Stroke

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Stroke
Namo lain Cerebrovascular accident (CVA), cerebrovascular insult (CVI), sarangan utak
MCA Territory Infarct.svg
CT scan utak nan manunjuakan sisi kiri utak nan maalami kakurangan darah (iskemik) dari sumbatan pado arteri. Parubahan pado CT buliah jadi indak tampak pado gejala mulo[1]
Spesialisasi Neurologi
Gejala Indak talok manggarik atau marasoi pado ciek sisi badan, masalah mamahami bahaso atau mangecek, paniang, ilang pandangan di ciek sisi[2][3]
Komplikasi Kondisi vegetatif persisten[4]
Panyabab Iskemik (sumbatan) jo hemoragik (padarahan)[5]
Faktor risiko Takanan darah tinggi, marokok, obesitas, kolesterol darah tinggi, diabetes mellitus, riwayaik TIA, fibrilasi atrium[2][6]
Diagnosis Manuruik gejala sarato pancitraan medis biasonyo untuak manyingkiran kamungkinan padarahan[7][8]
Kondisi sarupo Gulo darah randah[7]
Parawatan Manuruik tipe[2]
Prognosis Harapan iduik rato-rato 1 taun[2]
Frekuensi 42,4 juta (2015)[9]
Kamatian 6,3 juta (2015)[10]

Stroke (dibaco: strok) adolah karusakan jaringan utak baiak sabagian atau sadoalahannyo nan tajadi mandadak, balansuang labiah dari 24 jam sarato disababkan dek faktor-faktor masalah pambuluah darah (vaskular). Pambuluah darah arteri nan maaliakan darah ka utak tasumbek, kuyak, atau tirih.[11]

Stroke atau cerebrovascular accident (CVA), marupokan ilangnyo fungsi-fungsi utak sacaro capek, dek gangguan suplai darah ka utak. Hal iko dapek tajadi dek iskemia (bakurangnyo aliran darah) nan disababkan juo dek panyumbekan (thrombosis, arterial embolism), atau adonyo padarahan (haemorrhage).[12]

Stroke iskemik nan biasonyo disababkan dek diabetes manjadi mayoritas pado pandarito stroke sarato bisa mancapai 85 persen, sadangkan stroke padarahan hanyo 15 persen, tapi stroke padarahan dapek manyababkan kamatian pado 40 persen pasiennyo. Nan juo manjadi paratian adolah stroke iskemik ringan nan gejalanyo sarupo stroke, tapi ka ilang surang dalam 24 jam (transient ischemic attacks (TIA)). Hal iko tajadi dek pambuluah darah hanyo tasumbek samantaro. Ka baapun juo, kok lah kanai sakali, stroke nan labiah barek dapek muncua di kudian ari.[13]

Stroke adolah panyabab katigo kamatian paliang banyak sarato panyabab utamo kacacatan pado urang gadang di Amerika Serikat jo Eropa. Manuruik laporan Riskesdas 2007 (Riset Kesehatan Dasar), stroke pun marupokan panyabab kamatian partamo di Indonesia. Stroke tajadi pado 12 dari 1.000 urang jo ciek dari 7 pasien nan maalami stroke ka maningga.[14]

Stroke paralu tindakan darurat medis (medical emergency) pado maso amehnyo (golden period) nan paliang lamo hanyo balansuang babarapo jam sajo sasudah tajadinyo stroke. Hal ko diparalukan untuak manahan tajadinyo karusakan tatap atau karusakan nan labiah parah. Kok indak ditangani, malah bisa barakibaik pado kamatian. Dek itu, daerah utak nan takanai stroke indak dapek bafungsi samustinyo. Gejala-gejalanyo tamasuak: hemiplegia (kaindakmampuan untuak manggarikan ciek atau labiah anggota badan dari salah satu sisi badan), aphasia (kaindakmampuan untuak mangarati atau mangecek), atau kaindakmampuan untuak mancaliak salah satu sisi dari lapangan pandang (visual field).[15]

