Assessing and Discussing Prognosis and Natural History Of
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Transcript of Assessing and Discussing Prognosis and Natural History Of
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Assessing and Discussing Prognosis
and Natural History ofCerebrovascular Disorders
Pembimbing:
Dr. Agus Permadi, Sp.S
Disusun Oleh:
Rahmah, S.ked
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CAROTID OR VERTEBRAL ARTERYOCCLUSIVE DISEASE
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Asymptomatic Carotid Artery Disease
Carotid bruit occurs in 4 % to 5% of the population
aged 45 to 80 years. It is merely a reflection of
turbulance in the artery and relatively poor predictor
of underlying internal carotid stenosis inasymptomatic patients.
Patients with asymptomatic carotid bruits are at
greater risk than the general population for all forms
of atherosclerotic vascular disease.
The risk of myocardial infarction is also increased and
it is the leading cause of death.
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Symptomatic Carotid Artery Disease
Symptomatic carotid artery disease includes
symptoms related to transient or persistent
monocular visual loss, hemisperic transient
ischemic attack (TIA), and ischemic stroke
Patients who present with TIA or minor stroke related to
severe carotid stenotic lesions are at risk of stroke at the rate
of 13%/year for 2 years after onset of symptoms.
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Vertebrobasilar System Occlusive
DiseaseAlthough atherosclerotic occlusive
disease of the vertebral arteries is less
common than it is in the carotid system,
the development of disease in both is
associated with the same or similar riskfactors.
In the small studies available, the risk of brain stem stroke is
less than 1% to 2%/year, but it is higher if associated with
basilar stenosis. The risk of any stroke or myocardial
infarction is much higher than that in the general
population because of co-ocurring anterior circulation
atheromatous occlusive disease and coronary artery
disease.
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TRANSIENT ISCHEMIC ATTACK
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About one-third of patients with transient ischemic attack (TIA) have a
stroke within 5 years of the first attack. More than 20% of these stroke
occur within 1 month of the initial attack, and about 50% occur within 1
year, irrespective of the territory involved (carotid or vertebrobasilar
system).
The cause of death after carotid or vertebrobasilar TIA are similar(Approximately 45% cardiac and 30% hemorrhagic or ischemic stroke).
Survival is nearly 90% at 1 year after the first TIA and approximately 70%
at 5 years, 50% at 8 years, and 40% at 10 years.
The probability of stroke after TIA strongly correlates with the patients
age at onset, women who are older than 70 years have a worse survival
rate than do men who are older than age 70, but women younger than
70 years have a better survival rate than that of their male counter
parts.
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REVERSIBLE ISCHEMIC NEUROLOGICDEFICIT
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A neurologic deficit caused by focal cerebral ischemia that persists for morethan 24 hours but clears in less than 3 weeks is a cerebral infarction
subtype called a reversible ischemic neurologic deficit (RIND).
Survival rates in patients with RIND are similar to those of patients with
transient ischemic attack (TIA) and better than those of patients with major
cerebral infarction (ischemic stroke). The most common cause of death iscoronary artery disease, followed by cerebral infarction, cancer, and
respiratory disease.
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CEREBRAL INFARCTION
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After a person had cerebral infarction, the 30 days case fatality rate is
about 20%. Survival after the first cerebral infarction is about 65% at
1 year, approximately 50% at 5 years, 30% at 8 years, and about 25%
at 10 years.
The most common causes of death after cerebral infarction are
transtentorial herniation, pneumonia, cardiac disorders, pulmonary
embolus, and septicemia. Patients presenting with altered sensorium
and hemiplagia frequently die of herniation. Death from herniation
occurs more commonly on day 1 or 2 after the onset of infarct than
on any other days and considerably less frequently after day 7.
In general, about 60% to 70% of patients have early fuctional
disability after a stroke. Severe neurologic deficits with no returnof motor function within 1 month, marked cognitive perceptual
dysfunction, apraxia, or impairment in construction ability, and
urinary incontinence 2 weeks after a stroke are indicators of a poor
functional prognosis and identify patients who are likely to need
long term care.
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INTRACEREBRAL HEMORRHAGE
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For persons with intracerebral hemorrhage, survival rate ranges from
40% to 70%, immediate functional prognosis with intracerebralhemorrhage is usually better than that with cerebral infarction because
of differences in the amount of brain tissue dammage. The overall
mortality rate is about 15% to 30%, approximately 50% of survivors have
full functional recovery
For persons with Putaminal hemorrhage, the mortality
rate is about 40%, although the range of clinical
presentations is marked and typically depends on the
volume of hemorrhage. Radiologic imagingcharacteristics predictive of a poor prognosis include
large hemorrhage size and intraventricular extension.
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For patients with thalamic hemorrhage, the
functional status is usually poor, directly
depending on the size of the lesion hemorrhage
more than 3 cm in diameter are almost always
fatal.
In brain stem hemorrhage, death
usually occurs within a few hours, but,
occasionally, patients with a small
hemorrhagic lesion may survive.
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SUBARACHNOID HEMORRHAGE
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If the patient is seen at 24 hours after subarachnoid hemorrhage, the
mortality rate at 30 days is decreased to approximately 35%, at 48
hours to about 30%, at 1 week to about 25%, and at 2 weeks to 10%.
Approximately 10% patients die before they receive medical attention.
One of the major causes of mortality after the initial subarachnoid
hemorrhage is rebleeding. The rebleeding rate is approximately 2%/ day
during the first 10 days.
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