CASE REPORT Presentan : dr . Yudi Prasetyono Moderator : dr . H. Ahmad Asmedi, M.Kes, SpS Examiner : dr. H.

Pernodjo Dahlan, SpS (K dr. H. A!dul "o#ir, SpS $ommentator : dr. %etty Kurnia&ati May, ''th ())* Identity : +ame A,e Sex -..upation Edu.ation /eli,ion Address Date o# admisson Medi.al /e.ord : Mr. 0SP : *1 years : Male : /etired inspe.tor o# elementary s.hool : $olle,e : 2slam : "unun,sari, 0ejiharjo, Karan,mojo, "unun, Kidul : '3 April ())* : '.(4.*5.43

Anamnesis : -!tained #rom the patient and his &i#e on April, () th, ())* Chief complaint : 6ea7ness o# ri,ht arm and ri,ht le, The present history of illness : A!out '5 hours !e#ore admission to hospital, &hen he &a7ed up in the mornin, ()*.)) a.m. , suddenly he .omplained &ea7ness on the ri,ht arm and le,. He &as una!le to ta7e up a ,lass &ith ri,ht hand !ut a!le to ,et up #rom seat, to &al7 assisted !y his &i#e. He also .omplained spee.h lisp. Pre8iously, he did not .omplain #or heada.he. %here &ere no un.ons.iousness, nausea or 8omitin,, 8erti,o, a.ute !lindness or loss o# partial 8isual #ield, num!ness or &ithout #eelin, a hal# o# the !ody, &et the !ed, sei9ure, #e8er. %he patient ne8er had head injury !e#ore. A!out * hours !e#ore admission to hospital, his .omplaint &as &orsenin,. He &as una!le to ,et up #rom seat, so he .ould only raise ri,ht arm and le,. His #amily !rou,ht his to paramedi., and than he re##ered to Dr. Sardjito Hospital. Durin, * days stay in the hospital, the patient &as still .ons.ious and there &as no #e8er. He did not .omplain heada.he, 8omitin,, and dyspnoe. %he &ea7ness o# ri,ht extremities &ere not ,ettin, &orse, the patient .ould to s&allo& the #ood and a drin7 &ithout .ho7e. %he patient &as also o#ten :uiet, !ut he .ould to .ommuni.ate his .omplaint, and he &as a!le to re.o,ni9e his #amily. %he pro!lem o# hi,h !lood pressure

'

&as .ontrolled. %he patient ha8e !een also .onsulted to internal and .ardia. departments #or mana,ement o# hyper,ly.emia and .ardia. pro!lem. The history of previous illness : - Patient su##ered #rom hypertention a!out 5 years, he did not ha8e his !lood pressure .ontrolled re,ularly, and did not ta7e many medi.ines. - Patient su##ered #rom dia!etes mellitus and already to ta7e ,li!en.lamide (';(<)< ) sin.e ' year - Patient had history smo7in,, !ut he stopped sin.e () years a,o - Patient did not 7no& i# he had a history o# .ardia. pro!lem - Patient did not ha8e a history o# heart atta.7 - Patient did not ha8e a history o# stro7e and transtient is.hemi. atta.7s !e#ore - Patient did not 7no& i# he had a history o# hyper.holesterolemia The history of family illness : +o history o# stro7e, hypertension and dia!etes mellitus Systemic evaluation : $ere!rospinal system $ardio8as7uler system /espiratory system "astrointestinal system =ro,enital system Mu.ulos.eletal system 2nte,umental system Summary of anamnesis : A man, *1 years old &ith .hie# .omplaint o# &ea7ness on the ri,ht arm and le,, &ith the sudden onset. %he .omplaint o..ured &hen he &a7ed up in the mornin,, and he &as also .omplained spee.h lisp. %he symptom &as not a..ompany !y heada.he and un.ons.iousness. +o pre.edin, o# #e8er the !ody and head injury. %he &ea7ness ri,ht extremities !e.ame &orse re,ularly. Patient had a history o# un.ontrolled hypertension, dia!etes mellitus and smo7in,. FIRST DISC SSIO! 0ased on the anamnesis, &e ,ot symptom o# &ea7ness in the ri,ht extremities and spee.h lisp. %he symptom onset &as sudden and it o..ured &hen he &a7ed up in the mornin,. %here &ere no symptom o# #e8er and pro,ressi8e heada.he to su,,est .entral ner8ous system in#e.tion, as &ell as no pre8iously !rain injury. %he &ea7ness ri,ht extremities !e.ame &orse re,ularly. %he patient had a history o# un.ontrolled hypertension, dia!etes mellitus and smo7in,. %he .lassi. 8as.ular pro#ile in8ol8es sudden onset &ith rapid pro,ression to maximal de#i.it (instantaneously or in se.onds (6ie!ers et al., '>>? . %hese symptom o# the : &ea7ness on the ri,ht extremities, spee.h lisp : no .omplaint : no .omplaint : no .omplaint : no .omplaint : no .omplaint : no .omplaint

patient lead to 8as.ular lession, !e.ause the onset &as sudden. %hese su,,est to the dia,nosis o# stro7e. STRO"E Stro7e &as de#ined as rapidly de8elopin, .lini.al symptoms and ; or si,n o# #o.al and sometimes loss o# .ere!ral #un.tion &ith the symptom lastin, more than (3 hours or leadin, to death &ith no apparent .ause other that o# 8as.ular (6H- cit Dahlan and @amsudin, '>>1 Stro7e dia,nosis &as !ased on .lini.al examination, &hile type o# patholo,y &as !ased on result head $% s.an or Ma,neti. /esonan.e 2ma,in, (M/2 &hi.h is still limited in se8eral hospitals in 2ndonesia. Some s.orin,s su.h as "adjah Mada Stro7e Al,orithm .an !e used to repla.e $% s.an in patholo,i.al dia,nosis o# stro7e &hose parameters loss o# .ons.iousness, heada.he, and !a!ins7y si,n. (Dahlan and @amsudin, '>>1
Patient a.ute stro7e 6ith or &ithout =n.ons.iousness, heada.he, and 0a!ins7y re#lex %here are three or t&o o# these symptoms and si,ns (+ +o =n.ons.iousness (+ heada.he ( and 0a!ins7y re#lex ( +o =n.ons.iousness ( heada.he (+ and 0a!ins7y re#lex ( +o =n.ons.iousness ( heada.he ( and 0a!ins7y re#lex (+ +o =n.ons.iousness ( heada.he ( and 0a!ins7y re#lex ( Yes A.ute is.hemi. stro7e or in#ar.tion stro7e Yes A.ute is.hemi. stro7e or in#ar.tion stro7e Yes 2ntra.ere!ral hemorrha,i. stro7e Yes 2ntra.ere!ral hemorrha,i. stro7e