Faktor-faktor nan maningkekan risiko tajadinyo stroke adolah: umua, takanan darah tinggi, riwayaik stroke sabalunnyo, diabetes, kolesterol tinggi, marokok, fibrilasi atrium, migrain jo aura, sarato trombofilia (kacondongan untuak thrombosis). Dari sadoalah faktor-faktor tu nan paliang mudah dikandalikan adolah takanan darah tinggi jo marokok. 80 persen stroke dapek diilakan jo pangandalian faktor-faktor risiko.[16]

Klasifikasi[suntiang | suntiang sumber]

Stroke dibagi manjadi duo jinih yaitu stroke iskemik jo stroke hemorragik. Sabuah progonis hasia sabuah panalitian di Korea manyatokan baso[17] 75,2% stroke iskemik didarito dek laki-laki jo prevalensi barupo hipertensi, kabiasoan marokok, jo konsumsi alkohol. Deteksi dini dalam maso Golden Period babarapo jam sasudah sarangan stroke sangaik bararti untuak kasihatan pasien pasca stroke. Stroke iskemik, dek panyumbatan musti diagiah ubek pangencer darah untuak malancarkan sumbatan dalam wakatu indak labiah dari 3 jam salapeh sarangan stroke, sadangkan stroke hemorragik dimano tajadi padarahan musti sagiro dilakukan pambadahan untuak mambarasiahan darah dari utak. Kok talambek panangannyo, mako pasien ka mandarito kondisi pasca stroke nan labiah barek.[18]

Stroke hemorragik[suntiang | suntiang sumber]

Dalam stroke hemorragik, pambuluah darah pacah sainggo maambek aliran darah nan normal jo darah marembes ka dalam suatu daerah di utak inggo marusaknyo. Padarahan dapek tajadi di sadoalah bagian utak sarupo caudate putamen; talamus; hipokampus; frontal, parietal, jo occipital cortex; hipotalamus; area suprakiasmatik; cerebellum; pons; dan midbrain.[19] Ampia 70 persen kasus stroke hemorrhagik manyarang pandarito hipertensi.[20]

Stroke hemorragik tabagi manuruik tampek padarahannyo manjadi subtipe intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH),[21] cerebral venous thrombosis, jo spinal cord stroke.[22] ICH labiah lanjuiik tabagi manjadi parenchymal hemorrhage, hemorrhagic infarction, jo punctate hemorrhage.[19]

Stroke iskemik[suntiang | suntiang sumber]

Dalam stroke iskemik, panyumbatan bisa tajadi di sapanjang jalua pambuluah darah arteri nan manuju ka utak. Darah ka utak disuplai dek duo arteri karotis interna jo duo arteri vertebralis. Arteri carotis interna marupokan cabang dari arteri karotis komunis sadangkan arteri vertebralis marupokan cabang dari arteri subklavia.

Patofisiologi[suntiang | suntiang sumber]

Hasia otopsi utak nan maalami stroke.

Inggo kini patofisiologi stroke marupokan studi nan sabagian gadang didasarkan pado sarangkaian panalitian,[23] pado baragam proses nan saliang taubuang, maliputi kagagalan energi, ilangnyo homeostasis ion sel, asidosis, paningkekan kadar Ca2+ sitosolik, eksitotoksisitas, toksisitas jo radikal bebas, produksi asam arakidonat, sitotoksisitas jo sitokina, aktivasi sistem komplemen, gangguan sawar darah utak, aktivasi sel glial sarato infiltrasi leukosit.[24]

Pusek area utak gadang nan takanai iskemia ka maalami panurunan aliran darah nan dramatis, manjadi cidera jo mamicu sarangkaian reaksi co lintasan eksitotoksisitas nan baujuang pado kamatian sel (nekrosis) nan manjadi pusek area mati (infark) dikaliliangi dek penumbra/zona peri-infarksi. Manuruik morfologi, kamatiak sel marupokan bangkak seluler dek gangguan inti sel, organel, membran plasma, jo disintegrasi struktur inti jo rangko sel (sitoskeleton).

