VII

Facial: asymmetric (impaired left plica nasolabialis),

eye opening +/+, wrinkling of forehead +/+

N. VIII

Watch tickling (not checked)

N. IX

Not checked

N. X

Arcus pharynx symmetric, good swallowing

N. XI

Good movement of head and shoulder

N. XII

Tongue heading right, atrofi (-), fasiculation (-), left

deviation

Upper Extremities
Tonus
Normal

Physiologic reflex
Trofi

Normotrofi

Motoric
5555/1111

Biseps
Triseps

+2/+2
+2/+2

Pathologic reflex
Hoffmann- Trommer

Sensory
Cant be
assess

-/-

Lower Extremities
Tonus
Normal

Physiologic reflex
Trofi

Normotrofi

Motoric
5555/1111

Sensory
Cant be
assess

Patella
Achilles

+2/+2
+2/+2

Pathologic reflex

Babinski
-/+
Chaddock -/Schaeffer
-/Oppenheim -/Gordon
-/-

Laboratory Findings (24 June16)

Assessment
Hematology (Routine
Blood)

Result

Normal result

Leucocyte

8.600/uL

5000-10.000

Erytrocyte

4.08x106/

4,6-6,2

Haemoglobin

uL
12.9g/dL

14-16

Haematocrite

38%

42-48

Trombocyte

215.000/uL

150.000450.000

Laboratory Findings (24 June16)

Kimia Klinik
Renal Function
Ureum

Result
20 mg/dl

Normal result
17- 43

Kreatinin

0.9 mg/dl

0.7-1.3

Natrium (Na)

132 mmol/dl

134- 146

Kalium (K)

3.50 mmol/dl

3.4- 4.5

Clorida (Cl)

103 mmol/dl

96- 108

Glukosa Test

95 mg/dl

Electrolite

Laboratory Findings (25 June16)

Assessment
Kimia Klinik
Lipid Profile

Result

Trigliserida

107 mg/dl

60- 170

Cholesterol total

124 mg/dl

<200

Cholesterol HDL

35 mg/dl

40- 60

Cholesterol LDL

80 mg/dl

<130

AST (SGOT)

Result
19 U/I

Normal result
<35

ALT (SGPT)

11 U/I

<55

Assessment
Hepar Function

Normal result

Laboratory Findings (25 June16)

Assessment
Total Protein
Total protein

Result
6.6 g/dl

Normal result
6.4- 8.3

Albumin

3.4 g/dl

3.5- 5.2

Globulin

3.2 g/dl

2.6- 3.4

Assessment
Renal Function

Result

Uric Acid

4.6 mg/dl

Normal result
3.5- 7.2

Laboratory Findings (27 June16)

Assessment
Kimia Klinik
Electrolyte

Result

Natrium (Na)

133

134- 146

Kalium (K)

mmol/l
3.41

3.4- 4.5

Clorida (Cl)

mmol/l
101 mmol/l

96- 108

Normal result

Laboratory Findings (01 July16)

Assessment
Kimia Klinik
Electrolyte

Result

Natrium (Na)

136 mmol/l

134- 146

Kalium (K)

3.56

3.4- 4.5

Clorida (Cl)

mmol/l
90 mmol/l

96- 108

Normal result

Electrocardiogram

Sinus : Sinus rhythm, reguler

QRS rate : 90 Bpm
Axis : normal

Chest X- Ray (AP)

Cor
Cor CTR
CTR <
< 50%,
50%, normal
normal
Bronkovaskuler
Bronkovaskuler pattern
pattern is
is normal
Didnt
Didnt show
show spotting
spotting gloom
Sinus
Sinus costofrenikus
costofrenikus and
and diafragma
diafragma
are
are normal
normal
Costae
Costae and
and bones are
are good
good
Impression
Impression :: cor
cor and
and lung
lung normal
normal

Brain Ct- Scan

(without contrast)

