A Case Report

Tuesday, February 7th 2023

Hemorrhagic
Stroke

Anjas Julianto
2208436616
Supervisor
DR. dr. Riki Sukiandra, Sp.S
CASE REPORT
Case Report

PATIENT
IDENTITY
Name : Mr. Y
No. RM : 01117668
Age : 82 y.o
Gender : Male
Marital’s Status : Married
Address : Jalan Kesadaran gg Bahagia, Bukit Raya, Pekanbaru
Occupation : Self Employed
Day of admission : January 22nd 2023
AutoAnamnesis+AlloAnamnesis
AlloAnamnesis with patient’s wife (february, 1 st 2023on 17.00 pm, in Krisan
Room)

Chief Complain.
Weakness of left extremity since 3 hours before
admission to the hospital
PAST ILLNESS HISTORY
∙ There is no history of hypertension

∙ There is no history of Diabetes

∙ There is no history of colesterol
∙ There is no history of cardiac and lung disease
∙ There is no history of stroke
∙ There is no history of trauma
Present illness history
3 hours before admission to the hospital, patient’s wife complained her husband got weakness of the
left extremity. The weakness occurred suddenly when the patient on his way to the toilet. Severe
headeache and neck felt heavy were also denied. Patient was also got facial drop, flowing saliva and
slurred speech.

The complaints were also accompanied by once spontaneous vomiting contained food but not
projectile. Nausea, fever, blurred vision, double vision, and seizures were denied. Then, the patient was
taken to the emergency departement of Arifin Achmad General Hospital and then admited to Krisan
Ward..

Patient got a significat improvement of his clinical condition. Patient could move his left extremity but
still feel numbness. Patient also have dificulty of swallowing. .
The family disease history

∙ There is no history of hypertension

∙ There is no history of cardiac disease
∙ There is no history of diabetes
∙ There is no history of stroke
Social Economic History
∙ • The patient is a self employed
∙ • There is history of smoking, since his younghood till 3
months ago, 1 pcs a day
∙ • There is no history of alcohol comsumption.
∙ • Prequent consumption of fatty food and patient never
do the exercise
 SUMMARY
Mr. Y, 82 years old, was complained sudden weakness of the left extremity since 3 hours before
admited to the hospital. Patient were vomited contained food but not projectile, facial droop,
flowing saliva, and slurred speech. There are history of smoking since teenager till 3 month ago,
no histories of hypertension and, frequent consupmtion fatty food and never do exercise
regularly. Patient was admited to the Emergency then Krisan ward and got improvement on his
clinical condition.
Physical Examination (Emergency Room)

Blood Pressure : 183/121 mmHg

MABP : 142 mmHg
Heart Rate : 104 bpm
Respiratory rate : 20 tpm
Temperature : 36,5°C
Weight : 60 kg
Height : 165 cm
BMI : 22 (Normoweight)
Physical Examination (In Krisan Room)
Eyes
Pale conjunctiva (-/-), isocoria 3mm/3mm,
direct light reflex (+/+), indirect light reflex
(+/+)
Cardiovascular
HR : 98 bpm, regular, murmur (-), gallop (-)
Respiratory :
Vesicular (+/+), Ronchi (-/-), Wheezing (-/-),
symmetrical lung expansion.
Abdomen
Normal skin turgor, bowel sound : 8x/minutes
Lymph nodes
Swollen lymph nodes (-)
Neurological Status (In Krisan Room)
• Consciousness : Composmentis
• GCS : E(4)V(5)M(6)
• Cognitive Function : Normal
• Meningeal Sign :
Neck stiffness (-), Brudzinki I, II, III, IV
(-)
 Neurological Status (In Krisan Room)
1st Cranial Nerve ( Olfactory )
Right Left Interpretation

Sense of Smell Normal Normal Normal

2nd Cranial Nerve ( Optic )