Di area penumbra, apoptosis neural (kamatian saraf surang) diupayokan taambek dek kaduo mekanisme yaitu eksitotoksik jo paradangan,[25] dek karano sel utak nan masih normal ka mamanciang sistem kakebalan turunan untuak maningkekan toleransi jaringan utak pado kondisi iskemia, supayo dapek malakukan aktivitas metabolisme. Protein khas dalam cairan serobrospinal (cairan nan baedar dalam sistem saraf pusek) sarupo pancortin-2 ka bakontak jo protein modulator aktin, Wiskott-Aldrich syndrome protein verprolin homologous-1 (WAVE-1) jo Bcl-xL nan ka mambantuak kompleks protein mitokondrial untuak proses panghambatan tasabuik.

Faktor risiko[suntiang | suntiang sumber]

Faktor risiko nan indak dapek diubah[11]

  • Umua
  • Jinih kalamin, utamonyo laki-laki
  • Genetik
Panyumbatan darah pado pambuluah darah di utak manjadi panyabab stroke iskemik.

Faktor risiko nan dapek diubah[11]

Hipertensi[suntiang | suntiang sumber]

Hipertensi (takanan darah tinggi) ka marangsang pambantuakan plak aterosklerotik di pambuluah arteri jo arteriol dalam utak, sarato mamantiak mulainyo lintasan lipohialinosis di pambuluah ganglia basal utak, inggo manyababkan infark lakunar atau padarahan utak.[26]

Deteksi dini[suntiang | suntiang sumber]

Apo itu stroke? (bahaso Inggirih)

Deteksi dini kamungkinan tajadinyo stroke, bukanlah diagnosis, marupokan caro untuak tau kamungkinan tajadinyo stroke nan musti ditindaklanjuti jo pamaresoan lanjutan. Kok sasaurang indak dapek tagak jo ciek kaki salamo 20 datiak, mako ado kamungkinan (ka) tajadi stroke atau kamunduran kognitif, dek karano untuak malakukan tugas itu diparalukan kasaimbangan nan mamaralukan paredaran darah nan prima ka otak. Hal iko alah diungkapkan pado jurnal Stroke American Heart Association. Samakin payah batagak jo hanyo ciek kaki, samakin tinggi (ka) bakamungkinan tajadi stroke.[27]

Diagnosis[suntiang | suntiang sumber]

Diagnosis stroke dilakukan sacaro klinis sarato pamaresoan panunjang. Pamaresoan panunjang nan dapek dilakukan antaro lain CT scan kapalo, MRI. Untuak manilai kasadaran pandarito stroke dapek digunokan Skala Koma Glasgow. Untuak mambedakan jinih stroke dapek digunokan babagai sistem panilaian, sarupo Skor Stroke Siriraj, Algoritme Stroke Gajah Mada, atau Algoritme Junaedi.

Gejala[suntiang | suntiang sumber]

Fitur stroke iskemik nan sangaik umum, manuruik Uniformed Services University of the Health Sciences, masih manuruik pado banyaknyo hasia diagnosis pamaresoan fisik pado pandarito nan dirangkum dalam ciek kurun wakatu. USUHS marangkumnyo manjadi tabel barikuik bia dapek dipakai masyarakaik awam untuak mangenali gejala klinis stroke sadini mungkin. Dan untuak tanago medis profesional, The National Institute of Health alah mambuek tabel skala strok sabagai panduan guno malakukan diagnosis dalam wakatu kurang dari 5 inggo 10 minik.

