THE ROLE OF SURGERY IN HEMORRHAGIC STROKE

THE ROLE OF SURGERY IN HEMORRHAGIC STROKE

A. DEFINITION

Definition of stroke according to World Health Organization (WHO) is the clinical signs that developed rapidly due to focal brain dysfunction (or global), with symptoms lasting 24 hours or more, and can cause death.

Stroke is a brain attack caused by blockage or sudden onset of rupture of blood vessels of the brain that causes certain brain cells are deprived of blood, oxygen or nutrients and eventually death can occur in these cells in a very short time (Stroke Foundation of Indonesia, , 2006).

Hemorrhagic stroke is rupture of the walls of blood vessels, causing bleeding in the brain. Generally occurs when patients do activities. Bleeding and impairment of consciousness are real (Stroke Foundation of Indonesia, 2006).

B. EPIDEMIOLOGY

Stroke is a major health problem in modern life today. In Indonesia, an estimated 500,000 residents each year occur suffered a stroke, about 2.5% or 125,000 people died, and the remainder mild or severe disability. Number of patients with stroke tend to increase every year, not just attack the elderly, but also experienced by those who are young and productive. Stroke can strike at any age, but which often occurs at the age of 40 years. The incidence of stroke increases with age, the older someone is, the higher the chances of developing a stroke (Stroke Foundation of Indonesia, 2006).

In Indonesia, there are no data to complete epidemiologic stroke, but the proportion of stroke patients from year to year tend to increase. It is seen from the Household Health survey report MOH in various hospitals in 27 provinces in Indonesia. The survey results showed an increase between 1984 and 1986, from 0.72 per 100 patient pada1984 to 0.89 per 100 patients in 1986. In RSU Banyumas, in 1997 stroke patients hospitalized as many as 255 people, 298 people in 1998 sebnyak, in 1999 as many as 393 people, and in 2000 as many as 459 people (Hariyono, 2006).

Stroke or cerebrovascular accident, is the most frequent cause of invalidity in the age group over 45 years in industrialized countries stroke is the third leading cause of death after heart disease and malignancy (Lumbantombing, 1984).

C. Etiology

Hemorrhagic strokes occur because one of the blood vessels in the brain ruptures or tears objec hemorrhagic stroke patients are generally more severe than non-hemorrhagic stroke. Awareness is generally declining. They are in a state of somnolence, osmnolen, spoor, or commas in the acute phase.

D. CLASSIFICATION

According to the cause can be divided into:

1) intracerebral hemorrhage

Intracerebral hemorrhage was found in 10% of all stroke cases, consisting of 80% in the hemispheres of the brain and the rest in the brainstem and cerebellum.

2) Subarachnoid hemorrhage

Subarachnoid hemorrhage is a condition where there is bleeding in the subarachnoid space which arises in the primary.

E. Pathophysiology

Hemorrhage is the third most common cause of the stroke, is the main cause of this hypertension occurs when blood pressure increased significantly causing a torn artery causing bleeding in the brain tissue, it causes blood to form a mass of brain tissue resulting in urgency, shift, or depressed (displacement of brain tissue), the situation can be menyababkan disturbed brain function. The larger the hemorrhage that occurred, the greater the displacement of brain tissue that occurs. Patients with hemorrhagic stroke most experienced unconsciousness and can result in patient death

F. RISK FACTORS

The risk factors are prone to a stroke:

Many risk factors that can make a person vulnerable to a stroke, an outline of risk factors that can be classified into two, namely

Risk factors that can not be controlled are:

(1) Age, the older the higher the incidence of stroke,

(2) race / nation: Negro / African, Japanese, and Chinese are more often affected by stroke,

(3) Sex, men are more at risk than women,

(Fourth) family history who have had a stroke.

Risk factors can be controlled

(1) Hypertension,

(2) Diabetes Millitus,

(3) Smoking

(4) Hyperlipidemia and cholesterol,

(5) Obesity,

(6) The use of drugs - drugs that affect cerebrovascular, such as amphetamines, cocaine, and the like.

G. SYMPTOMS

Symptoms that appear vary depending on where the attack of hemorrhagic stroke for example:

1) intracerebral hemorrhage

Intracerebral hemorrhage was found in 10% of all stroke cases, consisting of 80%

in the hemispheres of the brain and the rest in the brainstem and cerebellum.