Right Left Interpretation
Visual Acuity Normal Normal
Visual Fields Normal Normal Normal
Colour Recognition Normal Normal
 Neurological Status (In Krisan Room)
3rd Cranial Nerve ( Oculomotor )
Right Left Interpretation
Ptosis (-) (-)
Pupil
Shape Round Round
Size Φ3mm Φ3mm
Normal
Pupillary reactions to light
(+) (+)
Direct (+) (+)
Indirect
 Neurological Status (In Krisan Room)
4th Cranial Nerve ( Troclear )
Right Left Interpretation
Extraocular
(+) (+) Normal
Movements

5st Cranial Nerve ( Trigeminal )

Right Left Interpretation
Motoric Normal Normal
Sensory Normal Normal Normal
Corneal reflex (+) (+)
 Neurological Status (In Krisan Room)

6th Cranial Nerve ( Abducens )

Right Left Interpretation
Eyes movement Normal Normal
Strabismus (-) (-) Normal
Deviation (-) (-)
 Neurological Status (In Krisan Room)
7th Cranial Nerve ( Facial )

Right Left Interpretation

Tic (-) (-)
Motoric:
- Frowning Normal Normal
- Raised eye brow Normal Normal
- Closed eyes Normal Normal 7th cranial nerve
- Corners of the mouth Deviation to Deviation palsy central
the right to the right type

- Nasolabial fold Normal Dissapear

Sense of Taste Normal Normal
Chvostek Sign (-) (-)
 Neurological Status (In Krisan Room)
8 th Cranial Nerve ( Acoustic )
Right Left Interpretation
Hearing sense Normal Normal Normal

9 th Cranial Nerve ( Glossopharyngeal )

Right Left Interpretation
Pharyngeal Arch Normal Normal
Sense of Taste Normal Normal Normal
Gag Reflex + +
 Neurological Status (In Krisan Room)
10 st Cranial Nerve ( Vagus )
Right Left Interpretation
Pharyngeal Arch Normal Normal
Normal
Dysphonia Normal Normal

11 st Cranial Nerve ( Accessory )

Right Left Interpretation
Motoric Normal Normal
Normal
Trophy Eutrophy Eutrophy
 Neurological Status (In Krisan Room)
12 nd Cranial Nerve ( Hypoglossal )
Right Left Interpretation
Motoric Deviation to Deviation to
the left the left 12th cranial
Trophy Eutrophy Eutrophy nerve palsy
Tremor - - central type
Disartria - -
Motoric System (In Krisan Room 🡪 1/02/23)
Right Left Interpretation
Upper Extremity
Strength
5 3
Distal
5 3
Medial
5 3
Proximal
Normal -
Tone
Eutrophy -
Trophy
- -
Involuntary movements
- -
Clonus

Lower Extremity Left hemiparesis

Strength
Distal 5 3
Medial 5 3
Proximal 5 3
Tone Normal -
Trophy Eutrophy -
Involuntary movements - -
Clonus - -
Body
Trophy Eutrophy - Normal
Involuntary movements - -
 Sensory System (In Krisan Room)
Right Left Interpretation
Touch Normal -
Pain Normal -
Left hemihypesthesia
Temperature Uncheck Uncheck
Propioseptive Normal Normal
 Reflex (In Krisan Room)
Right Left Interpretation
Physiologic
Biceps (+) (+)
Triceps (+) (+) Physiologic reflex (+)
Knee (+) (+)
Ankle (+) (+)

Pathologic
Babinsky (-) (-)
Chaddock (-) (-) Pathological reflex (-)
HoffmanTromer (-) (-)
Openheim (-) (-)
Schaefer (-) (-)
 Coordination (In Krisan Room)
Right Left Interpretation
Point to point Normal Normal
movement Uncheck Uncheck
Walk heel to toe Uncheck Uncheck Normal
Gait Uncheck Uncheck
Tandem Uncheck Uncheck
Romberg
 Others Examination

GAJAH MADA STROKE ALGORITHM

Consciousness loss () Severe headache (+) Babinsky reflex (-)