Sarangan stroke tajadi mandadak jo gejala-gejalanyo antaro lain:

  • Lamah atau lumpuah salah satu sisi wajah, langan, jo tungkai (hemiparesis: kaindakmampuan untuak manggarikan ciek atau labiah anggota badan dari salah satu sisi badan; hemiplegi)
  • Gangguan sensorik pado salah satu sisi wajah, langan, jo tungkai (hemihipestesi atau hemianestesi)
  • Gangguan bicaro (diartria)
  • Gangguan babahaso (afasia)
  • Gejala saraf lainnyo sarupo jalan oyong (ataksia), raso baputa (vertigo), sulit malulua (disfagia), pandangan ganda (diplopia), lapangan pandang manyampik (hemianopsia, kwadran-anopsia)

Urang nan mandarito panyakik ko bisa marasoan ciek atau labiah gejala di ateh. Dapek pulo tasuo pandarito nan juo nyeri kapalo, mual, muntah, panurunan kasadaran, jo kajang wakatu tajadi sarangan stroke. Untuak mamudahan tau jo gejala stroke bapakai pulo istilah FAST tadiri ateh Facial movement, Arm movement, Speech, jo Test all three.[11]

Pananganan[suntiang | suntiang sumber]

Pandarito stroke akut biasonyo diagiah SM-20302,[28] atau microplasmin,[29] oksigen, dipasang infus untuak mamasuakan cairan jo zat makanan, kudian diagiah manitol atau kortikosteroid untuak mangurangi pambangkakan jo takanan di dalam utak,[30] akibaik infiltrasi sel darah putiah. Panalitian tarakhia manunjuakan baso kalumpuahan jo gejala lainnyo bisa diadang atau dipuliahan kok recombinan tissue plasminogen activator (rtPA) atau streptokinase nan bafungsi mahancurkan emboli diagiah dalam wakatu 3 jam,[31] sasudah muncuanyo stroke. Trombolisis jo rtPA tabukti bamanfaaik pado manajemen stroke akut, walaupun dapek maningkekan risiko pandarahan utak,[32] utamonyo pado area sawar darah utak nan tabukak.[33]

Metode parawatan hemodilusi jo manggunokan albumin masih kontroversial,[34] tapi panalitian dek The Amsterdam Stroke Study magiah prognosis (kaluaran panyakik) barupo panurunan angko kamatian dari 27% menjadi 16%, paningkekan kamandirian aktivitas dari 35% manjadi 48%, katiko 3 bulan sajak tajadi sarangan stroke akut.

Pamuliahan[suntiang | suntiang sumber]

Sarangan stroke takaik jo tabateh puliahnyo fungsi utak, walaupun area peri-infark manjadi labiah basipaik neuroplastik. Hal iko mamungkinkan pamelokan fungsi sensorimotorik jo malakukan pametaan ulang di area utak nan maalami karusakan. Di tingkek seluler, tajadi duo proses regenerasi dalam korteks peri-infark, akson ka maalami parubahan fenotipe dari neurotransmiter ka dalam status regeneratif,[35] sarato manjuluakan tangkainyo untuak mambuek koneksi baru di bawah pangaruah trombospondin,[36], laminin, jo NGF hasia kaluaran (sekresi) sel Schwann,[37] dan tajadi pulo migrasi sel progenitor (sel nan ka mambantuak) sel saraf (neutron) ka dalam korteks peri-infark.[38] Ampia sapanjang 1 bulan sajak tajadi sarangan stroke, daerah peri-infark ka maalami panurunan molekul paambek tumbuah. Pado rantang wakatu ko, neuron ka maaktivasi gen nan mamicu tumbuah, dalam ritme nan bagalombang. Neurogenesis (proses pambantuakan neuron) baubuangan jo angiogenesis (pambantuakan pambuluah darah) pun tajadi bagalombang nan diawali jo migrasi neuroblas jo ekspresi GFAP,[39] nan talatak dalam zona subventrikular ka dalam korteks peri-infark. Migrasi ko dimediasi dek babarapo senyawa antaro lain eritropoietin,[40] stromal-derived factor 1 (SDF-1) dan angiopoietin-1, inggo mahasilkan neuroblas jo jarak tampuah migrasi nan labiah panjang jo rantang wakatu sitokinesis nan labiah pendek.[41]

Panagahan[suntiang | suntiang sumber]