Hyperdens
Hyperdens lesion
lesion bounded
bounded indecisive
indecisive in
in right
right
temporal
temporal with
with mild
mild perifokal
perifokal edema
edema
Lesion
Lesion with
with urging
urging the
the mass
mass effect
effect which
which clamp
clamp
left
lateralis
ventricle
left lateralis ventricle
Didnt
Didnt shown
shown shifting
shifting mid
mid line
line
Didnt
Didnt shown
shown patologic
patologic calcification
calcification
Ventricle
Ventricle system
system and
and cysterna
cysterna are
are normal
normal
Cerebellum
and
infra
structure
are
Cerebellum and infra structure are normal
normal
Subdural
Subdural and
and meningens
meningens are
are normal
normal
Bones
Bones are
are good
good
Impression:
Impression: Haemoragic
Haemoragic cerebri
cerebri di
di temporal
temporal
kanan
kanan

Resume
Patient come to emergency room with weakness left side of the body 15 hours before
hospital admission. A moment ago patient get headache and feel week on half of his body.
Patient took a bath at 02.00 Am. Patient fell in the bathroom with position back side of head
hit the bathroom floor. Patient was asking for help, he called his wife. After that patient
complained headache, syncope (-), fever (-), nausea (-), vomit (-), stuffy (-). Gradually,
beside the weakness on left side of the body, it Followed by slurred speech when he talked to
his wife. Then patient always fell a sleep, but he still could answered the questions that have
been given. He hadnt been the same symptomps before, but he has hypertension
uncontrolled, and patient complain about cramp and tingling often. His wife and his
brother suffered from stroke a long time ago. Everyday, patient consume coffee and he
is a smoker.
Physical Examination from patient, somnolence of conciuosness, blood pressure
170/100 mmHg. Generalis states are normal, Neurologic states, there are hemiparese
sinistra and parese VII and XII nerve sinistra central. Blood routine on laboratory
found eritropenia, hemoglobin and hematocrit are decreasing. Electrolyte found,
hiponatremia, and protein total checked that found hypoalbuminemia. For renal, heart
function, and lipid test are normal. ECG shown that sinus rhythm reguler, and normal axis.
Chest X-ray (AP) was normal. Brain ct scan without contrast that shown hemorrhage on
dextra hemisphere.

Assessmen
t
X1

Clinical diagnosis

Hemiparesis sinistra
Paresis N.7 sinistra central
Paresis N.12 sinistra central

Etiology diagnosis

Intra Cerebral Hemorrhage

Topical diagnosis

Right hemisphere

Pathology diagnosis

Hematom

X2

Grade II hypertension

Planning
Citicolin
Citicolin Injection
Injection 2x500
2x500 mg
mg
Assering
Assering Infus/
Infus/ 12
12 H/
H/ 1
1 kolf

Medicamentosa

Neurodex
Neurodex 2x1
2x1 tab
As.
As. Folat
Folat 2x1
2x1 tab
Nacl
Nacl caps
caps 2x1
2x1 tab
tab
CTCT- Scan
Scan

Prognosis
Ad Vitam
Dubia ad bonam
Ad Functionam
Malam
Ad Sanationam
Dubia ad malam

Follow Up
Date
Std, June
2516
06.30
WIB
(H+2)

Subjective
Weakness left
side of the body

Objective

GCS (E3M6V4)
BP 160/110 mmHg
HR 64 Bpm
RR 24 Bpm
T 37,2oC
Generalis state normal

Neurological state
Meningeal sign: (-)
Cranial nerve lession (+): Parese
N.7 and 12 sinistra sentral
Motoric: 5555/1111 left lateralization
5555/1111
Sensoric: cant be assess
Physiologic reflex: B+2/+2,
T+2/+2, P+2/+2, A+2/+2
Pathologic reflex: B-/+, C-/-

Sun, June
2616
06.00
WIB
(H+3)

Weakness left
side of the body

GCS (E3M6V4)
BP 180/100 mmHg
HR 72 Bpm
RR 20 Bpm
T 37,5oC
Generalis state normal

Neurological state
Meningeal sign (-)
Cranial nerve lession (+): Parese
N.7 and 12 sinistra sentral

Assessment
X1
Clinical:
Hemiparesis
sinistra, paresis
n.VII & n.XII
sinistra central
Etilogy : ICH
Topical : Right
cerebri
hemisphere
Pathology :
Hematoma
X2
Hiponatremi