Hemorrhagic stroke
 Siriraj Stroke Score
Consciousness (C) Alert 0
Vomitting (V) Yes +1
Headache within 2 hours (H) Yes +1
Diastolic Blood Pressure 93 93
(DBP)
Atheroma (A) - 0

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

SSS = 2,5 (0) + 2 (1) + 2 (1) + 0,1 (148) - 3 (1) - 12

= 0+2+2+9.3-3-12 = 1,3
Interpretation : >1 = Hemorrhagic stroke
ICH Score (AHA JOURNALS)

ICH Score Points

Score= 1, n= 32 (30 days mortality: 20%)
 Examination Resume (In krisan Room)

Blood Pressure : 158/93 mmHg. MABP 🡪 112 mmHg

Heart Rate : 98 bpm
Respiratory rate : 20 tpm
Temperature : 36,5°C
Cognitive Function : Normal
Meningeal sign : Neck stiffness (-), Brudzinski I-IV (-)
Cranial Nerves : Left 7th cranial palsy (central type)
Left 12th cranial nerve palsy (central type)
Motoric : Left side weakness (UMN type)
Sensory : Left Hemihypesthesia
Coordination : Normal
Autonomy : Normal
Reflex : Physiology (+), pathology (-)
Gajah Mada Score : Hemorrhagic stroke
Siriraj score : Hemorrhagic stroke
 Working Diagnosis
• Left Hemiparesis UMN type
Clinical • Left Hemihypesthesia
Diagnosis • Left 7th cranial nerve palsy central type
• Left 12th cranial nerve palsy central type
Topical • Right cerebral hemispher
Diagnosis
Etiologic • Hemorrhagic stroke ec ICH
Diagnosis
Differential • Infarct stroke
Diagnosis
Secondary • Hypertensive emergency
Diagnosis
 Sugessted Examination
- Routine blood test🡪 Hb, Ht, leucocyte, platelets

- Blood chemistry 🡪 Blood glucose, HBA1C, total

cholesterol, HDL, LDL, Trygliceryde, Ureum,
Creatinine, AST & ALT
- Electrolyte
- Arterial blood gas

- Head CT Scan without contrast

- Chest rontgen and ECG

 Laboratorium Finding (January 22 nd,
2023)

Routine blood count Electrolite

Hemoglobin : 12,5 g/dL (L) Na+ : 143 mmol/L
Leukocyte : 9,10 x 103/uL K+ : 3,7 mmol/L
Thrombocyte : 239 x 103/uL Chlorida : 111 mmol/L
Erythrocyte : 4,37 x 106/uL

Clinical Chemistry
Total cholesterol: 228 mg/dL (H)
HDL cholesterol : 58 mg/dL
LDL cholesterol : 142 mg/dL (H)
Triglycerides : 157 mg/dl (H)
ECG
Interpretation :
Rhytm : sinus bradhichardy
Frequency : 52 x/minute, regular
Axis : Normoaxis
PR interval : 0,24 s
P duration : 0,12 s
QRS complex : normal
ST Segment : normal
T wave : normal
Q pathologic : (-)

Conclusion :
Sinus rhytm, 52 bpm
 CT-Scan
Interpretation :
- Well-defined hyperdense lesion in the right basal ganglia and thalamus
- There is calcification in basal ganglia sinistra
- Sulci, ventrikel and sisterna was normal
- There is shifting midline structure 0.5 cm to the left
- Cerebellum and medulla oblongata appear normal
- Theres no fracture