Urang nan indak bafaktor risiko stroke jo umua di baruah 65 taun, risiko tajadinyo sarangan stroke dalam sataun sakitar 1%.[42] Salapeh tajadinyo sarangan stroke ringan atau TIA, panggunoan ubek anti-koagulan sarupo warfarin, salah satu ubat nan dipakai untuak pandarito fibrilasi atrial,[43] ka manurunkan risiko sarangan stroke dari 12% manjadi 4% dalam satahun. Sadangkan panggunoan ubek anti-keping darah (antitrombolitik) sarupo aspirin, umumnyo pado dosis aarian sakitar 30 mg atau labiah, hanyo ka maagiah palinduangan jo panurunan risiko manjadi 10,4%.[44] Kombinasi aspirin jo dipyridamole maagiah palinduangan labiah jauah jo panurunan risiko taunan manjadi 9,3%.

Caro paliang rancak untuak managah tajadinyo stroke adolah jo maidentifikasi urang-urang nan barisiko tinggi jo mangandalikan faktor risiko stroke sabanyak mungkin, sarupo kabiasoan marokok, hipertensi, jo stenosis (kakakuan) di pambuluah karotis,[45] maatua pola makan nan sihaik jo mailakan makanan nan manganduang kolesterol jaek (LDL), sarato olaraga sacaro teratur. Stenosis marupokan efek vasodilasi (palebaran pambuluah) endotelium nan umumnyo disababkan dek turunnyo sekresi NO dek sel endotelial, dapek diambek asam askorbat nan maningkekan sekresi NO dek sel endotelial malalui lintasan NO sintase atau siklase guanilat, mareduksi nitrita manjadi NO sarato maambek oksidasi LDL[46] di lintasan aterosklerosis.

Sabagian institusi kasihatan sarupo American Heart Association atau American Stroke Association Council, Council on Cardiovascular Radiology and Intervention maagiah panduan panagahan nan dimulai jo pananganan saksama baragam panyakik nan dapek ditimbulkan dek aterosklerosis, panggunoan ubek anti-trombotik untuak kardioembolisme jo ubek anti-kapiang darah untuak kasus non-kardioembolisme,[47] diikuti jo pangandalian faktor risiko sarupo diseksi arteri (arteri kuyak), patent foramen ovale, hiperhomosisteinemia, hypercoagulable states, sickle cell disease; cerebral venous sinus thrombosis; stroke wakatu kahamilan, stroke akibaik pamakaian hormon pasca menopause, panggunoan ubek anti-koagulan sasudah tajadinyo cerebral hemorrhage; hipertensi,[48] kabiasoan marokok, diabetes, fibrilasi atrium, dislipidemia, stenosis karotis, obesitas, sindrom metabolisme, konsumsi alkohol balabiahan, konsumsi ubek balabiahan, konsumsi ubek kontrasepsi, bakaruah, migrain, paningkekan lipoprotein dan fosfolipase.

Biasonyo di Indonesia CT Scan dan MRI baru dilakukan, sasudah tajadinyo stroke. Jarang angiografi manggunokan kaduo alaik itu untuak mandeteksi kamungkinan tajadinyo stroke dilakukan. Kini alah mulai banyak laboratorium klinik, klinik stroke, pambuluah darah jo panyakik kardiovaskular nan mampunyoi Doppler Transkranial,[49] dek karano alaiknyo ketek/mudha dibaok dan relatif murah jo biaya pareso sampai sapasalapan biaya panggunoan CT Scan atau MRI. Doppler Transkranial indak saakuraik kaduo alaik nan maha tasabuik, tapi salah satu kauntuangannyo, yaitu indak manganduang radiasi, sainggo dapek dilakukan sacaro barulang, misalnyo untuak pamantauan salamo atau sasudah stroke dan dapek pulo dilakukan pado pasien nan kritis, indak sadar, di ruang ICU.[50] Dek biayanyo nan condong murah, mako pamantauan kamungkinan tajadinyo stroke alah banyak pulo dilakukan manggunokan Doppler Transkranial, utamonyo di Amerika Serikat.