Planning
Assering inf/ 12 H
Manitol inf
4x125 ml
Citicolin injection
2x500 mg
Transamin
injection 3x500
mg
Lasix injection
1x1 amp
Neurodex 2x1 tab
Folat acid 2x1 tab
Nacl caps 2x1 tab
Amlodipine 1x10
mg
Kateter usage

X3
Hypertension
grade II
X1
Clinical:
Hemiparesis
sinistra, paresis
n.VII & n.XII
sinistra central
Etilogy : ICH
Topical : Right
cerebri
hemisphere

Assering inf/ 12 H
Manitol inf 4x125
ml
Citicolin injection
2x500 mg
Transamin
injection 3x500
mg
Lasix injection 1x1
amp
Neurodex 2x1 tab

Follow Up
Date

Subjective

Sun, June
2616
06.00
WIB
(H+3)

Mon,
June
2716
06.00
WIB
(H+4)

Objective
Motoric: 5555/1111 left
lateralization
5555/1111
Sensoric: cant be assess
Physiologic reflex: B+2/+2,
T+2/+2, P+2/+2, A+2/+2
Pathologic reflex: B-/+, C-/-

Weakness left side

of the body

GCS (E3M6V4)
BP 160/90 mmHg
HR 100 Bpm
RR 28 Bpm
T 37oC
Generalis state normal

Neurological state
Meningeal sign: (-)
Cranial nerve lession (+) : Parese
N.7 and 12 sinistra sentral
Motoric: 5555/1111 left
lateralization
5555/1111
Sensoric: cant be assess
Reflek fisiologis: B+2/+2, T+2/+2,
P+2/+2, A+2/+2
Refleks Patologis: B-/+, C-/-

Assessment
Pathology :
Hematoma
X2
Hiponatremi
X3
Hypertension
grade II
X1
Clinical:
Hemiparesis
sinistra, paresis
n.VII & n.XII
sinistra central
Etilogy : ICH
Topical : Right
cerebri
hemisphere
Pathology :
Hematoma
X2
Hiponatremi
X3
Hypertension
grade II

Planning
Folat acid 2x1 tab
Nacl caps 2x1 tab
Amlodipine 1x10
mg
Valsartan 1x160
mg
NGT usage

Nacl inf 0,9 %/

12 h
Manitol inf I4x125
ml
Citicolin injection
2x500 mg
Transamin 3x500
mg
Lasix injection 1x1
amp
Neurodex 2x1 tab
Folat acid 2x1 tab
Nacl caps 2x1tab
Amlodipine 1x10
mg
Captopril 3x50
mg

Follow Up
Date

Subjective

Tue, June
2816
05.30
WIB
(H+5)

Weakness left side

of the body

Objective

GCS (E3M6V4)
BP 145/90 mmHg
HR 108 Bpm
RR 20 Bpm
T 37,1 oC
Generalis state normal

Neurological state
Meningeal sign: (-)
Cranial nerve lession (+): Parese
N.7 and 12 sinistra sentral
Motoric: 5555/2222 left
lateralization
5555/1111
Sensoric: cant be assess
Physiologic reflex: B+2/+2,
T+2/+2, P+2/+2, A+2/+2
Pathologic reflex: B-/+, C-/Wed,
June 29
16
06.30
WIB
(H+6)

Weakness left
side of the body
Cough (+)

(-)

GCS (E3M6V4)
BP 145/90 mmHg
HR 108 Bpm
RR 20 Bpm
T 37,1 oC
- Eye : Isocor, RCL +/+, RCTL +/+
Thorax
- Lung: SNV +/+, RH -/-, Wh -/-,
Schlem +/+
- Cor: BJ I dan II regullar, M (-), G

Assessment
X1
Clinical:
Hemiparesis
sinistra, paresis
n.VII & n.XII
sinistra central
Etilogy : ICH
Topical : Right
cerebri
hemisphere
Pathology :
Hematoma
X2
Hiponatremi
X3
Hypertension
grade II
X1
Clinical:
Hemiparesis
sinistra, paresis
n.VII & n.XII
sinistra central
Etilogy : ICH
Topical : Right
cerebri
hemisphere
Pathology :
Hematoma