Yes

2ntra.ere!ral hemorrha,i. stro7e

Ischemic stro#e or infarction stro#e Symptoms o# is.hemia are .onsistent &ith neurolo,i. dys#un.tion #rom a sin,le arterial territory or i# impro8ement o..urs rapidly or early in the .lini.al .ourse. 2s.hemi. .ere!ro8as.ular disorders are .lassi#ied a..ordin, to temporal pro#ile, in.ludin, transient

is.hemi. atta.7 (resolution o# symptoms &ithin the #irst (3 hours , re8ersi!le is.hemi. neurolo,i. de#i.it (resolution o# symptoms a#ter (3 hours, &ithin 4 &ee7s , pro,ressi8e is.hemi. stro7e (pro,ressi8e de#i.it, o#ten #or as lon, as (3<?( hours , and .ompleted is.hemi. stro7e (resolution o# symptoms a#ter 4 &ee7s, i# e8er (6ie!ers et al., '>>? . Approximately 15 A o# all stro7e .ases are .aused !y is.haemi. or in#ar.tion that .aused !y de.rease o# !lood suply to the !rain. +ormally the !lood suply to the !rain is 51..;')),r !rain tissue per minute. 6hen the !lood suply redu.e to '1 ..;')) ,r !rain tissue per minute, the !io.hemistry .ell and mem!rane .ausin, the .han,e o# stru.ture and #un.tion o# uni8ersally in#ar7 teritory &ould .han,e (@indsay, '>>? . 2n#ar.tion stro7e in.lude su!type: throm!oti. stro7e, .ardioem!oli. stro7e and la.unar stro7e. %hrom!oti. stro7e: An atherothrom!oti. stro7e may !e sudden, stutterin,, or step&ise in onset (,radual . %he .lassi. history is a patient &ho a&a7en #rom sleep &ith the de#i.it. %his stro7e su!type result #rom throm!osis asso.iated &ith atheros.leroti. lession o# the lar,e and medium<si9ed arteries in the ne.7 or !rain. %he me.hanism o# .ere!ral in#ar.tion in this settin, is o#ten artery<toBartery em!olism o# platelet<#i!rin throm!i or atheros.leroti. material rather than purely hemodynami. (6ini7ates, ())' . $ardioem!oli stro7e: %he typi.al .ardioem!oli. stro7e has an a!rupt temporal pro#ile, &ith de#i.it that are maximal at onset. De#i.its may impro8ed shortly a#ter&ard i# the em!olus !rea7s up and tra8el to more distal !ran.hes o# the a##e.ted artery. %he .lassi. history is an onset o# symptoms durin, a.ti8ity or in asso.iation &ith palpitation or a 8alsa8a maneu8er. %he heart and aotri. ar.h are sour.es o# su.h em!oli ( 6ini7ates, ())' . @a.unar stro7e : %he symptom may o..ur durin, sleep, and pro,ression in a step&ise #ashion durin, ' to 3 days is not un.ommon (6ie!ers et al., '>>? . %here are #i8e .lassi. la.unar symptoms (6on,, ())5 : '. Pure motor stro7e;hemiparesis 2t .onsists o# hemiparesis or hemiple,ia tha typi.ally a##e.ts the #a.e, arm, and le,. Dysarthria, dyspha,ia, and transient sensory symptoms may !e present. %he la.une is usually in the posterior lim! o# the internal .apsule or the !asisi pontis. (. Pure sensory stro7e 2t .onsists o# persistent or transient num!ness and;or tin,lin, on one side o# the !ody (e,, #a.e, arm, le,, trun7 . -..asionally, the .omplaint is o# pain, !urnin,, or other unpleasant sensation. %he in#ar.t is usually in the thalamus. 4. Dysarthria ; $lumsy hand %he main symptoms are dysarthria and .lumsiness (ie, &ea7ness o# the hand. 3. Ataxi. hemiparesis 2t .onsists o# &ea7ness and .lumsiness on one side o# the !ody. 2t usually a##e.ts the le, more than the arm. 2t is also 7no& as homolateral ataxia and .rural paresis. %he most #re:uent sites o# in#ar.tion are the posterior lim! o# the internal .apsule, !asis pontis and .orona radiata. 5. Mixed sensorimotor stro7e 2t .onsists o# hemiparesis or hemiple,ia and ipsilateral sensory impairment. %he in#ar.t usually in the thalamus and adja.ent posterior internal .apsule.

$emorrha%ic stro#e Hemorrha,i. stro7e ha8e a .lini.al pro#ile that may not !e .learly distin,uisha!le #rom is.hemi. sto7e, the onset has sudden. A prominenet de.rease o# le8el .ons.iousness .an !e a .lue. Heada.he, nausea, 8omitin,, se8ere hypertention, or other si,n o# raised intra.ranial pressure also su,,est a hemorrha,i. stro7e (6ini7ates, ())' A!out ') A o# the stro7e .aused !y intra.ere!ral !leedin, and a!out 5 A are su!ara.hnoid !leedin,, &hi.h is .aused !y the smash o# aneurysma, mal8ormation arterio8enous, an,ioma .a8ernous, al.oholism, !lood dis.rasia, anti7oa,ulan therapy and an,iopati amyloid ( @indsay, '>>? . &or#in% dia%nosis : $lini.al dia,nosis %opi.al dia,nosis Etiolo,i.al dia,nosis : &ea7ness o# ri,ht extremities &ith sudden onset and &orsen ,radually, spee.h lisp : DD: le#t anterior &atershed area le#t internal .apsule : DD: la.unar stro7e throm!oti. stro7e

Physical e'amination : %he patient &as examined in April ()th , ())* (eneral status "eneral $ondition $ons.iousness 0lood pressure Pulse /espiratory rate %emperature Head +e.7 $hest Heart @un, A!domen Extemity Psychiatric state : %he psy.hiatri. s.reenin, used =$@A +europsy.hiatri. 2n8entory /esult : su,,est to distur!an.e in !eha8ior domain depression and apathy !eurolo%ical e'amination :
5

: #air, &ithin normal nutrition : .ompos mentis ("$S :E3,C5 M* : ri,ht: '*);>) mm H,, le#t: '*);>) mm H, : ri,ht: 13 x;minute, le#t: 13 x;minute : () x;minute : not #e!rile : .onjun.ti8a not anemis : !ruit .arotis ( : !reath mo8ement ri,ht and le#t is !alan.e : irre,ular rythme (+ , murmur ( : sonor, 8esi.ular, ron.hi ( : le8er and splen unpalpa!le, mus.le ri,idity ( : une:ual pulses (