Conclusion : ICH right basal ganglia

 Final Diagnose
Hemorrhagic stroke e.c intracerebral hemorrhage at right basal
ganglia
 Suggested Management
General o Specific
- Bed rest with 300 head elevation - Mannitol IV 2g/kg over 30-60 minutes
- Observation and vital sign monitoring - Neuroprotector 🡪 Citicoline injection 2 x 250 mg
- Oxygen 2-3 lpm via nasal canul - Gastric protector 🡪 Omeprazole 40 mg/12 h IV
- IVFD RL 20 dpm
- Consult the patient to physical medicine and
rehabilitation (PM&R)
 Follow Up
Date Assessment and Plan
Subjective and Objective
Thursday,
February Subjective: Assessment :
2nd 2023 Facial droop (+), slurred speech (+), flowing saliva (-), headache (-), weakness of Hemorrhagic stroke e.c intracerebral hemorrhage at
left extremities (+), nausea and vomite (-), seizure (-) dizziness (+) fever (+), right basal ganglia with cystitis
(10.00 pm)
abdominal pain whwn miction (+). Plan :
Objective: - IVFD RL 20 tpm
Alert - Citicoline injection 2 x 250 mg
GCS : E4V5M6 - frego 2 x 1
- Paracetamol 3 x 500 mg
BP : 158/93 mmHg Reflex : - Consult to urology
HR : 112 times/minute Physiologic (+),
RR : 18 times/minute Phatologic (-)
T : 36,7°C

Cranial Nerves :
Left 7th cranial nerve palsy (Central type)
Left 12th cranial nerve palsy (central type
Motoric : Left hemiparesis UMN type
Sensory : Left hemihypesthesia
Autonom : Normal
 Follow Up
Date Assessment and Plan
Subjective and Objective
Thursday,
February Subjective: Assessment :
2nd 2023 Facial droop (+), slurred speech (+), flowing saliva (-), headache (-), weakness of Hemorrhagic stroke e.c intracerebral hemorrhage at
left extremities (+), nausea and vomite (-), seizure (-) dizziness (+) fever (+), right basal ganglia with cystitis
(10.00 pm)
abdominal pain whwn miction (+). Plan :
Objective: - IVFD RL 20 tpm
Alert - Citicoline injection 2 x 250 mg
GCS : E4V5M6 - frego 2 x 1
- Paracetamol 3 x 500 mg
BP : 158/93 mmHg Reflex :
HR : 112 times/minute Physiologic (+), Urology consul answered 🡪 Result:
RR : 18 times/minute Phatologic (-) Assessment
T : 36,7°C Hemorrhagic stroke e.c intracerebral
hemorrhage at right basal ganglia with
Cranial Nerves : cystitis
Left 7th cranial nerve palsy (Central type)
Left 12th cranial nerve palsy (central type
Motoric : Left hemiparesis UMN type Plan
Sensory : Left hemihypesthesia Levofloxacin 1x500 mg
Autonom : Normal
DISCUSSION
What is definition of stroke??

Clinically defined syndrome

Infarct

Acute and focal neurological deficit “Vascular injury”

Hemorrhagic

Lasting 24 hours or longer

apparent cause other than of vascular origin

PREVALENCE 🡪 Hemorrhagic stroke contributes to 10% to 20%.

✔ USA, United Kingdom and Australia 🡪 18-15%

✔ Japan and Korea 🡪 18% - 24 %

✔ The incidence is more common in men and

increases with age

The mortality rate 🡪 15.9% (age 45-

🡪 55 years), 26.8% (age 55-64 years)
and 23.5% (age 65 years)

The global incidence are increasing, predominantly in A men more than women 🡪 age profile under 45
African and Asian countries years of 11.8%, 54.2% aged 45-64 years, and
age over 65 years amounted to 33.5%.
 ISCHEMIC STROKE

Most common:
Cause of blood vessels What is the risk factor of ischemic
obstruction are thrombosis stroke?
(usually developed on CARDIOVASCULAR FACTORS
atherosclerotic plaques) and
embolization DRUG USED

MIGRAIN WITH AURA

MALIGNANCY

INFECTIOUS DISEASE

HEMATOLOGICAL AND GENETIC

 HEMORRHAGIC STROKE

Most common:
rupture of a blood vessel
in the cerebrum

The etiology of ICH was

defined in accordance with
🡪 Related to thrombocytopenia,
the following criteria:
leukemia, hemophilia, von
Hypertension; ICH located
Willebrand disease,
in the putamen, thalamus,
afibrinogenemia, and exclusion of
internal capsule, brain stem,
other potential causes tumor.
cerebellum, or white matter
(including lobar
Cerebral Cortex ✔ Weakness part of the body on the opposite side
✔ Hemiparesis shows at face and hand (Brachiofacial weakness)
✔ lesion in the site a predominantly distal paresis of the upper limb
✔ The most serious functional consequence of which is an impairment of fine
motor control

Basal ganglia ✔ Change in body movement

✔ Cognitive impairment
✔ Unconsciousness, vomiting, headache
✔ Personality change.