Planning
Nacl inf 0.9 %/ 12
h
Manitol inf 4x125
ml
Transamin
injection 3x500
mg
Citicolin injection
2x500 mg
Lasix injection 1x1
amp
Neurodex 2x1 tab
Folat acid 2x1 tab
Nacl caps 2x1 tab
Amlodipine 1x10
mg
Captopril 3x25
mg
Nacl inf 0.9 %/ 12
h
Manitol inf 4x125
ml
Transamin
injection 3x500
mg
Citicolin injection
2x500 mg
Lasix injection 1x1
amp
Neurodex 2x1 tab

Follow Up
Date

Subjective

Wed,
June 29
16
06.30
WIB
(H+6)

Thu, June
3016
06.00
WIB
(H+7)

Objective
Neurological state
Meningeal sign: (-)
Cranial nerve lession (+): Parese
N.7 and 12 sinistra sentral
Motoric: 5555/2222 left
lateralization
5555/1111
Sensoric: cant be assess
Physiologic reflex: B+2/+2,
T+2/+2, P+2/+2, A+2/+2
Pathologic reflex: B-/-, C-/-

Weakness left
side of the body
Cough (+)

GCS (E3M6V4)
BP 145/90 mmHg
HR 128 Bpm
RR 24 Bpm
T 38.2 oC
- Eye : Isocor, RCL +/+, RCTL +/+
Thorax
- Lung: SNV +/+, RH -/-, Wh -/- ,
Schlem +/+
- Cor: BJ I dan II regullar, M (-), G

(-)
Neurological state
Meningeal sign : (-)
Cranial nerve lession (+) : Parese
N.7 and 12 sinistra sentral

Assessment
X2
Hiponatremi
X3
Hypertension
grade II

X1
Clinical:
Hemiparesis
sinistra, paresis
n.VII & n.XII
sinistra central
Etilogy : ICH
Topical : Right
cerebri
hemisphere
Pathology :
Hematoma
X2
Hiponatremi
X2
Hypertension
grade II

Planning
Folat acid 2x1 tab
Nacl caps 2x1 tab
Amlodipine 1x10
mg
Captopril 3x25 mg

Nacl inf 0.9 % 14

tpm
Citicolin injection
2x500 mg
Neurodex 2x1 tab
Folat acid 2x1 tab
Amlodipine 1x10
mg
Captopril 3x25 mg
Lung consultation
Chest X-ray
Ceftriaxone
injection 1x2 gr
Nebulizer 3x1
(ventolin :
pulmicort: nacl)

Follow Up
Date

Subjective

Thu, June
3016
06.00
WIB
(H+7)

Frd, July
116
06.00
WIB
(H+8)

Objective

Assessment

Planning

Motoric: 5555/2222 left

lateralization
5555/1111
Sensoric: cant be assess
Physiologic reflex: B+2/+2,
T+2/+2, P+2/+2, A+2/+2
Pathologic reflex: B-/-, C-/ Weakness left
side of the body
Cough (+)

GCS (E3M6V4)
BP 160/100 mmHg
HR 116 Bpm
RR 40 Bpm
T 38 oC
- Eye : Isocor, RCL +/+, RCTL +/+
Thorax
- Lung: SNV +/+, RH -/-, Wh -/-,
Schlem +/+
- Cor: BJ I dan II regullar, M (-), G

(-)
Neurological state
Meningeal sign : (-)
Cranial nerve lession (+) : Parese
N.7 and 12 sinistra sentral
Motoric: 5555/2222 left
lateralization
5555/1111
Sensoric: cant be assess
Physiologic reflex: B+2/+2,
T+2/+2, P+2/+2, A+2/+2
Pathologic reflex: B-/-, C-/-

X1
Clinical:
Hemiparesis
sinistra, paresis
n.VII & n.XII
sinistra central
Etilogy : ICH
Topical : Right
cerebri
hemisphere
Pathology :
Hematoma
X2
Hypertension
grade II
X3
Suspect
Pneumonia