$on.iousness Head D eye +e.7

$ranial ner8es n.2 n.22 n.222 Des.ription

: .ompos mentis, "$S : E3,C5 M* : meso.ephal pupil iso.or, diameter 4mm;4mm li,ht re#lex E;E, .orneal re#lex E;E : ne.7 sti##ness (<
/i,ht 6nl G';'( 6nl 6nl (< 6nl 6nl 6nl 4 mm /ound (E (E (< (< (E (< 6nl 6nl 6nl 6nl (< (E (< (< (E Dissapeared De.reased 6nl 6nl 6nl S7e&ed mouth to le#t 6ea7 6nl +ormal Simetris 6nl (E 6nl (E
*

@e#t 6nl G';'( 6nl 6nl (< 6nl 6nl 6nl 4 mm /ound (E (E (< (< (E (< 6nl 6nl 6nl 6nl (< (E (< (E 6nl 6nl 6nl 6nl 6nl 6nl 6nl +ormal

n.2C n.C

n.C2 n.C22

n.C222 n.2I

Smellin, Cisual Fun.tion Cisual Field $olour Cision Ptosis EyeHs motion to medial EyeHs motion to !elo& EyeHs motion to a!o8e Pupil Kind o# pupil Dire.t o# li,ht re#lex 2ndire.t o# li,ht re#lex A..omodation re#lex Stra!ismus di8er,en EyeHs motion to medial !elo& Stra!ismus 7on8er,en 0itin, -pen mouth Sensi!ility o# #a.e $orneal re#lex %rismus EyeHs motion to lateral Stra!ismus 7on8er,en Diplopia 0lin7in, +asola!ial Fold %he an,le o# the mouth 6rin7lin, o# the #orehead 6rin7lin, o# the eye!ro& $lose eye "rima.e 0lo&in, %aste on the (;4 anterior o# the ton,ue Hearin, o# the &hispered 8oi.e, ti.7in, &at.h Ar.upharyn, %aste on the ';4 posterior o# the ton,ue Comitin, /e#lex

n.I

nI2

n.I22

Pronoun.in, the lin,ual /et.hin, Pulse per minute Ar.upharyn, Spee.h S&allo&in, %urnin, head Shoulder position @i#t shoulder %ro#i o# mus.le shoulder %on,ue position Arti.ulation %remor o# toun,e %oun,e protra.tion %ro#i o# toun,eHs mus.le Fasi.ulation o# toun,e

(< (< 13 x Simetris (E (E 6nl Simetris 6nl Eutrophi S7e&ed to le#t Dysarthria (< S7e&ed to ri,ht Eutrophi (< /i,ht 6nl Eutrophi (< Eutrophi (< @e#t 6nl 6nl 6nl 6nl 6nl 6nl Free 5<5<5 +ormal Eutrophi (E (< 6nl 6nl 6nl 6nl 6nl Free 5<5<5 +ormal Eutrophi (E (< 6nl 6nl 13 x

0ody $hest Sensi!ility: Protopati. Propiosepti. : Pression Ci!ration Position Dis.rimination A!dominal /e#lex =pper Extremity Mo8ement Stren,th %onus %rophy Physiolo,i.al re#lex Patolo,i.al re#lex Sensi!ility : Protopati. Propiosepti.: Pression Ci!ration Position Dis.rimination @o&er Extremity Mo8ement Stren,th %onus %rophy Physiolo,i.al re#lex Patolo,i.al re#lex Sensi!ility : Protopati. Propiosepti.:

0reath mo8ement is !alan.e

6nl 6nl 6nl 6nl 6nl 6nl @imited 4<4<4 +ormal Eutrophi (E (< 6nl 6nl 6nl 6nl 6nl @imited 4<4<4 +ormal Eutrophi (E (E 6nl

Pression Ci!ration Position Dis.rimination

6nl 6nl 6nl 6nl

6nl 6nl 6nl 6nl

Ce,etati8e #un.tion : &ithin normal limit A!normality mo8ement : ( (ad)ah *ada Stro#e Scale : (3 +arthel inde' : '5 Activities of Daily ,ivin% : '* Co%nitive function : Mini Mental Examination State -rientation : 1 (orientation o# person and pla.e &ere not impaired, !ut orientation o# time &as impaired /e,ristration :4 Attention and .al.ulation : 3 /e.all : ( (ne& learnin, a!ility &as impaired @an,ua,e : 3, the patient did not do the option o# senten.e .ommand, !e.ause &ea7ness in the ri,ht hand $onstru.tion : the imitatin, o# pi.ture &as not examined, !e.ause o# &ea7ness in the ri,ht hand Attention : it &as impaired, the patient did not do .ompletely to mention the !a.7&ard di,it se:uen.e and the !a.7&ard month se:uen.e @an,ua,e : the patient .ould spea7 spontaneously, !ut it &as not #luentlyJ the mentionin,, repetition, interpretation o# 8er!al lan,ua,e and readin, &ere not impaired, !ut the &ritin, o# senten.e &as not examined, !e.ause o# &ea7ness in the ri,ht hand, apraxia &as not impaired Cisuospatial : it &as not impaired Cisuo.onstru.tion : it &as not examined, !e.ause o# &ea7ness in the ri,ht hand Memory : di,it span &as three (re.ent memory &as impaired , re.allin, o# 5 &ord &as t&o (ne& learnin, a!ility &as impaired , narratin, o# .urrent pu!li. e8ent &as ne,ati8e Exe.uti8e #un.tion : it &as impaired, mentionin, o# animal name &ithin ' minute &as six, t.ontinuin, the alternatin, pi.ture and the letter<di,it se:uen.e &as not examined, !e.ause o# &ea7ness in the ri,ht hand

DHesposito

$on.lusion : .o,niti8e impairment espe.ially in domain o# attention, memory,

and exe.uti8e #un.tion $achins#i score : '' Supportin% e'amination: @a!oratory #indin, (April, '3 th, ())* H! : '4,3 ,;d@ Di##tel : 4 A@ : 1.')) ; mm +eutro#il: *?.3 HA AE : 5,13 x ')* ; mm4 @im#osit : (?.' @A H.t : 34,' @A Monosit : 3.* @A A% : ('3.))) ; mm4 Eosino#il: ).> A 0aso#il : ),) A +a : '41 mmol ; @ K : 4.3 mmol ; @ $l : ')) mmol ; @ @a!oratory #indin, Fast ,lu.ose : ()> m,;d@ "lu.osa ( hour post prandial : '?1 m,;d@ Radiolo%y: /ont,en o# thora.i. ( April, '3 th ())* /esult: Pulmo : &ithin normal limit, $or: .ardiome,ali $ead CT Scan (April, '3 th ())* Hipodens lession on le#t su!.orti.al deep temporal lo!e (diameter ( mm and le#t peri8entri.ular (diameter 5 mm /esult : in#ar.tion on le#t su!.orti.al deep temporal lo!e and le#t peri8entri.ular Electrocardio%raphy April, '3 th ())*: Synus /hytm, Heart /ate ?* x;minute, 8entri.ular extrasystole #re:uent April, '* th ())*: Synus /hytm, Heart /ate ?( x;minute, 8entri.ular extrasystole !i,emini April, () th ())*: Synus /hytm, Heart /ate 13 x;minute, 8entri.ular extrasystole rare Consultations Cardiolo%y department (April, '3 th ())* : /esult: 8entri.ular extrasystole #re:uent $hol : 4'' m,;d@ %, : ''5 m,;d@ HD@ : 5' m,;d@ @D@ : ((> m,;d@ AS% : 4*.4 2=;@ A@% : 4?.( 2=;@ 0=+ : ''.> m,;d@ $reatinin : '.) m,;d@ =ri. a.id : (,* m,;d@ /andom ,lu.osa:(45 m,;d@