Internal Capsule ✔ Contralateral spastic hemiplegia

✔ Lesions contralateral paresis is flaccid at first (in the “shock phase”), and
becomes spastic within hours or days because of concomitant damage to
nonpyramidal fibers

Cerebral peduncle ✔ Produce contralateral spastic hemiparesis, possibly accompanied by an CLINICAL

ipsilateral oculomotor nerve palsy
MANIFESTATION
Pons ✔ The lesions involving the pyramidal tract (e. g., a tumor, cerebrum stem
ischemia, a hemorrhage) cause contralateral or possibly bilateral
hemiparesis

Medula Oblongata ✔ Flaccid contralateral hemiparesis is a possible result. The weakness is less
than total (i.e., paresis rather than plegia) because the remaining descending
pathways are preserved

Spinal Cord ✔ A lesion affecting the pyramidal tract at a cervical level causes ipsilateral
spastic hemiplegia ipsilateral
✔ The tract has already crossed at a higher level, and spastic because it contains
non pyramidal as well as pyramida fibers at this level
✔ A lesion affecting the pyramidal tract in the thoracic spinal cord causes spastic
ipsilateral monoplegia of the lower extremity
DIFFERENCE OF CLINICAL MANIFESTATION BETWEEN
INFARCTION AND HEMORRHAGIC STROKE
Siriraj
Score
ICH SCORE 🡪
Part of risk stratification for ICH an accurate predictor of outcome assessed as 30-day mortality
 SUPPORTIVE DIAGNOSTIC

🡪 Determine the location in the

carotid or vertebrobasilar system,
HEAD CT SCAN and determine there’s narrowing,
MRI occlusion or aneurysm in the blood
vessels

CT scan 🡪 shows in general is a

hypodense sign, while in a bleeding ANGIOGRAPHY
stroke it shows a hyperdense lesion EXAMINATION

MRI 🡪 It is also generally more

sensitive than CT scan, especially for
detecting posterior bleeding
 Ultrasound Examination Lumbar Puncture Examination

Intracerebral hemorrhage stroke 🡪

Asses intra and extra cranial Wash of meat or has a yellowish color.
blood vessels, determine Subarachnoid hemorrhage 🡪
Gross hemorrhagic CSF was found.
carotid artery stenosis
Stroke infarctionthere is no bleeding (clear)

And others : To determine risk factors such as blood routine, blood chemistry components (urea, creatinine, uric acid, lipid
profile, blood sugar, liver function), blood electrolytes, chest X-ray, ECG, echocardiography
Management of Intracerebral Hemorrhage

vs
 Intervention of hypertension for Hemorrhagic Stroke

Nicardipine 5 mg/hour 🡪 Increase 2,5 mg/hour

every 5-15 minutes

Labetolol 10-20 mg IV
in 1-2 minutes
EMERGENCY
Hydralazine 10-20 mg
MANAGEMENT!!
IV every 4-6 hours
✔ Systolic >200, or MAP >150
Enalaprilat 0,625-1,2 mmHg 🡪 quickly lower BP
mg iV every 6 hours with IV medication
✔ Systolic >180 mmHg or MAP
Sodium nitroprusside >130 mmHg 🡪 can
0,25-10 mcg/kg/min increased intracranial
pressure, keeping CPP >80
mmHg
✔ Systolic >180 mmHg / MAP
Diltiazem >130 mmHg 🡪 no evidence
to increased intracranial
pressure lower BP mildly
 COMPLICATIONS
Some complications can occure and need to be monitored