Rujuakan[suntiang | suntiang sumber]

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  28. (Inggirih) "The nonpeptide glycoprotein IIb/IIIa platelet receptor antagonist SM-20302 reduces tissue plasminogen activator-induced intracerebral hemorrhage after thromboembolic stroke.". Department of Neuroscience, University of California at San Diego; Lapchak PA, Araujo DM, Song D, Zivin JA.. http://www.ncbi.nlm.nih.gov/pubmed/11779904. Diakses pado 8 September 2011. 
  29. (Inggirih) "Microplasmin: a novel thrombolytic that improves behavioral outcome after embolic strokes in rabbits.". Department of Neuroscience, University of California at San Diego; Lapchak PA, Araujo DM, Pakola S, Song D, Wei J, Zivin JA.. http://www.ncbi.nlm.nih.gov/pubmed/12215599. Diakses pado 8 September 2011. 
  30. (Indonesia) Misbach, H Jusuf; Harmani Kalim. "Penanganan Stroke". Medicastore. http://medicastore.com/stroke/Penanganan_Stroke.php. Diakses pado 7 Nopember 2010. 
  31. (Inggirih) "Tissue plasminogen activator for acute ischemic stroke.". The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group.. http://www.ncbi.nlm.nih.gov/pubmed/7477192. Diakses pado 8 September 2011. 
  32. (Inggirih) "Reducing bleeding complications after thrombolytic therapy for stroke: clinical potential of metalloproteinase inhibitors and spin trap agents.". Department of Neuroscience, University of California San Diego; Lapchak PA, Araujo DM.. http://www.ncbi.nlm.nih.gov/pubmed/11700147. Diakses pado 8 September 2011. 
  33. (Inggirih) "Rapid breakdown of microvascular barriers and subsequent hemorrhagic transformation after delayed recombinant tissue plasminogen activator treatment in a rat embolic stroke model.". Neuroprotection Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School,; Dijkhuizen RM, Asahi M, Wu O, Rosen BR, Lo EH.. http://www.ncbi.nlm.nih.gov/pubmed/12154270. Diakses pado 8 September 2011. 
  34. (Inggirih) "Custom-tailored hemodilution with albumin and crystalloids in acute ischemic stroke". Department of Rheology, St. Lucas Hospital; Goslinga H, Eijzenbach V, Heuvelmans JH, van der Laan de Vries E, Melis VM, Schmid-Schönbein H, Bezemer PD.. http://www.ncbi.nlm.nih.gov/pubmed/1561645. Diakses pado 21 Agustus 2011. 
  35. (Inggirih) "Neural plasticity after peripheral nerve injury and regeneration". Group of Neuroplasticity and Regeneration, Institute of Neurosciences and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona; Navarro X, Vivó M, Valero-Cabré A.. http://www.ncbi.nlm.nih.gov/pubmed/17643733. Diakses pado 4 September 2011. 
  36. (Inggirih) "Thrombospondins 1 and 2 are necessary for synaptic plasticity and functional recovery after stroke.". Department of Neurosurgery, Stanford University School of Medicine; Liauw J, Hoang S, Choi M, Eroglu C, Choi M, Sun GH, Percy M, Wildman-Tobriner B, Bliss T, Guzman RG, Barres BA, Steinberg GK.. http://www.ncbi.nlm.nih.gov/pubmed/18594557. Diakses pado 4 September 2011. 
  37. (Inggirih) "Peripheral nerve regeneration.". Department of Anatomy and Neurobiology, Eastern Virginia Medical School; Liuzzi FJ, Tedeschi B.. http://www.ncbi.nlm.nih.gov/pubmed/1821734. Diakses pado 4 September 2011. 
  38. (Inggirih) "Cellular and molecular mechanisms of neural repair after stroke: making waves.". Department of Neurology, David Geffen School of Medicine at the University of California; Carmichael ST.. http://www.ncbi.nlm.nih.gov/pubmed/16634041. Diakses pado 4 September 2011. 