Nacl inf 0.9 % 14

tpm
Nebulizer 3x1
Ceftriaxone
injection 1x2 gr
Citicolin injection
2x500 mg
Neurodex 2x1 tab
Amlodipine 1x10
mg
Captopril 3x25 mg
Fisiotherapy

Follow Up
Date
Sat, July
216
06.00
WIB
(H+9)

Subjective
Weakness left
side of the body
Cough (+)

Objective

GCS (E3M6V4)
BP 140/90 mmHg
HR 100 Bpm
RR 32 Bpm
T 37.2 oC
- Eye : Isocor, RCL +/+, RCTL +/+
Thorax
- Lung: SNV +/+, RH -/-, Wh -/-,
Schlem +/+
- Cor: BJ I dan II regullar, M (-), G

(-)
Neurological state
Meningeal sign : (-)
Cranial nerve lession (+) : Parese
N.7 dan 12 sinistra sentral
Motoric: 5555/2222 left
lateralization
5555/1111
Sensoric: cant be assess
Physiologic reflex: B+2/+2,
T+2/+2, P+2/+2, A+2/+2
Pathologic reflex: B-/-, C-/Sun, July
316
06.00
WIB
(H+10)

Weakness left
side of the body
Less cough

GCS (E3M6V4)
BP 140/100 mmHg
HR 92 Bpm
RR 22 Bpm
T 37.4 oC

Assessment
X1
Clinical:
Hemiparesis
sinistra, paresis
n.VII & n.XII
sinistra central
Etilogy : ICH
Topical : Right
cerebri
hemisphere
Pathology :
Hematoma

Planning
Nacl inf 0.9 % 14
tpm
Nebulizer 3x1
Ceftriaxone
injection 1x2 gr
Citicolin injection
2x500 mg
Neurodex 2x1 tab
Amlodipine 1x10
mg
Captopril 3x25 mg

X2
Hypertension
grade II

X1
Clinical:
Hemiparesis
sinistra, paresis
n.VII & n.XII
sinistra central
Etilogy : ICH

Nacl inf 0.9 % 14

tpm
Nebulizer 3x1
Ceftriaxone
injection 1x2 gr
Citicolin injection

Follow Up
Date

Subjective

Sun, July
316
06.00
WIB
(H+10)

Objective
- Eye : Isocor, RCL +/+, RCTL +/+
Thorax
- Lung: SNV +/+, RH -/-, Wh -/-,
Schlem +/+
- Cor: BJ I dan II regullar, M (-), G
(-)
Neurological state
Meningeal sign : (-)
Cranial nerve lession (+) : Parese
N.7 dan 12 sinistra sentral
Motoric: 5555/2222 left
lateralization
5555/1111
Sensoric: cant be assess
Physiologic reflex: B+2/+2,
T+2/+2, P+2/+2, A+2/+2
Pathologic reflex: B-/-, C-/-

Mon, July
416
06.00
WIB
(H+11)

Weakness left
side of the body
Less cough

(-)

GCS (E3M6V4)
BP 140/100 mmHg
HR 120 Bpm
RR 24 Bpm
T 36,6 oC
- Eye : Isocor, RCL +/+, RCTL +/+
Thorax
- Lung: SNV +/+, RH -/-, Wh -/-,
Schlem +/+
- Cor: BJ I dan II regullar, M (-), G

Assessment
X1
Clinical:
Hemiparesis
sinistra, paresis
n.VII & n.XII
sinistra central
Etilogy : ICH
Topical : Right
cerebri
hemisphere
Pathology :
Hematoma

Planning
Neurlin 2x1 tab
Amlodipine 1x10
mg
Captopril 3x25 mg

X2
Hypertension
grade II

X1
Clinical:
Hemiparesis
sinistra, paresis
n.VII & n.XII
sinistra central
Etilogy : ICH
Topical : Right
cerebri
hemisphere
Pathology :
Hematoma