>

%reatment : oxi,enation 8ia .anule, amiodarone oral 4 x ')) m, E8aluation assessment (April, '* th ())* : /esult: 8entri.ular extrasystole !i,emini %reatment : oxi,enation 8ia mas7, amiodarone drip 35) m,;(3 hours E8aluation assessment (April, () th ())* : /esult: 8entri.ular extrasystole rare %reatment : oxi,enation 8ia .anule, amiodarone drip 35) m,;(3 hours Internal department (April, '3 th ())* : /esult: dia!etes mellitus type ( non o!ese E8aluation assessment (April, (5 th ())* : %reatment: re,ular insulin 4 x 3 2= *edical reha-ilitation department (April, '* th ())* : /esult: /i,ht hemiparesis on in#ar.tion stro7e patient Pro,ram: Exer.ise pro,ram Mus.le stren,thenin, Mo!ili9ation and AD@ impro8ement SECO!D DISC SSIO! %he results o# physi.al examination, sho&ed .ons.iousness, ri,ht hemiparesis and ri,ht #a.ial &ea7ness (paresis o# ri,ht #a.ial ner8e<upper motor neuron and paresis o# ri,ht hipo,lossus ner8e <upper motor neuron, 8as.ular .o,niti8e impairment. %he patient had hypertension. /esult o# ele.tro.ardio,raphy sho&ed 8entri.ular extrasystole and .hest I ray sho& there &as .ardiome,aly. %he result o# Head $% s.an examination sho&ed in#ar.tion on le#t su!.orti.al deep temporal lo!e, le#t peri8entri.ular. %he !lood la!oratory examination sho&ed hyper,ly.emia, hyper.holesterolemia. $onsultin, to the .ardiolo,y department there &as #re:uent 8entri.ular extrasystole &hi.h in the .lini.al .ourse de8elop into !i,emini 8entri.ular extrasystole, &hile .onsultin, to the internal department there &as non o!ese dia!etes mellitus type (. Stro7e is .aused !y multi#a.tor disease su.h as hypertention, dia!etes mellitus, .ardia. distur!an.e, dyslipidemia and many other #a.tors are listed as ris7 #a.tors. %his patient had un.ontrolled hypertention, dia!etes mellitus, 8entri.ular extrasystole and dyslipidemia as the ris7 #a.tors. %he pathophysiolo,y o# hypertension, dia!etes mellitus, dyslipidemia .an .ause stro7e throu,h atheros.lerosis path&ay. Four major ,roups o# diseases asso.iated &ith is.hemi. .ere!ro8as.ular disorders are .ardia. disorders (8al8e related em!oli, intra.ardia. throm!us or tumor, systemi. 8enous throm!i &ith ri,ht to le#t .ardia. shunt , lar,e 8essel disease (atheros.lerosis, .arotid artery disse.tion, #i!romus.ular dysplasia , small 8essel disease (hypertension, in#e.tious and nonin#e.tious arteritis , hematolo,i. disease (poly.ythemia, throm!o.ythemia, throm!oti. throm!o.ytopeni. purpura (6ie!ers et al., '>>? . @a.unar in#ar.t &as de#ined as an a.ute stro7e syndrome &ith a $% lesion .ompati!le &ith the o..lusion o# a sin,le per#oratin, artery, .onsistin, o# a su!.orti.al (!asal ,an,lia, internal .apsule, !rainstem , small, sharply demar.ated hypodense lesion &ith a diameter K'5 mm. 2# no su.h lesion &as 8isi!le or i# no $% &as per#ormed, &e used

')

the esta!lished .riteria o# unilateral motor and;or sensory si,ns that in8ol8ed the &hole o# at least ( o# the 4 !ody parts (#a.e, arm, le, &ithout distur!an.e o# .ons.iousness, 8isual #ields, lan,ua,e, or other .orti.al #un.tions. 6e distin,uished 3 la.unar syndromes: pure motor stro7e, sensorimotor stro7e, pure sensory stro7e, and ata.ti. hemiparesis;dysarthria .lumsy hand syndrome (De Lon, et al., ())( . %he small penetratin, !ran.hes o# the major intra.ranial arteries ha8e poor .ollateral .onne.tions, o!stru.tion o# !lood #lo& .aused !y #i!rin deposition, lipohyalinosis, mi.roatheroma, or throm!us leads to in#ar.tion in the limited distri!ution o# one o# these arteries (6ie!ers et al., '>>? . %here isn a time pro#ile #or appearan.e o# this lesion a#ter the .lini.al e8ent. =sin, $% ima,in,, the lo&est pre8alen.e o# positi8e ima,es o..urs in the #irst &ee7 a#ter the e8ent. From reported data, early $% positi8ity #or lesions .on,ruent &ith a .lini.ally de#ined la.unar in#ar.t ran,es #rom '(A to 5)A o# patients. 2n the #irst #e& days, M/2 is reported to sho& a re.ent la.unar in#ar.t in up to >3A o# patients. Di##usion 6ei,hted Ma,neti. /esonan.e 2ma,in, (D6<M/2 per#ormed a#ter 4 days &as >5A sensiti8e and >3A spe.i#i. #or re8ealin, an a.ute la.unar in#ar.t (2n9itari and @amassa, ())4 . %he study to determine the .lini.al presentation and aetiolo,y o# small su!.orti.al in#ar.tions as #ound on D6<M/2. +inety three patients &ere identi#ied sho&in, su!.orti.al or !rainstem D62 lesions K'.5 .m in diameter &ithin a maximum o# ? days #rom the onset o# stro7e symptoms (Sei#ert et al., ())5 . 2n study a!out e##e.t o# #re:uent 8entri.ular extrasystole on !rain .ir.ulation in patients &ith .oronary heart disease, to demonstrated that redu.tion o# .ere!ral !lood #lo& .an indu.ed !y #re:uent premature 8entri.ular !eats (Ha,endor## et al., '>>4 . -n the .o,niti8e #un.tion examination, the patient had MMSE examination to result in distur!an.e o# orientation, attention and .al.ulation, as &ell as re,istration. 6hile in the DHesposito examination to result in distur!an.e o# attention, memory, and exe.uti8e #un.tion. 0ased on result o# this examination, the patient had 8as.ular .o,niti8e impairment. Su!.orti.al is.hemi. 8as.ular injury and la.unar in#ar.tions rele8ant to 8as.ular dementia tend to pre8entially in8ol8e the su!.orti.al &hite matter o# the #rontal lo!es and the anterior aspe.ts o# the !asal ,an,lia in.ludin, the .audate nu.leus and ,lo!us pallidus. Patient &ith su!.orti.al 8as.ular dementia exhi!it more se8ere impairment o# exe.uti8e #un.tion and less impairment o# memory, parti.ulary re.o,nition memory ($ummin,s, ())4 . Final dia%nosis : $lini.al dia,nosis %opi.al dia,nosis Etiolo,i.al dia,nosis *ana%ement : la.unar stro7e syndrome 8as.ular .o,niti8e impairment : posterior lim! o# le#t internal .apsule le#t su!.orti.al deep temporal lo!e, le#t peri8entri.ular : hypertension small 8essel disease, dia!etes small 8essel disease, hyper.holesterolemia small 8essel disease