Clinical symptoms:

a. Onset is sudden bleeding, especially when doing activities and may be preceded by prodromal symptoms include increased blood pressure are headaches, nausea, vomiting, memory impairment, confusion, perdarhan retina, and epistaxis.

b. Severe impairment of consciousness to coma with hemiplegia / hemiparese be accompanied by seizures and focal / common.

c. Signs of brain stem suppression, unilateral pupillary symptoms, reflex eye movement disappeared and deserebrasi

d. Can be found signs of high intracranial pressure (TTIK), such as papilledema and hemorrhage subhialoid.

2) Subarachnoid hemorrhage

Subarachnoid hemorrhage is a condition where there is bleeding in the space

Subarachnoid primarily arising.

Clinical symptoms:

a. Onset of sudden headache as explosive, dramatic, takes place within 1-2 seconds to 1 minute.

b. Vertigo, nausea, vomiting, a lot of sweat, chills, irritability, anxiety and seizures.

c. Can be found impairment of consciousness and then realized in a few minutes to several hours.

d. Found symptoms of meningeal stimulation

e. Retinal hemorrhages in the form of bleeding subhialid Subarachnoid hemorrhage is a characteristic symptom.

f. Autonomic function disorders in the form of bradycardia or tachycardia, hypotension or hypertension, a lot of sweating, increased body temperature, or interference pernafasan.2

H. DIAGNOSIS

a. Clinical history and examination, neurological

b. Scoring system to distinguish the type of stroke

c. Siriraj Stroke score formula:

(2.5 x level of consciousness) + (2 x vomiting) + (2 x headache) + (0.1 x diastolic pressure) - (3 x atheroma markers) - 12

Degrees of consciousness: (0 = compost mentis; 1 = somnolence; 2 = sopor / commas)

Vomiting: (0 = no, 1 = no)

Headache: (0 = no, 1 = no)

Atheroma: (0 = no, 1 = one or more of: diabetes, angina, peripheral artery disease).

Siriraj stroke score results:

Score> 1: p e r d a r a h a n supratentorial

Score -1 s.d. 1: need CT Scan

Score <-2: infarct cerebri

d. CT-scan is the gold standard examination to differentiate infarction with hemorrhage

e. Scan of magnetic resonance (MRI) is more sensitive than CT-Scan preformance early detection of cerebral infarction and brain stem infarction.

I. THERAPY

A. Acute attack therapy.

Time is brain, an expression which indicates the importance of early treatment of stroke, stroke karen therapeutic window of only 3-6 hours. Management of rapid, precise and meticulous ememgang major role in determining the final outcome of treatment. This should be done is

- Stabilization of the ABC action

- Consider intubation if consciousness stupor, coma and respiratory failure.

- Connect the infusion line with normal saline solution intavena by 0.9% with 20ml/jam speed, do not wear hipotonis fluids such as dextrose 5% in water and saline 45%, as it may aggravate brain edema.

- Give him oxygen 2-4 liters / minute via nasal cannula.

- Do not give food or drink by mouth.

- Create a record electrocardiogram (ECG) and thoracic rongent do photos.

- Take blood samples for examination: a complete examination of peripheral blood and platelets, blood chemistry (glucose, electrolytes, and creatinine ureun), prothrombin time and partial thromboplastin time.

- If there is any indication, do the following tests: alcohol levels, liver function tests, arterial blood gas and toxicology screening.

- Enforce diagnosis based on history and examination

- CT scan and magnetic resonance when the tools are available, if not, the Siriraj SCOR to determine the type of stroke.

B. Surgical therapy

For the location of bleeding near the surface of ota

C. Supportive therapy

Infusion of mannitol

D. Overcoming therapy Bleeding

Frozen plasma and vitamin K, Protamin, tranexamic acid

E. Maintenance or Prevention of Stroke Therapy

A. TerapiAntihipertensi

Needed because hypertension is a risk factor (50% in ischemic stroke and 60% in hemorrhagic stroke) Use of antihypertensive should pay attention to cerebral blood flow and peripheral blood flow to maintain cerebral function

Drug of choice:

• group AIIRA (angiotensin II receptor antagonist) example: candesartan

• ACE inhibitor group

2. Estrogen hormone therapy

In the post-menopausal women the therapy is proven to reduce the incidence of stroke.

3. Therapy to restore the brain metebolisme

Objectives:

• Improve cognitive abilities

• Increase alertness and mood

• Increase the memory function

• Eliminate apathy

• Eliminate dizzines

Example: citicholin, codergocrin mesilate, piracetam

4. Rehabilitation therapy

For example: physiotherapy, speech and language therapy, etc..

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