Nacl inf 0.9 % 14

tpm
Nebulizer 3x1
Ceftriaxone
injection 1x2 gr
Citicolin injection
2x500 mg
Neulin 2x1 tab
Amlodipine 1x10
mg
Captopril 3x25 mg
Paracetamol
4x500 mg

Follow Up
Date

Subjective

Objective
Neurological state
Meningeal sign : (-)
Cranial nerve lession (+) : Parese
N.7 dan 12 sinistra sentral
Motoric: 5555/2222 left
lateralization
5555/1111
Sensoric: cant be assess
Physiologic reflex: B+2/+2,
T+2/+2, P+2/+2, A+2/+2
Pathologic reflex: B-/-, C-/-

Tue, July
5 16
06.00
WIB
(H+12)

Weakness left
side of the body

GCS (E3M6V4)
BP 140/90 mmHg
HR 96 Bpm
RR 24 Bpm
T 36,7 oC
- Eye : Isocor, RCL +/+, RCTL +/+
Thorax
- Lung: SNV +/+, RH -/-, Wh -/-,
Schlem +/+
- Cor: BJ I dan II regullar, M (-), G

(-)
Neurological state
Meningeal sign : (-)
Cranial nerve lession (+) : Parese
N.7 dan 12 sinistra sentral
Motoric: 5555/2222 left
lateralization
5555/1111

Assessment

Planning

X2
Hypertension
grade II

X1
Clinical:
Hemiparesis
sinistra, paresis
n.VII & n.XII
sinistra central
Etilogy : ICH
Topical : Right
cerebri
hemisphere
Pathology :
Hematoma
X2
Hypertension
grade II

Nacl inf 0.9 % 14

tpm
Nebulizer 3x1
Ceftriaxone
injection 1x2 gr
Citicolin injection
2x500 mg
Neulin 2x1 tab
Amlodipine 1x10
mg
Captopril 3x25 mg
Paracetamol
4x500 mg

Follow Up
Date

Subjective

Tue, July
5 16
06.00
WIB
(H+12)
Wed, July
6 16
06.00
WIB
(H+13)

Objective

Assessment

Planning

Sensoric: cant be assess

Physiologic reflex: B+2/+2,
T+2/+2, P+2/+2, A+2/+2
Pathologic reflex: B-/-, C-/ Weakness left
side of the body

GCS (E3M6V4)
BP 140/90 mmHg
HR 96 Bpm
RR 20 Bpm
T 36 oC
- Eye : Isocor, RCL +/+, RCTL +/+
Thorax
- Lung: SNV +/+, RH -/-, Wh -/-,
Schlem +/+
- Cor: BJ I dan II regullar, M (-), G

(-)
Neurological state
Meningeal sign : (-)
Cranial nerve lession (+) : Parese
N.7 dan 12 sinistra sentral
Motoric: 5555/2222 left
lateralization
5555/1111
Sensoric: cant be assess
Physiologic reflex: B+2/+2,
T+2/+2, P+2/+2, A+2/+2
Pathologic reflex: B-/-, C-/-

X1
Clinical:
Hemiparesis
sinistra, paresis
n.VII & n.XII
sinistra central
Etilogy : ICH
Topical : Right
cerebri
hemisphere
Pathology :
Hematoma
X2
Hypertension
grade II

Nebulizer 3x1
Cefixime 2x1 tab
Citicolin 2x1 tab
Neulin 2x1 tab
Amlodipine 1x10
mg
Captopril 3x25 mg
Paracetamol
4x500 mg

Case Review
Stroke is a state of partial or
complete loss of neurological
function (neurologic deficit focal
or global) that occurs suddenly,
occurs during 24 hours and
become the cause of death. Without
any underlying caused except from
vascular problems

Neurologic deficit :

Weakness left side of

the body
Slurred speech
Edema cerebri make
increasing intracranial
pressure
Impair of conciussness
(somnolence)

Risk Factors of
Stroke

NonModifiable
Factors

33,5%
33,5% people
people had
had stroke
stroke in
in age
age >65
>65
years
years
In
In older
older people,
people, blood
blood vessels
vessels more
more
rigid
rigid than
than young
young people.
people. That
That easily
easily
to
to get
get hypertension
Blood
Blood vessels
vessels get
get weaker
weaker than
than
before,
before, so
so the
the blood
blood can
can leak
leak out
out