''

-xy,enation is a ,reat importan.e durin, periods o# a.ut .ere!ral is.hemia in order to pre8ent hypoxia and potential &orsenin, o# the neurolo,y.al injury (Adams, ())4 . +europrote.tan dru,s ,i8e 8ariety result in stro7e patient. %he +ational "uideline o# Stro7e has not re.ommended neuroprote.tan neither has AHA "uidelines . +e8erthless 2ndonesian +eurolo,i.al Asso.iation still re.ommended pira.etam and .iti.holine as neuroprote.tan dru,s #or stro7e patients (Perdossi, ())3 . Pira.etam has t&o me.hanisms a##e.ted to neuronal and 8as.ular le8els (Perdossi, ())3 : a. +euronal le8el: related to phospolipid, .ell mem!ran #luidity repaired, neurotransmitter repair, adenylate .y.lase stimulation. !. Cas.ular le8el: in.rease o# erythro.yte de#orma!ility, de.rease o# platelet anti a,re,ration, mi.ro.ir.ulation repaired. 2t is indi.ated to !e ,i8en at se8en hours o# stro7e onset. First '( ,rams o# pira.etam per in#ussion o8er () minute, and then #ollo&ed &ith 4 ,rams !olus e8ery * hour or '( ,rams e8ery '( hour until the #ourth day. -n day 5 until the end o# 3 &ee7s, is pira.etam ,i8en 3,1 ,ram di8ided 4 times a day orally, and on the &ee7 5 until '( it is ,i8en (,3 ,ram t&i.e a day ( Perdossi, ())3 . A randomi9ed, dou!le<!lind parallel ,roup desi,n trial o# >(? patients at 55 .enters. 2n.lusion .riteria are presentin, &ithin '( hrs o# onset o# a.ute is.hemi. supratentorial stro7e, disa!lin, symptoms (-r,o,o9o s.ale s.ore o# G5 and K?) and arousa!le, the a,es o# 3) and 15. Patients re.ei8ed pla.e!o or '( , pira.etam as an initial intra8enous !olus #ollo&ed !y '( , daily #or 3 &ee7s and then 3.1 , daily #or 1 &ee7s. %he out.ome assesment used -r,o,o9o s.ale and 0arthel 2ndex. Additional analyses o# patients &ith moderate and se8ere stro7e &ithin the early treatment ,roup also sho&ed si,ni#i.ant impro8ement on pira.etam in !oth out.omes (pK).)( (De Deyn, '>>? . $iti.holine treatment &ill impro8e .ere!ral #un.tion passin, throu,h some &ays as #ollo& (Adi!hlata et al., ())' : a. 2n.rease phosphatydil .holine to ma7e mem!rane repair !. 2nhi!it #ree #atty a.id and #ree radi.al .. 2n.rease a.etyl.holine neurotransmitter produ.tion &hi.h has theurapeti. e##e.t as lon, as is.hemi. d. As ,lutation resour.es &hi.h 7ind o# primary endo,eni. antioxidant in the !rain For is.hemi. stro7e, .iti.holoine should !e ,i8en on #irst (3 hour sin.e stro7e atta.7 at dose (5)<'))) m,, intra8enous (<4 times a day o8er (<'3 day (Perdossi, ())3 . 2n systemati. sear.h o# all prospe.ti8e, randomi9ed pla.e!o<.ontrooled, dou!le !lind trial, a!out oral .iti.oline treatment #or a.ut is.hemi. stro7e (8arious doses 5)), '))) and ())) m, to demostrated that .iti.oline &ithin the #irst (3 hours a#ter onset in patents &ith moderate to se8ere stro7e in.rease the pro!a!ility o# .omplete re.o8ery at 4 months (Da8alos et al., ())( . %rial o# $AP/2E &as a randomised, !linded, international trial desi,ned to assess the relati8e e##i.a.y o# .lopido,rel (?5 m, on.e daily and aspirin (4(5 m, on.e daily in redu.in, the ris7 o# a .omposite out.ome .luster o# is.haemi. stro7e, myo.ardial in#ar.tion, or 8as.ular deathJ their relati8e sa#ety &as also assessed. %he interpretation this study is lon,<term administration o# .lopido,rel to patients &ith atheros.leroti. 8as.ular disease is more e##e.ti8e than aspirin in redu.in, the .om!ined ris7 o# is.haemi. stro7e,

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myo.ardial in#ar.tion, or 8as.ular death. %he o8erall sa#ety pro#ile o# .lopido,rel is at least as ,ood as that o# medium<dose aspirin ($AP/2E Steerin, $ommittee, '>>> . %his multi<.enter study &ill re.ruit (5)) parti.ipants (() per.ent o# &hom &ill !e Hispani. Ameri.ans to #ind out i# usin, aspirin and .lopido,rel to,ether is more e##e.ti8e than usin, aspirin alone to pre8ent re.urrent stro7e in patients &ith la.unar stro7e, and i# lo&erin, a patientHs !lood pressure !elo& the usual limits &ill also help pre8ent re.urrent stro7e and maintain thin7in, a!ility (0ena8ente, ())4 . %he #lo& .hart o# hypertension mana,ement in a.ute stro7e (Perdossi, ())3 :
A.ute stro7e Sistoli. > (4) mmH, Diastoli. > '3) mmH, Sistoli. > (4) mmH, Diastoli. '(' < '3) mmH, Sistoli. '1) < (4) mmH, Diastoli. ')5 < '() mmH, Sistoli. < '1) mmH, Diastoli.< ')5 mmH,

/epeat to examination a#ter '5 minute Sistoli. > (4) mmH, Diastoli. '(' < '3) mmH, 2ntra.ere!ral hemorrha,i. or distur!an.e o# end or,an Positi8e +e,ati8e