NEUROLOGICAL NON NEUROLOGICAL

COMPLICATIONS COMPLICATIONS
 PROGNOSIS
STROKE STATISTICAL STROKE DATA
STROKE ASSOCIATION

Cause a variety of
morbidity, mortality,
and recurrence in the
future
Recurrence of stroke
increases with time

UK shows that 42% disability caused by

Possibility of recurrent stroke is permanent. In 2010, stroke
stroke within five years accounted for 7% of all causes of mortality
was 26.4% and in ten in men and 10% of all causes of death
years was 39.2% among women
cystitis
Definition
• Cystitis is an inflammation that happen in vesica urinaria. Cystitis can
be caused by bacterial infection and also non infection factor such ass
drugs, irittable, or radiologic
 Risk Factor
Primary risk Secondary risk
∙ Female gender ∙ Male
∙ Significant comorbid Older
∙
∙ Older than 50 years
∙ There is urological disease
∙ Lack of systemic antibiotic
∙ UTI caused by Serratia marcescens
∙ Serum creatinine level more than 2 mg/dl
∙ Indwelling catheter
BASIC CLINICAL
DIAGNOSE
BASIC CLINICAL DIAGNOSE
• Left Hemiparesis UMN
Type
• Left hemihypesthesia
• Left 7th cranial nerve palsy
central type
• Left 12th cranial nerve palsy
central type
HISTORY STROKE ASSESSMENT TOOLS
• Weakness of the left extremity • GMSA : Hemorrhagic Stroke
• Dropped face • SSS : >1 (Cerebral hemorraghe)
• Slured speech
PHYSICAL EXAMINATION
RISK FACTOR • Left hemiparesis
• Left hemihypesthesia
• Age • Deviation of the corner of the mouth to
• Smoker the right, left nasolabial fold disappear
• Hyperlipidemia • Deviation of tounge to the left
• hypertention
BASIC OF CLINICAL DIAGNOSIS
BASIC CLINICAL DIAGNOSE

If the hemiparesis occure because of lession on UMN theres

could be pastic paralysis, hyperflexion, babinsky reflec
positif, hypertonia
 corticospinal tractus was from cortex and spinal
cord, from cortex 🡪go down to subcorticospinal, 🡪
interna capsule 🡪 go down to
mensenchepalon/pons 🡪 to medulla oblongata, and
the side one cross over to decussatio piramidalis

Note: However, not all for 7th nerve are contralateral

✔ Only the contralateral 7th cranial nerve

innervates the lower face.
✔ The upper face is bilateral. It still gets motor
impulses from the right cerebrum and left
cerebrum. And still gets innervation from the
piramydalis tract side

✔ The intrenal and external muscle of the tounge was

innervate by 12th cranial nerve. Most of the
tounge muscle inervated by ipsilateral and
contralateral of 12th cranial nerve except for the
genioglossus muscle.
✔ Any lession on the UMN of the 12th cranial nerve
will manifest by the weakness of the contralateral
tounge muscle and slured speech.8
Second order neuron of the spinothalamic
pathway crossing the spinal cord after sinaped
with first order neuron on substansia gelatinosa
of the same level of spinal cord.

The second order neuron continue to ascend

along the way of spinothalamic tract to the
thalamus.

From the thalamus the third order neuron radiate

the neuron to the coresponded primary sensoric
cortex.