Age
Gender
Race
History of
stroke before

More often man to get stroke

than female
2:1
Cause of hormone like estrogen
can protect women from stroke

In America, 62,9% blacks

people get stroke

Risk Factors of
Stroke

Modifiable
Factors
Hypertension
DM type II

Cholesterol
Tobacco
Heart
disease

Current
Current of
of blood
blood flow
flow becomes
becomes faster
faster
than
than usual, collision
collision to wall
wall of
of blood
blood
vessels
vessels is
is more
more often
often happen.
happen. The
The
wall
of
blood
vessels
becomie
wall of blood
balloning
balloning out,
out, make
make aneurysm
aneurysm in
in
artery
artery wall, the artery wall
wall become
weaker
weaker than
than before,
before, easily
easily to
to get
get
rupture,
rupture, leak
leak out
out and
and become
become
hemoragic
stroke
hemoragic stroke
Small
Small blood
blood vessels
vessels will
will be
be thicker,
thicker, as
as
a
a compensation
compensation from
from high blood
pressure,
pressure, its
its called
called by
by Hyaline
Hyaline
arteriolosklerosis.
arteriolosklerosis. The diameter of
blood
blood vessels
vessels become
become narrow,
narrow, it
it can
can
make
make distubance
distubance of
of circulation
circulation
Toxin
Toxin of
of tobacco
tobacco
Increasing
Increasing of
of coagulability
coagulability
Visicosity
Visicosity of
of blood
blood
Increasing
Increasing fibrinogen
fibrinogen levels
levels
Push
Push the
the platelet
platelet aggregation
aggregation
Hematocrit
Hematocrit increasing
increasing
Decreasing
HDL
Decreasing HDL
Increasing
Increasing LDL
LDL

Pathogenesis Hypertensive Intracerebral

Hemorrhage

Motor
Pathways
Descending
tracts

Corticospinal
Corticospinal Tract
Tract

Corticobulbar tracts

Upper
Upper Motor
Motor Neuron
Neuron
(central/
(central/ supranuclear)
supranuclear)

Lower Motor
Neuron

Motoric Examination

From motoric examination there is hemiparesis sinistra (score: 1).

This is upper motor neuron syndrom which often happen in

pyramidal system impairment.
Commonly, in pyramidal system impairment, theres paralysis,

hiperreflexia, and pathologic reflexes.

Hemiparese on the opposite side of the site of bleeding is a sign of

the involvement of the internal capsule, bleeding is usually the

internal carotid artery or the anterior, posterior, and media
cerebral artery, supply motor area so give clinical manifestations
that form of a contralateral hemiparesis.

Cranial Nerve Examination

Paralysis Vii and XII nerve Sinistra

central

Paralysis of n.VII sinistra

sinistra
central because the
central
central impairment
around
around eye
eye and
and
forehead
forehead got
got the
the
nerves
nerves from
from both
both
sides are
are not
not
paralyzed but
but the
the below
below
side
side of
of the
the face
face is
is
paralyzed.
paralyzed.

Paralysis of n.XII
sinistra central is
supranuclear and
there is no
atrophy of
tongue papiles
and fasciculation

In peripheral impairment (in

the nuclei or nerve fibers) can
caused one sided face paralyzed.

Intracerebral hemorrhage: Clinical

manifestasion based on bleeding location

Common locations
of cerebral
aneurysms

Diagnosis
sudden
sudden onset of headache
headache

Anamnesis

Nausea
Nausea
Vomit
Vomit
Weakness
Weakness half
half of
of
body

General
General States
States

2 Physical
Examinatio
n

3Supporting
Examinatio
n

Neurological
Neurological
states

focal neurologic
deficits
deficits

impaired
impaired
consciousness
consciousness

Somnolence
Somnolence

blood
blood glucose
level
level

Slurred
Slurred speech
speech

distinguished
distinguished from
from other
other causes
causes of
of acute
acute
neurologic
neurologic deficits
deficits eg,
eg, seizure,
seizure,
hypoglycemia
hypoglycemia