Parenteral antihypertension Dru,

-!ser8ation -ral antihypertension dru, ,i8e o8er the se8enth until tenth day

%he study a!out statin therapy to sho&s that statin therapy rapidly redu.es the in.iden.e not only o# heart atta.7s !ut also o# is.hemi. stro7es, &ith no ad8erse e##e.t on hemorrha,i. stro7es. Allo.ation to 3) m, sim8astatin daily redu.ed the rate o# is.hemi. stro7es. $ompared &ith the pla.e!o ,roup, the ,roup assi,ned to 3) m, sim8astatin daily had an a8era,e redu.tion in lo&<density lipoprotein .holesterol o# ' mmol;@. %he in8esti,ators re.ommend that statins !e routinely .onsidered #or all patients at hi,h ris7 o# stro7e (0ar.lay, ())5 . Ele8ated !lood ,lu.ose is .ommon in the early phase o# stro7e. %he pre8alen.e o# hyper,ly.emia, de#ined as !lood ,lu.ose le8el G*.) mmol;@ (')1 m,;d@ , has !een o!ser8ed in t&o thirds o# all is.hemi. stro7e su!types on admission and in at least 5)A in ea.h su!type in.ludin, la.unar stro7es. Extensi8e experimental e8iden.e in stro7e models supports that hyper,ly.emia has ad8erse e##e.ts on tissue out.ome, and an asso.iation !et&een !lood ,lu.ose and #un.tional out.ome has !een #ound in an in.reasin, num!er o# .lini.al studies. Althou,h no inter8entional stro7e studies ha8e addressed the a.ute re8ersal o# hyper,ly.emia, a.ti8e lo&erin, o# ele8ated !lood ,lu.ose !y rapidly a.tin, insulin is re.ommended in most pu!lished ,uidelines, e8en in nondia!eti. patients (European Stro7e 2nitiati8e ME=S2N ,uidelines G') mmol;@, Ameri.an Stro7e Asso.iation

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MASAN ,uidelines G4)) m,;d@ (@inds!er, and /oine, ())4 . 2nsulin in#usion has an e##e.t that is opposite to that o# hyper,ly.emia. 2t not only lo&ers !lood ,lu.ose le8els !ut also exerts an antioxidant and anti<in#lammatory e##e.t. 2nsulin also impro8es +produ.tion and results in impro8ed !lood .ir.ulation to the is.hemi. areas ("ar, et al., ())* . Amiodarone is used to .orre.t a!normal rhythms o# the heart (an antiarrhythmi. medi.ation . Amiodarone is .onsidered a O!road spe.trumO antiarrhythmi. medi.ation, that is, it has multiple and .omplex e##e.ts on the ele.tri.al a.ti8ity o# the heart &hi.h is responsi!le #or the heartPs rhythm. Amon, its most important ele.tri.al e##e.ts are (Anonim, ())* : '. A delay in the rate at &hi.h the heartPs ele.tri.al system Ore.har,esO a#ter the heart .ontra.ts (repolari9ation J (. A prolon,ation in the ele.tri.al phase durin, &hi.h the heartPs mus.le .ells are ele.tri.ally stimulated (a.tion potential J 4. A slo&in, o# the speed o# ele.tri.al .ondu.tion (ho& #ast ea.h indi8idual impulse is .ondu.ted throu,h the heartPs ele.tri.al system J 3. A redu.tion in the rapidity o# #irin, o# the normal ,enerator o# ele.tri.al impulses in the heart (the heartPs pa.ema7er J 5. A slo&in, o# .ondu.tion throu,h 8arious spe.iali9ed ele.tri.al path&ays (.alled a..essory path&ays &hi.h .an !e responsi!le #or arrhythmias. A multi.enter, international, randomi9ed, pla.e!o<.ontrolled trial a!out e##i.a.y and tolera!ility o# donepe9il in 8as.ular dementia &as randomi9ed to (3 &ee7s o# treatment &ith donepe9il 5 m,;day and donepe9il ') m,;day, as &ell as pla.e!o. At &ee7 (3, !oth donepe9il ,roups sho&ed si,ni#i.ant impro8ement in .o,nition and ,lo!al #un.tion 8ersus pla.e!o. Donepe9il treated patient sho&ed si,ni#i.ant !ene#its in a.ti8ities o# daily li8in, o8er pla.e!o. Donepe9il &as &ell tolerated. 6ithdra&al rates do to ad8erse e8ents &ere relati8ely lo& (0la.7 et al., ())4 . Medi.al reha!ilitation pro,ram should !e initiated sin.e the patient admitted to the hospital. $ommonly, in the #irst day a#ter stro7e atta.7, the a.ti8e medi.al reha!ilitation pro,ram, hasnHt !een initialed. 2n ,eneral, #irst day pro,ram &as aimed to a,ainst .ompli.ation .aused !y prolon,ed !ed rest, #or example !y doin, proper !ed positionin,. %here &ere a lot o# opinion a!out !ed rest period a#ter stro7e atta.7 , !ut ,enerally &ere re.omended !et&een '<4 &ee7s (Santoso, ())3 . Many opinions su,,est a.ti8e medi.al reha!ilitation pro,ram to !e done earlier. $riterion .an !e used as ,uide: a.ti8e medi.al reha!ilitation pro,ram .an !e started i# patient .ondition &ere sta!il there &ere no .ompli.ation and there &ere no medi.al .ondition that endan,er patient ( li#e<threatenin, (Santoso, ())3 . Early medi.al reha!ilitation &as aimed to maximi9e healin, or repairin, potention and pre8ent .ompli.ation o# prolon, immo!ili9ation as soon as possi!le (Santoso, ())3 . %he tar,et o# medi.al reha!ilitation pro,ram : a. %o pre8ent, re.o,ni.e and handle medi.al .ondition that a..ompany stro7e, in.ludin, re..urent stro7e, repairin, hydration and nutrition. !. %o maximi9e #un.tional sel#<supportin, throu,h 8arious exer.ise pro,ram .. %o #a.ilitate patient and #amily psy.holo,i.al and so.ial li8in, adaptation d. %o support reinte,ration on so.iety and &or7 pla.e