Any lession at the C1 or above of the spinal cord

could result of hemihypestesia.
BASIC TOPIC
DIAGNOSE
 Pemeriksaan
Fisik
• Dropped face and slurred speech
• Left hemiparesis UMN Type
• Weakness of the extremity
• Left 7th cranial nerve central type
• Left 12th cranial nerve central
type
Anamnesis
Right Cerebral hemispher
Case 🡪
patient was consider to be above the
mesencephalon, its likely the lession
was at contralateral hemishperium.
Stroke occurs in the right side of the
cerebral, the nerve cells in the right
side of the cerebral die and cannot
produce signals to control the
movement of the muscles on the left
side.
The muscles on the right side of the
body will paralysis due to the
deflection of the nerve.
BASIC ETIOLOGICAL
DIAGNOSE
 Risk factor for intracerebral hemorrhage in
BASIC ETIOLOGICAL DIAGNOSE young people

2020
82 yo, male

a history of :
✔ Active smoker
✔ Severe headhache

STROKE ASSESSMENT TOOLS

• ASGM : Stroke Hemoragik
• SSS : >1 (Cerebral hemorrhage)
BASIC DIFFERENT
DIAGNOSE
From the table, the patient has several hemorrhagic symptoms. However, further investigation is needed regarding

examination of the heart and head CT scan without contrast to be able t determine the type of stroke

Syptoms and signs Infarct Stroke Hemorrhagic Stroke Case

Symptoms TIA (+) 50% TIA (-) (-)
Activity or rest Rest Often during physical activity Activity
Headache and vomite Infrequently Very frequent Very frequent
Loss consciousness Infrequently Often (+)
Hypertension Mild/normotension Heavy until mild Hypertensive
emergency

Hemiparesis Often from beginning Often from beginning (+)

Speech disorder Often (+) (+)
Meningeal stimulation (-) May (+) (-)

TIC symptoms /papilledema Rarely Papiledema and subhialoid Funduscopy (-)

hemorrhage performed
BASIC WORK UP
2021

1. Routine blood tests 🡪 detect risk factors🡪increased hematocrit

2. PT and APTT 🡪 detect platelet activity which plays a role in hemostasis
after the use of oral anticoagulants
3. Blood sugar 🡪 Detect risk factors for stroke, namely DM
4. Liver function and kidney function 🡪 performed to rule out the
differential diagnosis of hepatic encephalopathy and other toxic-
metabolic conditions
5. Lipid profiles 🡪 detect risk factors, namely dyslipidemia and also to
plan treatment if abnormalities in lipid profiles are found
6. Serum electrolyte 🡪 Rule out the differential diagnosis of stroke,
namely hyponatremia
7. Artherial blood gases are performed to detect the risk of hypoxia.
8. ECG 🡪 To evaluation due to chronic disease such as chronic
hypertension
9. CT Scan 🡪 to determine the etiology of a hemorrhagic stroke such as
hyperdense lesion.
BASIC FINAL DIAGNOSE
 FINAL DIAGNOSE: hemorrhagic stroke e.c intracerebral hemorrhage right basal
ganglia

Anamnesis

Physical examination

Work up examination

CT scan
Examination found
🡪 ganglia basalis
dextra was bleeding,
at putamen caused
by hypertension
Emergency Hypertension

Hypertension can damage small Hemorrhagic stroke in this patient

blood vessels by produce
caused by bleeding in the
degeneration of media, breakage of
the elastic lamina and fragmentation periventricular space
of smooth muscle of the arteries.
 GENERAL TREATMENT SPESIFIC TREATMENT

✔ Observation of vital signs and neurological status
✔ Bed rest with head elevated 30’
✔ Mannitol dosage range 0,25 - 2 g/kg
intravenously over 30-60 minutes
✔ Citicoline as a neuroprotective agent
✔ Omeprazole which is a class of proton pump
inhibitors
✔ Antihypertensive drugs
✔ Tranexamic Acid as antifibrinolytic agent

✔ Medical mobilization and rehabilitation 🡪 prevent

disability or complications
✔ Low natrium diet for non-pharmacological management
of hypertension
✔ O2 2-3 liters per minute via nasal cannula 🡪 given to
increase oxygen intake to body tissues, especially the
cerebral so as to prevent further cerebrum hypoxia.
✔ Infusion of RL 20 drops/minute to maintain a state of
euvolemia. In general, the search requirement is 30
ml/kg/day (parenteral or enteral).
 THANKYOU
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