  39. (Inggirih) "A neurovascular niche for neurogenesis after stroke.". Department of Neurology, University of California; Ohab JJ, Fleming S, Blesch A, Carmichael ST.. http://www.ncbi.nlm.nih.gov/pubmed/17167090. Diakses pado 4 September 2011. 
  40. (Inggirih) "Poststroke neurogenesis: emerging principles of migration and localization of immature neurons.". David Geffen School of Medicine at UCLA; Ohab JJ, Carmichael ST.. http://www.ncbi.nlm.nih.gov/pubmed/18024854. Diakses pado 4 September 2011. 
  41. (Inggirih) "Neuroblast division during migration toward the ischemic striatum: a study of dynamic migratory and proliferative characteristics of neuroblasts from the subventricular zone.". Neurology Department, Henry Ford Health Sciences Center; Zhang RL, LeTourneau Y, Gregg SR, Wang Y, Toh Y, Robin AM, Zhang ZG, Chopp M.. http://www.ncbi.nlm.nih.gov/pubmed/17376977. Diakses pado 4 September 2011. 
  42. (Inggirih) "Atrial fibrillation and apoplexy--risks and prevention". Københavns praktiserende laegers laboratorium, AFASAK 2 Center; Koefoed BG, Gulløv AL, Petersen P.. http://www.ncbi.nlm.nih.gov/pubmed/8700641. Diakses pado 21 Agustus 2011. 
  43. (Inggirih) "Stroke risk factors and stroke prevention.". Department of Neurology, College of Physicians and Surgeons, Columbia University; Elkind MS, Sacco RL.. http://www.ncbi.nlm.nih.gov/pubmed/9932614. Diakses pado 21 Agustus 2011. 
  44. (Inggirih) "Dipyridamole for preventing stroke and other vascular events in patients with vascular disease". Julius Center for General Practice and Patient Oriented Research / Univ. Department of Neurology, University Medical Center Utrecht; De Schryver EL, Algra A, van Gijn J.. http://www.ncbi.nlm.nih.gov/pubmed/12535415. Diakses pado 21 Agustus 2011. 
  45. (Inggirih) "Primary stroke prevention". Department of Neurology, University of Cincinnati; Sauerbeck LR.. http://www.ncbi.nlm.nih.gov/pubmed/17068431. Diakses pado 21 Agustus 2011. 
  46. (Inggirih) "How does ascorbic acid prevent endothelial dysfunction?". Department of Medicine, Vanderbilt University School of Medicine; May JM.. http://www.ncbi.nlm.nih.gov/pubmed/10924860. Diakses pado 24 Agustus 2011. 
  47. (Inggirih) "Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline". American Heart Association; American Stroke Association Council on Stroke; Council on Cardiovascular Radiology and Intervention; American Academy of Neurology.; Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, Gorelick P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ, Marks M, Schwamm LH, Tomsick T. http://www.ncbi.nlm.nih.gov/pubmed/16432246. Diakses pado 21 Agustus 2011. 
  48. (Inggirih) "Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group". American Heart Association; American Stroke Association Stroke Council; Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD, Culebras A, DeGraba TJ, Gorelick PB, Guyton JR, Hart RG, Howard G, Kelly-Hayes M, Nixon JV, Sacco RL. http://www.ncbi.nlm.nih.gov/pubmed/16785347. Diakses pado 21 Agustus 2011. 
  49. "TRANSCRANIAL DOPPLER (TCD)". http://www.pramita.co.id/index.php/19-artikel/bulletin/39-trans-cranial-doppler-tcd. Diakses pado 3 April 2015. 
  50. Rizaldi Pinzon. "Penggunaan Trans Cranial Doppler untuk Deteksi Perubahan Hemodinamik Serebral pada Pasien Kritis". http://www.jurnalmedika.com/edisi-tahun-2011/edisi-no-02-vol-xxxvii-2011/284-artikel-penelitian/625-penggunaan-trans-cranial-doppler-untuk-deteksi-perubahan-hemodinamik-serebral-pada-pasien-kritis. Diakses pado 3 April 2015. 

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