'3

e. %o repair li#e :uality o# the patient /eha!ilitation is needed to ,ain #un.tional re.o8ery throu,h relearnin, pro.ess. 0e#ore mo!ili9in, and a.ti8e exer.isin, the patient is ,i8en positionon, to re.o8ery his !ody #un.tion and to prote.t spastisity (Aliyah, et a., ())' . %he patient had ,i8en therapies: (eneral: Air&ay, 0reathin, and .ir.ulation maintenan.e: -( 4 @;min 2CFD /in,er a.etat () ,tt per min Pharmacotherapy Pira.etam inj 3 x 4 ,ram $iti.holin inj ( x 5)) m, $lopido,rel ' x ?5 m, Sim8astatine ' x ') m, Amiodarone drip 35) m, ; (3 hours Plannin, therapy #or 8as.ular .o,niti8e impairment: donepe9il ' x 5 m, Diet: diet DM '>)) 7alori Physiotherapy Pro%nosis %he study &as to in8esti,ate the lon,<term pro,nosis o# #irst<e8er la.unar stro7es and the possi!le role o# .lini.al pro,nosti. #a.tors. A .ohort o# .onse.uti8e patients presentin, &ith #irst<e8er la.unar in#ar.ts &as prospe.ti8ely e8aluated a#ter stro7e onset at day ) to 4 and;or day ?, e8ery 4 months up to ' year, and e8ery * months therea#ter. Fi8e< year sur8i8al rate #ree o# re.urrent stro7e &as *4A, &hile 5<year sur8i8al rate &as 1*A. A,e &as the only si,ni#i.ant predi.tor o# sur8i8al #ree o# re.urrent stro7e. A,e and the de,ree o# neurolo,i.al dys#un.tion and #un.tional disa!ility at ? days a#ter the index stro7e measured !y the %oronto Stro7e S.ale and a 0arthel 2ndex s.ore K3) &ere the only si,ni#i.ant predi.tors o# death. %he 5<year pro!a!ility rate o# stro7e<#ree re.urren.e &as ?(A. Sixty<three per.ent o# the #irst re.urrent stro7es &ere la.unar in#ar.ts (Sal,ado et al., '>>* . %he results o# study a!out #un.tional out.ome in patients &ith la.unar in#ar.tion &as moderate or se8ere hemiparesis ' month a#ter stro7e onset as the stron,est predi.tor o# physi.al dependen.e or death at 4 years ( pK),))' , #ollo&ed !y &hite matter hyperintensities on M/2 (pK),))' . /e.urrent stro7e in.reased disa!ility and handi.ap !ut &as not a statisti.ally si,ni#i.ant independent ris7 #a.tor (Samuelsson et al., '>>* . %he .ohort study in pure motori. stro7eJ a,e, male sex and nonuse o# a.etylsali.yli. a.id &ere stastiti.ally si,ni#i.ant #or independent determinants o# death. 6hile, hypertension and dia!etes mellitus &ere stastiti.ally si,ni#i.ant #or independent ris7 #a.tor o# re.urrent stro7e (Staa# et al., ())' . %he study a!out t&o type o# la.unar in#ar.ts per#ormed a #ollo&<up in 444 patients &ith #irst la.unar stro7e, distin,uishin, those &ith ' asymptomati. la.unar lesions (@A$2E #rom those &ithout su.h lesions (@A$2< . %he .on.lusion to sho& pro,nosis #or

'5

mortality, re.urrent stro7e, and o8erall #un.tional out.ome in la.unar stro7e patients &ith ' silent la.unar lesions is more un#a8ora!le than in patients &ithout su.h lesions. %hese #indin,s sustain the idea o# ( la.unar stro7e entities (De Lon, et al., ())( . %he patient had many pro!lems in.ludin, hypertension, dia!etes mellitus, dyslipidemia, 8entri.ular extrasystole, !arthel index '5, and three la.unar lesion in the head $% s.an #indin, &ith symptom pure motori.. 0ased on these study, so the pro,nosis #or this patient are: Death Disease Dis.om#ort Dissatis#a.tion Dissa!ility Distitution Follo. up
Follo. up "eneral .ondition "$S Cital si,n +..ranialis E7stremity : Mo8ement Stren,th E$" @a!oratorium %herapy April/ 00 th/ 0112 Fair, E 3C5M * 0PQ'?);')) PQ11x, //Q ()x tempQnot #e!rile Paresis +.C22, I22 dextra =M+ @imited Free @imited Free 4;4;4 5;5;5 4;4;4 5;5;5 Centri.ular extrasystole ( , synus rythme April/ 03 th 0112 Fair, E 3C5M * 0PQ'3);>) PQ11x, //Q ()x tempQ not #e!rile Paresis +.C22, I22 dextra =M+ @imited Free @imited Free 4;4;4 5;5;5 4;4;4 5;5;5 Centri.ular extrasystole ( , synus rythme Fast 0" : ()5 ( h PP 0" : (?1 Al!umin : (.51 -( 4 @;min 2CFD /in,er a.etate () ,tt per min Pira.etam inj 3 x 4 ,r $iti.oline inj (x5)) m, $lopido,rel ' x ?5 m, @osartan ' x 5) m, Sim8astatine ' x ') m, /e,ular 2nsulin 4x3 2= Al!umin in#use Diet DM '>)) 7alori Physiotherapy April/ 04 th 0112 Fair, E 3C5M * 0PQ'3);>), PQ11x, //Q ()x tempQ not #e!rile Paresis +.C22, I22 dextra =M+ @imited Free @imited Free 4;4;4 5;5;5 4;4;4 5;5;5 Centri.ular extrasystole ( , synus rythme ( h PP 0" : '?* Al!umin : 4.)1 %o stop o# -(, 2CFD Pira.etam oral 4x1)) m, $iti.oline oral (x5)) m, $lopido,rel ' x ?5 m, @osartan ' x 5) m, Sim8astatine ' x ') m, /e,ular 2nsulin 4x3 2= Patient dis.har,e #rom hospital, &ith edu.a tion: .ontrol to stro7e unit, memory, end.rine and physiotherapy .lini.

: du!ia ad malam : du!ia ad malam : du!ia ad malam : du!ia ad malam : du!ia ad malam : du!ia ad malam

-( 4 @;min 2CFD /in,er a.etate () ,tt per min Pira.etam inj 3 x 4 ,ram $iti.oline inj ( x 5)) m, $lopido,rel ' x ?5 m, @osartan ' x 5) m, Sim8astatine ' x ') m, Amiodarone drip stop Diet DM '>)) 7alori Physiotherapy