CT
CT or
or MRI
MRI

Hyperdens
Hyperdens in
in right
right hemisphere
hemisphere

lumbar
puncture

In
In subarachnoid
subarachnoid hemorrhage
hemorrhage

Siriraj Stroke Score

(2,5) Degree of awareness + (2) Vomit + (2)
Headache + (0,1) diastole blood pressure (3)
Atheroma marker 12
(2,5 x 1) + (2 x 0) + (2 x 1) + (0,1 x 100) (3 x 1)
12
= -0,5

Uncertain

The SSS performed marginally better and had a much

higher sensitivity for detecting intracranial hemorrhages.

Treatment

Management in emergency
room
Quick evaluation and diagnosis
Airway stabilitation and
breathing (adequate
ventilation)
Hemodynamic stability
Physical examination for the
first assessment
Controlling elevation of
intracranial pressure
Hemoragic transformation
handling
Seizure controlling
Controlling of body temperature
Supporting examination

Management High Blood Pressure

in Acute Stroke

In
In patient
patient with
with acute
acute intracerebral
intracerebral
hemorrhage,
hemorrhage, if
if systole blood pressure
pressure
>200
>200 mmHg
mmHg or MAP >150 mmHg, the
blood
blood pressure
pressure decreasing
decreasing with
continious
continious antihypertension
antihypertension i.v
i.v and
and
controlling
controlling blood
blood pressure
pressure every 5
minutes
minutes

In
In patient
patient intracerebral
intracerebral hemorrhage
hemorrhage with
with
systole
systole blood
blood pressure150-220
pressure150-220 mmHg,
decreasing
decreasing quickly
quickly of
of blood
blood pressure
pressure
until
until systole blood pressure is 140
mmHg
mmHg safe
safe enough
enough

Antihypertension
Antihypertension parenteral
parenteral B-blocker
B-blocker
group
group (labetolol and esmolol), Calcium
channel
channel blocker
blocker (nikardipin
(nikardipin and
and
diltiazem)
diltiazem) use in above
above condition
condition

Treatment
Citicolin Injection 2x500
2x500 mg
Assering
Assering Infus/
Infus/ 12
12 H/
H/ 1
1 kolf
kolf

Neurodex 2x1 tab

As.
As. Folat
Folat 2x1
2x1 tab
tab
Nacl caps 2x1 tab
CTCT- Scan
Scan

Assering
Assering given
given to
to cope
cope if
if patients
patients have
have
hemorrhagic
hemorrhagic shock, and can
can resolve
electrolyte
electrolyte imbalance
imbalance in
in patients
Neurodex
Neurodex and
and citicoline
citicoline function
function as
as
neuroprotectan
neuroprotectan

Prognosis

Patients who
who have small
small
hematomas (smaller than
than 30
30
cm
cm33)) seem
seem to
to do
do generally
generally well
well
without
without surgical
surgical evacuation
evacuation
However, larger
larger hematomas
hematomas
(larger than 60
60 cm
cm33)) do
do poorly,
poorly,
even when
when evacuated
evacuated surgically
surgically
Hematomas between
between 30
30 and
and 40
40
cm33 may
may do
do best
best after
after surgical
surgical
evacuation.

Ad Vitam
Dubia ad bonam
bonam

Bleeding Volume Formula

Px L x T = 3.5x3.5x3
2
2
Result is 18,75cm33, thats
categorized as small hematomas

Ad
Ad Functionam
Functionam
Malam

If the patient survives the bleed, the

ultimate neurologic
neurologic recovery
recovery
depends on
on the
the hemorrhage
hemorrhage
location
location and
and residual
residual deficits.
deficits.

Its
Its depends
depends on
on physiotherapy
physiotherapy have
have
done
done by
by him
him (patient)
(patient)
Ad Sanationam
Sanationam
Dubia ad
ad Maalm
Maalm
Patient
Patient has
has hypertension,
hypertension, as
as a
a risk
risk
factors
factors its
its need
need awareness
awareness and
and
attention
attention of
of the
the patient
patient to
to control
control