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REFERE!CES Adi!hlata, /.M., Hat.her, 0.S., Dempsey, /.L., ())', E##e.ts o# $iti.holine on Phospholipid and "lutation @e8els in %ans.ient $ere!ral 2s.haemia, Stroke 32: 2376-2381 Anonim, '>>?, Amiodarone, Medicine Net. Com. Aliyah, A., Kus&ara, E.F., @imoa, 6uysan,, "., '>>4, "an,,uan Peredaran Darah -ta7 dalam Harsono (ed : Kapita Selekta Neurologi, "adjah Mada =ni8ersity, Yo,ya7arta 0ar.lay, @., ())5, Statins May /edu.e Stro7e /is7, $ontinuin, medi.al Edu.ation, Med cape Medical Ne! 0ena8ente, -., ())4, Se.ondary Pre8ention o# Small Su!.orti.al Stro7es (SPS4 %rial, =ni8ersity o# %exas Health S.ien.e $enter, San Antonio, %exas, National "i#rar$ o% Medicine 0la.7, S., /oman, ".$., "eldma.her, DS., Sallo&ay, S., He.7er, L., 0urns, A., Perdomo, $., Kumar, D., Pratt, /., %he Donepe9il 4)? Cas.ular Dementia Study "roup, ())4, E##i.a.y and tolera!ility o# Donepe9il in Cas.ular dementia, "lenpointe $entre 6est, %eane.7, Ameri.an Hearth Asso.iation, Stroke, &ttp:''!!!. trokea&a.org $AP/2E Steerin, $ommittee, '>>>, A randomised, !linded, trial o# .lopido,rel 8ersus aspirin in patients at ris7 o# is.haemi. e8ents ($AP/2E , "ancet 3(8)*+38,:132*3*, +ational @i!rary o# Medi.ine and the +ational 2nstitutes o# Hearth, &&&. pu!med. "o8 $ummin,s, L.@., Cinters, H., Felix, L., ())4, -&e Neurop $c&iatr$ o% .l/&eimer0 1i ea e and 2elated 1ementia , Martin Dunit9, %aylor and Fran.is "roup pl., +e& Fetter @ane, @ondon, =nited Kin,dom. Dahlan, P., @amsudin, /., '>>1, 1iagno i 3eni 4atologi Stroke 5ntuk Kepentingan 4enanganan Stroke $ang 2a ional, Manajemen Stro7e Muta7hir, Suplemen 0KM I2C Da8alos, A., $astillo, L., Sa!in, L.A., Sa.ades, L.L., Mer.adal. L., @ope9, S., $o!o, E., 6ara.h, S., Sherman, D., $lar7, 6.+., @o9ano, /., ())(, -ral $iti.oline in A.ute 2s.hemi. Stro7e, Ameri.an Stro7e Asso.iation, Stroke 33: 286+-2867

'?

De Lon,, "., Kessels F., @odder, L., ())(, %&o %ypes o# @a.unar 2n#ar.ts, Department o# +eurolo,y, =ni8ersity Hospital Maastri.ht, Maastri.ht, +etherlands, Stroke 33: 2+72 De deyn, P.P., De /eu.7, L., De!erdt, 6., Clietin.7, /., -r,o,o9o, L.M., '>>?, %reatment o# A.ute 2s.hemi. Stro7e 6ith Pira.etam, Department o# +eurolo,y, =ni8ersity o# Ant&erp, Ant&erp, 0el,ium, Ameri.an Heart Asso.iation, Stroke 28: 23(7-2362 "ar,, /., $haudhuri, A., Muns.hauer, F., Dandona, P., ())*, Hyper,ly.emia, 2nsulin, and A.ute 2s.hemi. Stro7e, %he Di8ision o# Endo.rinolo,y, Dia!etes and Meta!olism , and Department o# +eurolo,y (F.M. , State =ni8ersity o# +e& Yor7 at 0u##alo, +e& Yor7, Ameri.an Heart Asso.iation, Stroke 37: 267 Ha,endor##, A., Dettmers, $., 6irt9, P., 0lo.7, A., Hartmann, A., @uderit9, 0., '>>4, E##e.t o# Fre:uent Centri.ular Extrasystole on 0rain $ir.ulation in Patients &ith $oronary Heart Disease, Medi9inis.he =ni8ersitats7lini7 0onn, 7 Kardiol. 82)12,:781-6. 2n9itari, D., @amassa, M., ())4, Small 8e el 1i ea e !it& "acune , in: 9 c&emic Stroke: .d:ance in Neurolog$, @ippin.ott 6illiams and 6il7ins, Philadelphia. @indsay, K.6, 0one, 2, $allendar , /., '>>?, Neurolog$ and Neuro urger$ 9llu trated, 4rd ed.$hur.hull, @i8in,stone, %o7yo. @inds!er,, P.L., /oine, /.-., ())3, Hyper,ly.emia in A.ute Stro7e, Department o# +eurolo,y, Helsin7i =ni8ersity $entral Hospital, and +euros.ien.es Pro,ramme, 0iomedi.um Helsin7i, Helsin7i, Finland, Ameri.an Heart Asso.iation, Stroke 36: 363 Perdossi, ())3, ;uideline Stroke, Kelompo7 Studi Sere!ro8as7uler Perdossi, La7arta Sal,ado, A.C., Ferro, L.M., -li8eira, A.", '>>*, @on,<term Pro,nosis o# First<E8er @a.unar Stro7es, Departments o# +eurolo,y and 0iostatisti.s, Hospital de Santa Maria, Fa.uldade de Medi.ina de @is!oa, Portu,al, Stroke. 27: 661-666 Samuelsson, M., Soder#eldt, 0., -lsson, ".0., '>>*, Fun.tional -ut.ome in Patients 6ith @a.unar 2n#ar.tion, Department o# +eurolo,y, -re!ro Medi.al $enter Hospital, S&eden, Ameri.an Heart Asso.iation, Stroke 27:8(2-8(6 Santoso, 0., ())3, 2e&a#ilita i 4enderita Stroke, Stro7e in Depth B+o& and the Future, Pendidi7an Kedo7teran 0er7elanjutan, Sura!aya Sei#ert, %., En9in,er, $., Stor.h, M.K., Pi.hler, "., +ieder7orn, K., Fa9e7as, F., ())5, A.ute Small Su!.orti.al 2n#ar.tions on Di##usion 6ei,hted M/2: $lini.al Presentation and Aetiolo,y, Department o# +eurolo,y, "ra9 Medi.al =ni8ersity,

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Auen!ru,,erplat9, AustriaJ 3ournal o% Neurolog$, Neuro urger$, and 4 $c&iatr$ J 0ML Pu!lishin, "roup @td Staa#, "., @ind,ren, A., +orr8in,, 0., ())', Pure Motor Stro7e Presumed @a.unar 2n#ar.t: @on, %erm Pro,nosis #or Sur8i8al and /is7 o# /e.urrent Stro7e, Department o# +eurolo,y, @und =ni8ersity Hospital, S&eden, Stroke 31:2827 6ie!ers D.-., Fei,in C.@., 0ro&n /.D., '>>?, Cere#ro:a cular 1i ea e in Clinical 4ractice, First Edition, Mayo Foundation, /o.hester, Minnesota, =nited States o# Ameri.a 6ini7ates, L.P., ())', Cere#ro:a cular 1i ea e, in +eurolo,y se.ret, 4rd ed. Hanley and 0el#us, 2n., Philadelphia 6on,, E.H., ())5, @a.unar Stro7e, Department o# $lini.al +eurolo,i.al S.ien.es, @ondon Health S.ien.es $entre, =ni8ersity o# 6estern -ntario, Ameri.an A.ademy o# +eurolo,y and Ameri.an Heart Asso.iation, eMedicine <ournal

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